At whits end - cant' get care from HMO

[rtlink]

What is the name of your state? Oregon

*Wife and I are both covered by Kaser Permanente HMO.
*She received a leg injury about 5-weeks ago while training for marathon (lower calf)
*Requested referal for sports medicine specialist - none in the network - referred to one of two possible doctors.
*Only doctor available is a physiatrist who she's seen in the past - the doctor was awful, but options are limited...welcome to the HMO.
*Diagnosed with accute achiles tendinitis.
*Conveyed conert to Dr. that this seems like the wrong diagnosis - pain is in lower calf.
*Dr. dismisses her concerns - does not "tests" (no X-ray, no MRI, no biomechanical measurements, no evaluation of orthotics he prescribed two years ago)
*Recommends ice, rest, ibuprofin
*We convey conern that this only treats the symptons - what is the cause?
*Dr. makes no effort to investigate root cause (i.e. orthodics, biomechanis of running motion, shoes, leg length discrepency, etc.)
*We ask about specific stretches that might help.
*Dr. has no advice - recommends we look stretches up on internet. Thanks, Doc, you're so helpful.
*We ask for second opionion.
*Only other doctor is booked through the entire period for which they take appointments (two months).
*Stuck with no means to get second opinion. Meanwhile, leg pain worsens, spreads to knees, and she gets feeling of numbness in lower legs.
*With no real means to get medical attention, we research the web and various books. Our research tells us she has compartmental syndrome, confirming our suspicion of misdiagnosis.
*Wife visits sports massage therapist to try to get relief...therapist also is 90% certain she has compartmental syndrome...massage helps lower calf, but not knees and numbness.
*Wife takes detail 8-hour round trip from HMO providers through August.
*Appeal to see someone outside of the network.
*Appeal denied...reason..."Care can be provided within network".
*Obviously, our definition of "care" differs from the HMO. We feel that care entitles someone to get a diagnosis and to perhaps see a physician, let alone not have to drive 8-hours to do so.
*Finally get appointment with second Doctor (only because he will be coming in on a Friday two weeks from now for a "seminar"...otherwise he works only 4 days per week...no wonder his schedule is booked)
*Frustrated and in disbelief that our dog gets better care through our vet than we get through our HMO!
*End result - it's been 1-month since my wife's been misdiagnosed, she's received no advice in the interim despite repeated (daily) attempts to get some help, problem has progressed from calf pain to include knee pain and numbness in legs.
*My wife is emotionally spent...she's spent hours on the phone with Kaiser. Now, just dialing their number causes her to break down in tears. I feel like our options are spent. Is there anything we can do, or is this just the way it is!
*I'm seriously considering getting a medical degree just to treat myself and my family.

Any advice? Is there any legal action we can take?

[purple2]

What happened instead is your insurer decided to uphold its contract with you. Nothing illegal in doing that.

Unless your contract (insurance policy) has been violated, there's not much you can do except complain to your insurer about their handling of your wife's case.

It may seem unfair to you but it's not illegal.

[rtlink]

I can see the arguement that they're upholding their contract, and in general have no beaf with being told we can get the care within the network. But, what I'm wondering is what is the definition of the term care.

They say they can provide care within the network, but is there any time limitation attached to this? For example, if they determine that they can provide the required care within the network and deny an appeal to see an outside specialist, but that care comes 6-months down the road...is that legally care? Just to make a point...suppose they say they can get you in to see a doctor next year...is that care?

The doctor's appointment book is full through August. I assume that each day, the appointment book extends one more day. That means we would need to call everyday (it's at least an hour on the phone just to get through the system) until an appointment can be made as they roll their appointment book forward with the march of time.

We've gone with an appointment outside of the HMO and are just going to pay for it out of pocket. It's like we're uninsured...but worse, since we still have to pay the premiums for the HMO.

[ellencee]

rtlink
I sure hope your wife has followed the perfectly sound medical advice that she received from the physician who told her to use ice and to rest her leg and to take ibuprofen. That's all that can be done to relieve the symptoms of tendonitis.

If she had followed the doctor's instructions instead of looking for stretches to further irritate the tendon and increase the amount of inflammation, she would not have developed compartmental syndrome. You and she brought that about, not your insurance benefits or lack thereof.

As for the pain in her lower calf, exactly where do think achilles tendonitis would hurt if not the calf of the leg? (hint: anywhere else is the wrong answer)

If you want your wife to get well, have her elevate her leg, put ice on the tendon (from the ankle to the mid-calf) leaving the ice on for 15 minutes and then taking it off for 20 minutes. Take the ibuprofen as prescribed and avoid dairy products which have lactic acid in them, the same lactic acid produced by inflamed muscles, and let the inflammation resolve.

No wonder you are at your whit's end, whatever a whit is; you've done everything but what your wife needed to do. FYI--the word is "wit" and the idiom is "at your wit's end".

EC

[rtlink]

EC,

Thanks for the response. It shows, case in point, precisely why this entire process has been so frustrating. It's like we can't get people to actual listen to us!

Recall, the achilles tendinitis diagnosis is not the correct diagnosis. I won't go into the details, but given the symptoms and events leading up to the injury, we are near certain she has compartmental syndrome, which is a total seperate and different injury requiring entirely different treatments. One does not cause the other. Hence the request for a second opinion.

In any event, my wife DID follow the doctors advice...she did use ice, she did rest, and she has been taking ibuprofin. She stopped running entirely, and followed the doctors orders that other activities to maintain fitness were okay (i.e. bicycling, swimming, etc.). She followed this to a tee (that is her personality). Anyhow, the problem got worse and other symptoms started to surface. Seeking advice at this stage has been impossible with only one other doctor available and no openings for a consultation.

Finally, as I mentioned, we are seeking to find out the actual CAUSE of the injury - not just a treatment of the symptoms. This is precisely why we requested a sports medicine specialist, but this option was not available to us. This is not to downplay the need for the ice, rest, and ibuprofin. The injury needs to be treated, but at the same time, we want to understand what caused it. If one does not attempt to find out why the injury happended to begin with, once "healed", it will come back because the original problem was not addressed.

We live in Portland, where there is a large and active running community. We encounter runners all the time who have had similar injuries and with the advice of competant medical professionals, were able to determine exactly why the injury occured in the first place, which enables the problem to be addressed and corrected. There are many ways to do this (i.e. gate analysis, biometric measurements, etc.). Those we know with similar injuries that were able to see a good sports medicine specialist received treatment and preventative care to address the problem - either through orthodics, specific shoes, muscle development, or at last resort surgery.

It's not acceptable for a doctor to spend 5 minutes LOOKING at someone's leg to come up with a diagnosis. No tests, no attempt to find the root cause, no effort to address the patients concerns.

I am convinced that this approach to medicine is a problem with the HMO. Spending five minutes with a patient, looking at their leg, and prescribing rest, ice, and over the counter ibuprofin costs them nothing. Trying to run tests to find the root cause takes time and money.

We're not disobeying the doctors orders, simply trying to get a second opinion, which we have every right to do. Try to consider for a moment the possibility that our doctor is (a) the wrong practitioner for the injury and (b) simply not a good doctor. Then, you can begin to understand our frustration. If you accept that possibility, our options have been very limited.

[cbg]

So go to the outside doctor of your choice and pay for the visit yourself. Problem solved.

[rmet4nzkx]

I have to agree with both Ellen and CBG.
If your wife wants to see a sports medicine specialist, then she should go and pay for the TLC she will get there, it is not likely to change the treatment and or the time to regain previous use. RICE treatment is appropriate for most sports or sports type injuries, I have have had several of these myself and they are very frustrating and take a long time to heal and I didn't receive the injuries from sports activities. Many people become addicted to the natural hormone and opaites released through exercise and over train, this is especially true for women who may not eat properly although they may follow strict diets. While it may be useful to know the cause, it is very important for your wife to really listen to her body especially when it comes to pain amd remember bodies were not made to undergo such abuse. There is a difference between normal amounts of exercise and extreems, HMOs are not required to cater to needs beyond medically indicated, eg they may charge extra for treatment such as plastic surgery or other elective treatments. You have no cause of action, while HMOs may not always provide appropriate care, this is not the case here. Actually, the psychiatrist may be a very appropriate provider for her pain and sports related injuries.

[ellencee]

rtlink
Your response reveals the cause of your frustration--you are the one not listening.

Compartmental syndrome is the result of the swelling brought about by the tendonitis or whatever muscle strain your wife sustained and from which your wife did not allow herself to heal before she moved on to the next level of rehab.

Your wife is not entitled to gait analysis and all the other crap that you listed. It is not a part of healthcare but is a part of an exercise program. If your HMO provides for professional direction of an exercise program, then once your wife heals sufficiently she can seek those benefits and care.

Running is not good for joints, especially joints in women because of the center of gravity in the female body. All of the people in your town are asking to have hip and knee replacement surgery in a few years if they keep running like a herd of fools. I doubt more than 10% of the running population is an athlete capable of running without injuring themselves.

Your wife may require up to six months or longer to recover from whatever muscle sprain she sustained. Leave her alone and let her heal. After she has healed, she can begin to regain some of her former endurance and some of her former activities.

Forget about surgery for muscle or tendon strain unless you really dislike your wife and want her permanently out of the herd.

I know I'm wasting my words; people like you do not want to accept simple regimens as being the definitive answer and you will continue to attack this problem as if your wife was the number one gymnast in the world and a team of Olympic sports therapist are required for her recovery.

Go running and let your wife rest until she heals and give up in your pursuit of thinking medical malpractice occurred or your insurance company has acted in bad faith. You are the only liability in this situation.

EC

[rtlink]

Okay,

I have an update. We were already pursuing a visit with a doctor outside of the HMO. That appointment occured today, and in fact, it occured two hours prior to the time scheduled. Why the rush? After reviewing my wife's case history (not the administrative problems with our HMO, but the medical problems) that my wife sent to him prior to the appointment, the doctor recommended that she come in immediately.

The doctor diagnosed my wife with deep posterior compartment syndrome, as we had suspected (by the way, we did not "lead" the doctor to this conclusion in any way). This explains why the pain progressed to the knees and why she has had numbness in her legs. With compartment syndrome, pressure gradually builds up in the leg muscle causing pain. In my wife's case the pressure hasn't released naturally due to some tears in the muscle. The pressure caused her to change her gate, causing ITB syndrome (her knee pain), along with cutting off blood flow to her lower legs (and hence the numbness). Her condition is rather serious given the lack of blood flow to her feet. If untreated, there are cases where people have lost their lower legs as a result of the lack of circulation.

The recommended treatment is physical therapy, orthodics, and strength training. Rest doesn't improve the ailment. Ice, administered with a wrap, was the worst thing because it only increased the pressure due to the compression. As we suspected, she was misdiagnosed initially. The length of time it took to try to get a second opinion within the HMO due to lack of appointments caused the condition to worsen. We're still working within the HMO to get that appointment, we'll see what happens. If the physical therapy doesn't work, the condition would likely require surgery - which has a very high success rate. Olympic fans may remember that Mary Decker had this exact surgery 6-weeks prior to winning the gold medal during events in the 1980's (?).

Regardless of the legal aspects, we finally found someone willing to actually listen and to take the time to try to figure out the cause of the problem. I still think this is just wrong. Why do we even pay an insurance premium if we can't use it? Who knows, maybe our HMO will take the outside diagnosis to heart and finally take some action, or maybe they'll stick to their guns??

[ellencee]

All you did was pay someone to tell you what you wanted to hear. Pick up a few medical journals or read some online and you will find that the RICE method is the preferred method of treating your wife's injury.

I'm glad you found someone willing to tell you what you wanted to hear and that you were willing to pay the cost. Now, if only someone would get your wife to a divorce lawyer before you kill her...
EC

[rmet4nzkx]

rtlink,
In less than three hours you suddenly come up with this convenient story?
Please, you didn't lead the doctor on? She sent him her list of symptoms ahead of time, influenced by all her running friends. These were not objective clinical findings. She got in early because someone cancelled. You are also in need of a psychiatrist more so than an attorney.

Inflamation increases all the symptoms you cited but is a part of the body's healing process and signals for the person to rest and let the body heal it's self. Ice reduces inflamation and increases comfort but is not used constantly to allow the healing process to continue. Your wife needs to heal before she begins to re injur herself, there is a big difference between maintaining ROM and strengthing exercise. Your wife can obtain as much health benefit from any number of fitness routines, walking and or swimming without the damage that occurs from running. Surgery is not the answer.

[panzertanker]

Originally Posted by rtlink

The doctor diagnosed my wife with deep posterior compartment syndrome, as we had suspected (by the way, we did not "lead" the doctor to this conclusion in any way). This explains why the pain progressed to the knees and why she has had numbness in her legs. With compartment syndrome, pressure gradually builds up in the leg muscle causing pain. In my wife's case the pressure hasn't released naturally due to some tears in the muscle. The pressure caused her to change her gate, causing ITB syndrome (her knee pain), along with cutting off blood flow to her lower legs (and hence the numbness). Her condition is rather serious given the lack of blood flow to her feet. If untreated, there are cases where people have lost their lower legs as a result of the lack of circulation.

The recommended treatment is physical therapy, orthodics, and strength training. Rest doesn't improve the ailment. Ice, administered with a wrap, was the worst thing because it only increased the pressure due to the compression. As we suspected, she was misdiagnosed initially.

Um.....If I may interject....

Here you go, you and your wife DO NOT LISTEN.

[url]http://www.postgradmed.com/issues/1999/03_99/swain.htm[/url]

Acute compartment syndrome requires emergency fasciotomy due to the constriction of the arteries and veins from the swelling. It is almost always caused by a traumatic blow.
Chronic compartment syndrome happens from the long term re-injury of a less acute original injury. The pressure SLOWLY builds up, and eventually CAN require fasciotomy for symptomatic relief.

The recommended care for a sub-acute injury that MAY cause a compartment syndrome is:
RICE.

READ.

LEARN.

You wasted ALOT of money going out of network and looking for a way to blame your HMO for YOUR ignorance...
pity.

[rtlink]

Wow, what’s with all the animosity?

Panzertanker, please stop YELLING.

Rmet4nzkx, thanks for the advice provided. But, why accuse me of making things up…what’s my incentive to lie. I don’t know you and certainly don’t feel the need to make things up and share them with you.

Ellencee, you did offer a few nuggets of advice…for that thank you. As for alluding to the break up of my marriage – unnecessary. And, I’m not sure what the reference to “you people” means, but that was unnecessary as well. You don’t know who I am and have interacted with me only after reading an abbreviated version of my story on an advice forum. Please stop passing judgment.

Purple2, thanks providing advice without moving into accusations and personal attacks.

I only came onto this forum because my wife and I were both getting frustrated and felt we were not being treated fairly. The idea was to seek advice and to find out if anyone else had encountered a similar situation who was willing to share there story with me. We’re not gold diggers, we’re not trying to scheme to find a way to get money out of our HMO, we’re very simply trying to get the care we feel we deserve.

I’m not getting anything out of this, so this is the last you will hear from me.

[rmet4nzkx]

Originally Posted by rtlink

Wow, what’s with all the animosity?

Panzertanker, please stop YELLING.

Rmet4nzkx, thanks for the advice provided. But, why accuse me of making things up…what’s my incentive to lie. I don’t know you and certainly don’t feel the need to make things up and share them with you.

Ellencee, you did offer a few nuggets of advice…for that thank you. As for alluding to the break up of my marriage – unnecessary. And, I’m not sure what the reference to “you people” means, but that was unnecessary as well. You don’t know who I am and have interacted with me only after reading an abbreviated version of my story on an advice forum. Please stop passing judgment.

Purple2, thanks providing advice without moving into accusations and personal attacks.

I only came onto this forum because my wife and I were both getting frustrated and felt we were not being treated fairly. The idea was to seek advice and to find out if anyone else had encountered a similar situation who was willing to share there story with me. We’re not gold diggers, we’re not trying to scheme to find a way to get money out of our HMO, we’re very simply trying to get the care we feel we deserve.

I’m not getting anything out of this, so this is the last you will hear from me.

I didn't say you lied per se, but that your story raises questions because of it's convenient timeing. You are missing all the points eveyone was making and your wife is the one who will pay the price for your arrogance.

YOUR WIFE RECEIVED APPROPRIATE CARE. INJURIES TAKE A LONG TIME TO HEAL. IN THE FUTURE SHE SHOULD CONSIDER SOMETHING OTHER THAN RUNNING FOR EXERCIZE. YES I AM SHOUTING BECAUSE YOU DON'T APPEAR TO HEAR!!!!!

[panzertanker]

Originally Posted by rtlink

Wow, what’s with all the animosity?

Panzertanker, please stop YELLING.

Rmet4nzkx, thanks for the advice provided. But, why accuse me of making things up…what’s my incentive to lie. I don’t know you and certainly don’t feel the need to make things up and share them with you.

Ellencee, you did offer a few nuggets of advice…for that thank you. As for alluding to the break up of my marriage – unnecessary. And, I’m not sure what the reference to “you people” means, but that was unnecessary as well. You don’t know who I am and have interacted with me only after reading an abbreviated version of my story on an advice forum. Please stop passing judgment.

Purple2, thanks providing advice without moving into accusations and personal attacks.

I only came onto this forum because my wife and I were both getting frustrated and felt we were not being treated fairly. The idea was to seek advice and to find out if anyone else had encountered a similar situation who was willing to share there story with me. We’re not gold diggers, we’re not trying to scheme to find a way to get money out of our HMO, we’re very simply trying to get the care we feel we deserve.

I’m not getting anything out of this, so this is the last you will hear from me.

Actually, I did not yell, I EMPHASIZED.

Learn the difference....
rmet, now she was yelling!
lol