Case 172: Diabetic Foot: HMO Does Not Cover Treatment of Patient with Painful Ulcerated Legs

This HMO patient was referred for boot therapy on February 6th, 1998 by his primary care physician. He had been under the care of a podiatrist, a vascular surgeon, a cardiologist and a nephrologist. The latter was providing dialysis three days a week. His legs were reddened, swollen, tender, painful and ulcerated in multiple areas. He was in pain 24 hours a day.

Pain, pain, pain....24 hours a day.

We telephoned his primary physician the day of the consultation and subsequently wrote him:

"I advised him" (the patient) "that he was a good candidate for therapy with the Circulator Boot and I think that both legs would benefit greatly. We also advised him, however, that he would have to gain permission from" xxxxxx (his HMO) "before we could begin the treatment. Boot therapy, for him, would be like dialysis. He likely would require therapy three times a week to both legs for life. With such therapy, I believe we can keep his legs intact until his head or heart fail (stroke or fatal myocardial infarction). He will likely be pushed by" xxxxxx (his HMO) into high bilateral leg amputations, which, considering his overall poor physical condition, he may not survive. In the meantime he will continue to suffer pain from his lesions."

"A" xxxxxx (his HMO) "representative called the office for more information last week. I spelled out his unfortunate situation for her. We have had no subsequent follow-up."

Comments: We got the name of the appropriate "Medical Director" who advised us that his HMO did not cover the service. This episode is typical of our contacts with this particular HMO. First, there is rarely a timely decision regarding patient care. This slow response is suspected by many to be purposeful; the patient may receive free care during the time delay. Second, there is rarely a paper trail. Both approvals and denials are given by the telephone making it difficult both to collect for actual services rendered and to appeal their decisions. Third, we have never been asked about the best interests of the patient and his/her care. Fourth... fifth... ....tenth... One wonders why the HMO has Medical Directors. If they are to follow a rule book, the HMO could save additional money and fire them all... A computer would provide more consistent responses. Presumably, the Medical Director is there to deny unnecessary care and arrive at an effective economic therapeutic program. Unfortunately, they are provided with incentives to deny care. Do they remember or did they ever know the Hippocratic oath: ".... In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction...."

This patient is added to illustrate another fact of life today. The Circulator Boot was designed to help many people who will never be benefited because of decisions by others who profit by their denials.

Follow-up: Refused care and left with no options save bilateral leg amputations, the patient chose death as a means of escaping his leg pain. He discontinued his dialysis and started Hospice care. Within a few days he developed congestive heart failure and died. Death, the cheapest outcome for the HMO.