Prostheses on demand ?

Prostheses on demand ?

Vicky

7/7/1999

Hello everyone,
In response to a question I posed -

' How true is it that provided an amputee meets prescription criteria
they have access to the best available prostheses for
their needs ? I would assume that cost is a critical factor and that
funding would be a key issue dependent upon where the patient lives,
private medical insurance and especially in the UK, which Health Authority
you happen to come under. This then becomes not a matter of free choice,
but an issue of finance and accountability.
Opinions please'.

The following replies were recieved. The replies were mostly gloomy and I have
included a summary of statements. It appears that many amputees have a sad
story to tell, with cupboards full of useless prostheses that were first prescribed
for them as 'a novice'. The general opinion seems to be that they are treated like
idiots and that it is only when they become clued up with the system
and demand better componentry that they then get it. I had an
extremely gloomy portrayal of prosthetic prescription and supply from
Canada and the US - it did not make pleasant reading.


' My opinion sides with yours. The consumer is entitled to the best health
care their money can buy, either through private funds, or other benefits
inclusive of charity. The statement you present for discussion is a pipe
dream both the industry and the profession can share '.

' In reference to your question, in canada we are entitled to the best of
what is available - the only limitations being the lack of
skill/interest/knowledge of the prosthetist (but the one that does the
most damage as in the USA as well) and the coverage of the final 25% of the
costs, most of which is covered by other organizations '.


VM> How true is it that provided an amputee meets prescription criteria
    (what ever that means), they have access to the best available
    prostheses for their needs ?

' In the USA it is simply not true at all. Years ago I was denied a Flex
Foot by my insurance company (yes: I had an Rx for it--plus
justification from my primary care physician) when I was speedwalking
10K/day. They claimed it was not in keeping with my 'lifestyle', about
which they knew less than nothing'.

VM> I would assume that cost is a critical factor and that funding would
    be a key issue dependent upon where the patient lives, private
    medical insurance and especially in the UK, which Health Authority
    you happen to come under.

' Possibly in Britain, but not in the US. My benefits were just (last
year) limited to $1000 a year US by the board that oversees my
employer's medical benefits. So yes, cost is definitely a critical
factor in our system of Managed (some would suggest Mangled) Care. And
yes, funding is an obvious factor. But the point of 'managed care' is to
save the providers money, and to provide the amputee with the least
costly device '.

VM> This then becomes not a matter of free choice, but an issue of
    finance and accountability.

' Free choice in medical care is not part of managed care. Clients are
usually required to see a primary care physician (who acts as a
gatekeeper) and then to go --only-- to a prosthetist who is part of the
managed care provider's network. Of course, if you wish to pay out-of-
pocket...if you are wealthy, then all of this is a moot issue and you
can go to any prosthetist of your choosing. But for most of us, that is
simply not the case '.

' If you have enough money (m-o-n-e-y) and an Rx you can have anything you
want in the US of A. And I notice you opt for the word 'required.' Under Mangled
Care in the US, a person (non-physician) often determines what is medically necessary.
Their goal is to save money--not to do what might be best for the
amputee. So, they determined a number of years ago the Flex was not
necessary since I had for years used a Safe foot. All of this in spite
of the fact I was speedwalking 10K/day and the Flex foot with its energy
storing-push off would have (1) increased my speedwalking (2) walking is
excellent exercise and PREVENTS additional medical problems (3) the
whole point of an HMO or any medical expenditure should be PREVENTION in
order to save money down the road. This simple observation escaped them
since they are short-term thinkers and short sighted.

There a dozens of amputees on my list who have similar tales. Again, what might
be medically true in Britain is not true in the USA' .


' Hi Vicky,
Good question! Let me start by saying that I am probably not in the best
position to answer it as I have only ever worked at the one centre. I
have however worked under 2 different contractors (the joys of
competitive tendering) and 2 different contract systems.

I can tell you that at my centre, we have criteria set for different hi tech
componentry which helps us in our prescription process. A simple example
would be that for someone to be considered for a Mauch/Catech they should
be a free knee walker without aids followed by other tests. These
criteria are set by the full clinical team at monthly multi-disciplinary
team meetings. Usually the prosthetist will present the
component/technology and its suggested applications to the meeting and
then everyone gets to comment/argue/discuss as appropriate. At the end of
the process we may agree that anyone being considered for a change of
prescription should have the opportunity to try the components on an
existing limb or a check socket or a new limb before committing to the
definitive limb build.

This may involve the centre buying a trial Catech, Ultimate knee, IP+ or
the like to facilitate the process. We have found this to be money well
spent as we have in the past had folk who are convinced by the
advertising in the likes of Step Forward magazine that we are fobbing
them off with substandard gear. Allowing someone a trial on a limb of
their dreams does demonstrate in the most decisive of ways that you have
their best interests at heart even when they don't do any better with it.
Of course, there will also be the times when someone surprises us and
does much better than we had expected although this is a good bit less
common.

As for prosthetic feet, many manufacturers are quite happy to supply
loaner units for patients to try. For example I recently borrowed a 1C40
from Otto Bock for someone who was blown away by it after his Seattle
foot broke for the nth time. This is a good deal for the company as this
is one foot which we will be considering very favourably from now on.

There is of course the thorny issue of BUDGET. We have found this a
useful tool in controlling budget as we are, hopefully, prescribing more
appropriately and not wasting money trying things on the off chance.
This is not to say we don't get it wrong now and again but now we feel we
have a system which meets the needs and aspirations of the patients while
allowing us to control the spending of the finite resources of a small
centre like ours'.

The limitation to this, if it is a limitation, is that a clinical team
comprising any or all of: the Patient, Prosthetist, Physiotherapist,
Occupational Therapist, Nurse and of course Doctor (AKA Rehabilitation
Consultant) should agree that there is a likelihood of a sufficient
benefit to the patient.

The Prosthetist, generally, works for a private company which will have a
contract to provide limbs at a limb centre usually within a National
Health Service Hospital. These companies have a contract awarded to them
for periods of between 3 and 10 years depending on local conditions. The
terms of the contracts vary of course and each type of contract has its
supporters. The quality of work is controlled by the clinical team headed
by the consultant Physician who carries the overall responsibility for
this. Fiscal responsibility is the province of the Centre Manager although
we all play our part in making best use of finite resources.

On the whole I think this system works quite well but then I am not a
user. There is of course the budget to work to and this means some
compromise on occasion. For instance if an AK amputee has a sophisticated
knee such as a Mauch or an Endolite IP+ then the second limb may have a
simpler knee. The rational for this is that 99% of users wear the one
favourite limb all the time and would use the other for emergencies only.
As most repairs can be done quickly there is little point in having
expensive hardware sitting in a wardrobe when we can spend that money on
giving a sophisticated knee to someone else. Naturally these rules are not
set in stone and a young working man might well get 2 identical limbs to
minimise any downtime for him for instance.

There are variations on this model within the NHS but this is typical of
the type of service provision most amputees will meet in the UK' .

' I am the moderator of AMP-L, an amputee listserv at University of
Washington, although I live in Nashville, TN. There a dozens of amputees
on my list who have similar tales. Again, what might be medically true
in Britain is not true in the USA' .

' Dear Vicky,
Your summation of the issue of freedom of choice is fairly succinct. The patient/client will
always have availability of the latest componentry, however, the cost of that componentry will
ultimately prove to be the underlying factor influencing the final choice. Here in Australia we
have an Artificial Limb Scheme run by the State Governments. The ALS allows for standard
componentry to be provided at no cost to the patient/client. The determination of standard
componentry should be governed by function but in the real world with budgets to be abided by it
is the cost that ultimately dictates this approval. It then becomes the Prosthetists' duty to
inform the patient/client of the alternatives they have that suit their prescription criteria.
This of course will require additional funding from the patient/client. This system is
undergoing evolution in Australia with one State already altering its program, with the rest of
the States likely to follow suit. Instead of paying for a component part and labour part the
States are moving to a set price for a certain style of prostheses, thus accentuating the cost
component for the prosthetic supplier. Hope the above is helpful '.


Hi Vicky

Many of the prosthetists in the USA and Canada are notorious for being
hacks and for stealing from the amputees and the prosthetists wont tell
you that you have the right to fire them or complain about them.
They want the medical model to stay in place so they can continue to lie
to the amputee - and they want to instill a sense of passivity in the
amputee and conversely a sense of authority for themselves so they can
continue. The amputee is never told that they don't have to use the prosthetist
recommended by the hospital or clinic, they are never told that some
manufacturers offer kickbacks to the prosthetist if they switch the
customer out of one component to theirs, they are not even told about the
regulatory body that ensures their rights.
It is a one sided relationship that ignores the ones that are the most
important in the relationship, the customer. We are the ones who pay their
bills and keep them in business but they treat us as though we are idiots
with no thoughts in our heads when many of us are considerably more
educated and more experienced in the industry than they are.
They get very upset when we question their practices - like splitting the
limb to bill extra from the insurance companies, requiring amputees who are
not told differently to sign their insurance papers on the first visit so
the amputee has no recourse for a proper fitting limb, taking photographs
of casting and gait analysis and handing them around where they end up on
the Internet on pervert sites, devotee prosthetists who are sexually
aroused by the residual limb of the amputee.....
The prostheses are substandard, the components improperly installed, the
prosthetists themselves are quite often undereducated and have no idea
about good business practices.
You can tell just how many are more concerned with our knowing our place
than with the quality of their product by the responses from some of them
on this list when the subject comes up.
There are a few very good ones here but due to the fact that they are few
and far between, you have to wait a considerable amount of time to get in
because everyone else also wants to hire them - and when you need something
right away, you usually get stuck with the hack in the shop down the
street.
The only ones who do not see this situation for what it is are the
prosthetists. Ask any amputee how many closet limbs they have, the ones
that they paid for but were useless from the start and you'll start to see
the situation as it really is and not how the industry would portray
themselves....
It is the sad truth - the prosthetists get rich while the amputees get
robbed '.

' Hello Vicky,
' Before working in Belgium I was often frustrated how the insurance
could influence the length of the amputation. The longer the stump,
the less they have to reimburse the victim.
Amputees should definitely participate in choosing their prosthesis, after
all the patient is part of the team. They should be well informed on the
pro and contra of each fitting. But then again, can they always afford the
best choice?
Our center makes around 100 prostheses / month. The only choice they have
is a PTB or a Supra Condyle Trans Tibial. But then again, I am all the way
in Cambodia '.


' Dear Vicky,
I think the average Prosthetist does not inform their patient/client adequately about the
component options available to them. Silly really, given that this information would not only
reinforce their professional standing but also become a basic marketing tool for their
businesses '.

' Vicky, here in Australia, there is a Free Limb Scheme operating in all
states. The state of Victoria has a slightly different system operating on
similar lines : all patients regardless of financial status or insurance are
entitled to prostheses. The government pays for all of these, the components
of which comply with a generous schedule of 'allowable' items. If more
expensive or sophisticated components are prescribed then the patient may be
asked to contribute a nominal amount towards the cost: say the first $200
for people with incomes over a certain level and $50 for welfare types. If
the Patient is compensable under Traffic Accident laws or Worker's
Compensation, then those agencies are billed. All Veterans pay
nothing '.


Greetings Vicky

Re your rhetorical comment - This then becomes not a matter of free =
choice, but an issue of finance and accountability. I reply:

Public aid amps get the clunky old stuff; private pay/good insurance =
amps get the comfy new stuff.
      1. The emperor has no clothes.
      2. It's always about money.=20

      If you believe #1, then #2 MUST follow !'.

Pretty depressing stuff !!!