Case 98: Managed Care: Loss of Limb and Independence Attributed to HMO

At age 80 this black man had type 2 diabetes and a recent femoral-tibial bypass in his left leg. He was referred May 14th, 1991 for boot therapy by his vascular surgeon because of persistent rest pain in the lower leg and claudication occurring with minimal effort such as walking around his house. Covered by Medicare, he received 26 boot treatments over the next two months and his rest pain was relieved. His walking distance was improved but remained limited. He disappeared from our follow-up.

Responding to HMO advertisements for Medicare patients that promised all costs would covered, he signed up with the HMO and found a new doctor. Over Easter of 1996, he had a small myocardial infarction. He was able to walk about a block at that time. In late August, he developed a blister on his first toe bunion and was given a prescription for Cipro and Tylenol with codeine. A visiting nurse was enlisted to go to his house to change his dressings. His foot worsened leading to a four-day hospitalization for intravenous antibiotics. A three-phase bone scan showed a diffuse uptake most compatible with diffuse cellulitis. He was discharged on antibiotics. And again his foot worsened. His diabetes doctor referred him on an emergency basis for boot therapy on the 13th of September, 1996. Examination then showed a pulseless foot with dry skin, rubor on dependency of the distal half of the foot, an ulcer over the web space between the 1st and 2nd toes on the dorsum of the foot and a deep penetrating fistula in the webbing between the 1st and 2nd toes where the culture probe was introduced an inch. The cellulitic process extended to the mid-foot making an immediate transmetatarsal amputation unfeasible.

Here the photographer was trying to catch the ulcer between the 1st and 2nd toes.

He was given one injection of gentamicin into the end of his foot and one Mini-Boot treatment. His HMO was then called to gain permission for a series of treatments and advised we would like permission to do appropriate vascular testing to best apply our therapies. We were advised to stop our treatment pending review of their medical director. Multiple phone calls were placed from September 16th to the September 24th. The visiting nurse called reporting that his foot was worsening; this news did not interest the HMO secretary who hung up the phone on our call. The primary care physician of the patient likewise called the HMO. No answer. Finally, on September 30th, a letter was received saying the treatment was not a covered benefit and was permission for treatment was denied. The patient, in the meantime, had been advised that this HMO in the past had allowed us to treat patients and subsequently denied their coverage, that until Medicare forcibly instructs the HMO as to their coverage responsibilities they would likely continue in their denials, that we thought we could help him again but he would be responsible for some of the costs and, finally, that he needed immediate care somewhere else if not in our office..

He found his way to an academic wound care center in Philadelphia where noninvasive vascular tests were done, an angioplasty attempted and eventually his leg amputated. He was subsequently discharged to a nursing home where he remains today.

Comments: With his first course of boot therapy, his circulation was improved sufficiently to carry him five years. He presented on the second occasion with a foot that compared to most in these Webpages was not excessively advanced. Having already had bypass surgery in 1991, he had no vein and was hardly a candidate for further surgery in 1996. Even if bypass had been possible, our boot treatments were more economical and posed less risk. We attribute the loss of this man's leg and his commitment to the nursing home to the ignorant and tardy behavior of his HMO and question the legality of their denials. In contrast to US HealthCare, for example, which has sent a group of doctors to visit our boot center and examine our results, the doctors from this particular HMO have refused such an invitation and indeed cannot be reached to discuss patient care whether for boot therapy or other problems.