Case 94: Managed Care: Outpatient Care Not Covered by Her HMO So Lady Pays Bill Herself and Heals Chronic Ulcers

Born March 16th, 1952, this lady had bilateral adrenalectomies for Cushing Disease at age 20. Diabetes was discovered at the same time and she was started on insulin. The diabetes was not well regulated and she developed peripheral neuropathy and hammer toes. Ulcers developed under her right 3rd and left 1st metatarsal heads. The later were followed by a general surgeon and a podiatrist for two years. In spite of treatment with Ceftin, an infection in the ulcer of the left foot progressed to form an abscess under the ulcer that tunneled distally along the proximal phalanx of the 3rd toe and exited at the juncture of the toe and plantar skin. Her surgeon admitted her for a potential drainage procedure and intravenous antibiotics and called for a boot consultation. The surgeon's letter to the family doctor read, (the right foot ulcer) ..."appears quite large and I am concerned that she will eventually lose both feet."

The abscess was irrigated with Sea Soaks, then injected with gentamicin and pumped in the Mini-Boot. Within a few days, the foot was much improved. A drainage procedure was not carried out. She was impressed with the progress of her foot. Unfortunately, her employer provided her with an HMO program that did not cover outpatient boot therapy. She was advised of her options: (a) standard care including serial foot x-rays and/or scans to look for osteomyelitis (which was thought to be likely present), intravenous antibiotics both in the hospital and by the visiting nurse and avoidance of weight-bearing; (b) oral antibiotics as needed, locally injected antibiotics and Mini-Boot therapy as started in the hospital. Not impressed with the results of standard measures to date, she chose the latter and signed an appropriate sheet signifying she was to be responsible for her costs herself.

Shortly after discharge from the hospital her foot ulcer was cleaner and smaller and her cellulitis had abated, February 7th, 1966.

Here the residual abscess exit is better seen under the 3rd toe. The diagram illustrates her hammer toe deformity. The skin under the plantar surface is more normal. February 26th, 1996

She was treated 3-5 days a week through February and March. Before each treatment, gentamicin was generally injected into the ulcer bed. Fungizone and Urecholine were added to the Mini-Boot bath. She returned to work and again developed callus on the sole of her foot around the ulcer area; this was shaved back periodically. As her drainage lessened and her red cell sedimentation rate improved, her treatments were tapered

Except for the debridement of recurrent callus, the right foot has required no more care. Follow-up August 3rd, 1996.

When the right foot was declared cured, she took off her left shoe and asked that we begin treatment on it. She could not afford to pay for the treatment of both feet simultaneously. As of this writing, February 10th, 1997, the left foot is doing well but will be slow as she comes for treatment but once a week.

Comments: One wonders if this lady's insurance company inspired the book, The Rainmaker. They are slow to make determinations as to whether care is covered and, if the care is given without approval in an urgent situation, they rarely pay for it. Their executives live well and their reviewing physicians are well versed in any minutiae allowing them to deny care. Their plans are not cheap but are competitively priced enough to entice employers to buy them. This lady is disillusioned.

A reviewing physician would again be critical. We performed no serial x-rays or bone scans to prove or disprove the existence of osteomyelitis. We had no home visiting nurse giving intravenous antibiotics. We change our treatment in many cases relatively little on the basis of the serial x-rays; we shall inject draining sites with appropriate antibiotic until they stop draining whether or not the underlying bone has been proven to be infected. Our treatment is straightforward economical and free of complications. One might think an informed insurance company would embrace our methods and some have. This lady is added to our Website not because her case was so difficult or her pictures so dramatic; we had even forgotten to take baseline photographs. She is here to demonstrate problems patients and physicians have dealing with insurance companies good and bad... in this case especially bad.