Sequela

Plural sequelae

\-?kwe-(?)l?\

  1. An aftereffect of a disease, condition, or injury
  2. A secondary result

As defined in the Merriam-Webster dictionary

As I sit here at home waiting to learn when I’ll finally have my physical therapy (PT) appointment, I wondered how many other injured workers’ suffer from sequela/ae due to the foot dragging, oops I mean the review process, that’s used so very often by the Workers’ Compensation (W/C) claims adjuster to verify that the treatment recommended by the injured worker’s treating physician is “reasonable”.

On November 14, 2016 my physician submitted the form PR-2, aka Primary Treating Physician’s Progress Report, followed on November 28, 2016 a formal request for authorization to my claims adjuster (Ms. CA). So before Ms. CA could give my physician the green light off to utilization review (UR) it went and after a couple of back and forth UR approved albeit it was a “modified” approval but my physician’s PT request was authorized. Yet here I sit more than one month later still waiting to begin my PT. Why? You may ask, all because Ms. CA has yet to respond to my physician to approve the actual physical therapist facility/person. So without her green light, here I sit waiting in pain.

Under a traditional healthcare plan there’s usually a 5 to 7 day window for the plan to approve a referral, and the member then receives a referral letter that either shows the referral is approved with the name of the specialist or therapist to call. If the referral is declined the member can appeal and again there is a set period of time for which this must occur. Unfortunately, with W/C this is very often not the case with the treating physician being required by the claims adjuster through the use of UR to “justify” that the injured worker is indeed in need of the specialized care, treatment or tests. Should UR approve the request then the treating physician can refer the patient, but the claims adjuster can throw a monkey wrench in things if the specialist or request treatment still requires approval from the claims adjuster for the injured worker to see the specialist.

When this kind of foot dragging occurs the only recourse is to go back to the W/C “court” and seek the intervention of an administrative law judge. Even when the attorney makes this request for a hearing the injured worker can expect to wait 30 days or months for a hearing date. In the meantime the injured worker’s injury is left to endure an extended period of time without appropriate treatment for their injury. Meanwhile if that injured worker had been treated through the traditional medical track one can reasonably conclude that the injured person would’ve received treatment more quickly and thus be at a lesser risk of suffering additional sequela/ae.

I think that much of this waiting and foot-dragging is directly related to the adversarial system that has become rooted in our W/C system. It would appear that many employers in order to “manage the claim” come to see the injured worker as someone who is out to take advantage of the system, and while this may be true in a small number of cases it’s not so for the majority of the cases. The majority of injured workers simply wish to get back to pre-injury condition (as much as is medically possible) and back to work. But when the injured worker and treating physician have to plead and fight for treatment and then wait for the W/C courts to sort it out essential progress in healing is delayed and to some great extent denied. What I find outrageous is that even when there’s a court order that supports the injured worker the employer, through the claims adjuster, can decide to simply ignore it; leaving the injured worker with no recourse but to go back to court waiting again sometimes for months for another hearing, which stretches things out even more. And around and around it goes when it’ll stop nobody knows.

When I suffered my work-related injury being represented by an attorney was the furthest thing from my mind that is until I felt that Adventist Health (that religious hospital/healthcare corporation) was “messing” with my care.

After my fall on the wet floor of the restroom at the hospital I was sent to our employer’s workers’ compensation clinic/physician for care. While I was somewhat underwhelmed by the physician’s level of knowledge he seemed attentive and taking the appropriate steps to evaluate and treat my numerous injuries. The problem arose several weeks later when I found myself unable to place any weight on my right leg. While I had injured this leg in my fall the physician found primarily soft tissue/strain-like injuries, so I couldn’t understand why I couldn’t bear weight on my right leg. Stumped, I returned to the clinic for re-evaluation and surprise, surprise, I had a fracture that the physician had overlooked.

The physician ordered a cast walker, better known as a moonboot. Unfortunately, he didn’t have one he could fit me with so it was up to me to call around and find a store where I could purchase one. I was expected to pay for it out-of-pocket for which Adventist Health (that religious hospital/healthcare corporation) would reimburse me, which they eventually did thanks to a very professional and compassionate employee in Human Resources at Glendale Adventist Medical Center (GAMC). However, you’d think that a health organization would have such materials on hand or have a relationship with vendors/suppliers that could get them what they needed them stat – but I guess not.

So with the moonboot found and fitted I prepared myself to “wait-out” the almost six weeks that the physician estimated it would take to ensure full healing. In the meantime I began a series of physician visits to treat my other assorted injuries, including consulting with an orthopedic surgeon to fix the torn meniscus in my left knee, another injury that was the result of the same workplace accident. During one of my orthopedic appointments the surgeon agreed that I was a good candidate for surgery and we discussed the surgical plans. It was at this point that I asked him that if I had surgery immediately and considering that my right leg was currently in a moonboot this would leave me confined to my bed if I had surgery before my moonboot was removed. The orthopedic surgeon thought about this for about a minute and asked when the moonboot was to be removed and I replied in two more weeks. After some additional discussion he decided that since I was a diabetic we should wait until my moonboot was removed so I’d have at least “one good” leg to get around on while recuperating from left knee surgery. Since being confined to a bed for two or more weeks was not sound medicine for a diabetic such as myself and could lead to more dire consequences. I left his office that day not only with a treatment plan, but an appointment two weeks out for surgery. Everything was set, or so I thought.

Shortly before my surgery date I received a letter from the Adventist Health (that religious hospital/healthcare corporation) claims adjuster, Mr. CA, informing me that since I had refused surgery I had been deem “permanent and stable”. This designation would also affect my workers’ compensation payments and I would now be receiving permanent disability (PD) since I was no longer eligible for total temporary disability (TTD). Shocked by this change I contacted Mr. CA (I could do this since I had no attorney at that time) and asked him about the status change, since when I left the surgeon’s office two weeks earlier I was deemed TTD. Mr. CA went on to explained that he had contacted the surgeon and asked him to review his opinion, which the surgeon did and it was decided that I was now PD. I explained to Mr. CA that, at least in California, a physician cannot change a medical diagnosis of a patient without reexamining that patient which, hadn’t occurred in my case and any way I had a surgery date set and would be having surgery shortly, so how could I have refused surgery?

It was at that time the Mr. CA would utter those fatal words “we do it all the time”. I asked him to hold on for a moment so I could get my daughter in the room to listen to our conversation on the speakerphone. Once there I asked him to repeat his response to my question of the legality of having a physician changing a medical diagnosis without reexamining the patient, and Mr. CA repeated once again “we do it all the time”.

It was at that time that I knew I would need an attorney to sort this situation all out, and the search for a shark began.

More to follow. . .

Let’s talk about pain

A while back I published several articles on pain and opioid use.  I wrote these article to shed light on the other side of the pain and opioid use debate that seemed to me to be very one-sided.  And while opioid abuse has undoubtedly destroyed many lives, what concerned me most was the focus on opioid abuse without equal time being given to the estimate 25.3 million Americans suffering from chronic pain (8/11/15 NIH press release).

That said you can find my articles on the issue here

Nov. 2011 – Working Nurse Magazine – Chronic Pain: What nurses don’t know about pain management WNM Chronic Pain1 copy

Sept. 2012 – Working Nurse Magazine – The Great Opioid Debate: Balancing the need for pain management with the potential for abuse — WNM The Great Opioid Debate1 copy

May – Apr. 2014 – Working Nurse Magazine — The Opioid “Epidemic”: Why we need to dial back the sensationalism and find common-sense solutions — WNM Opioid Epidemic1 copy

The other day I read an interesting post written by Dr. Kathleen Kozak a physician from Hawaii who has a column in Honolulu Civil Beat. Her column, which can be read here bolstered my own personal theory that has been germinating for quite some time now. I’ve often wondered over the past many years if we looked objectively at both care models, Workers’ Compensation and the private, which model would have the injured worker back to pre-injury condition (or at least as close to it as possible) faster? Based on my own experience (both nursing and personal) I think we’d find that an injured person would “recuperate” more quickly if provided care through their private insurance.

I think this story from Hawaii illustrates the problem quite well. Reading about Bonnie Chan’s struggle to get appropriate care for her work-related injury struck a chord with me, especially in her fight to get timely care. When I underwent ankle bone graft and partial fusion/surgery, I suffered an unexpected outcome and consequently developed Complex regional pain syndrome (CRPS) and though my orthopedic surgeon made numerous requests for physical therapy, which by the way is one of the treatment of choice for CRPS his request were continually denied. At least one of the reasons given was that I had already had the maximum number of physical therapy allowed by our state’s WC regulations. While I had had physical therapy, it was ordered for my elbow as part of my recovery post-surgery elbow surgery. To this health professional it makes little sense that the physical therapy ordered for my ankle would be denied because I had “used” up my allotted physical therapy on my elbow. One would think that if physical therapy is the treatment of choice then that should supersede some arbitrarily set limit.

But then again we are talking about WC, a bureaucratic, governmental system that by definition is not always known for being logical. All thanks to the self-insured Adventist Health (that religious hospital/healthcare corporation).

More to follow. .

Eureka! I think I figured out how employers or at least my former employer, Adventist Health (that religious hospital/healthcare corporation), saves money on the treatment of my work-related injury – they pawn it off on my private insurance. I think it’s the Workers’ Compensation (WC) version of a patient dumping scheme.

Over the past several years, through the use of utilization review and the claims adjuster simply ignoring the pleas of my WC physician they, Adventist Health (that religious hospital/healthcare corporation), have managed to pawn of the cost of nearly a year and a half of medications and numerous labs and medical exams onto my private insurance. This is a version similar to the patient dumping that numerous hospitals in the Los Angeles area have been accused of doing. On 2014, Glendale Adventist Medical Center (my former employer and where I suffered my work-related injuries) paid out $700,000 in settlements from patient dumping claims stemming back several years.

So here’s how, I think the WC patient dumping scheme works. They simply stop providing care, hiding behind utilization review (UR), even though the injured worker hasn’t been returned to pre-injury condition and may still be living with debilitating pain. Or because the process of getting care takes so long the injured worker then suffers additional injury/sequelae from the initial injury and from the failure of the employer to address the work-related injury in a timely manner. Then if the patient is provided care or finds a way to pay for the care/medications the employer sees this as an “out” for them from providing additional care, and each time the injured worker finds a way to pay for care for their work-related injury the employer see this as a “savings” and the process continues with the employer using UR to continue to deny any care or medication requested until the injured worker learns that the only way they’ll receive much needed care for their work-related injury is pay for it out-of-pocket and/or with their private insurance.

I find it interesting that UR review will deny let’s say pain medication for a work-related injury being handled through WC, but your private physician and insurance will cover the same pain medication. How is it that the private insurance company that everyone rails against seems to believe that its medically necessary and acceptable, but your WC claims adjuster and their UR agent comes to a different conclusion?

I guess its because your private physician really believes in his/her Hippocratic Oath. Meanwhile the WC claims adjuster has no such oath and the UR agent is someone who will never see you, the injured worker, and maybe hasn’t seen a patient in years. He/she just scans “the literature” so he/she can find a way to deny or at least reduce the care the injured worker receives all in the name of saving a buck at the expense of the injured worker – sounds like a patient dumping scheme to me!

More to follow . . .

As I ended in my last post, I left my internal medicine consult with the need to get a cardiac clearance before I could be cleared for right shoulder surgery. Once again, Adventist Health (that religious hospital/healthcare corporation) left it to me, the injured worker, to make all the necessary arrangements to secure the needed cardiac clearance.

Normally, this is something that’s paid for by the employer; but, oh no not in my case since it would appear that Adventist Health (that religious hospital/healthcare corporation) had decided to simply abandon their responsibility and pawn it off on my private insurance and personal physician. Or perhaps Adventist Health (that religious hospital/healthcare corporation) decided that if they refused to pay for the necessary medical clearances and thus delaying this surgery long enough as they did with my spinal stimulator permanent implantation that I’d give up on my right shoulder surgery, as well. You see after Adventist Health (that religious hospital/healthcare corporation) delayed for almost a total of two years the approval of the spinal stimulator surgery I agreed to forgo the spinal stimulator surgery all together if Adventist Health (that religious hospital/healthcare corporation) agreed to approve my right shoulder surgery. I suggested this since the medical literature showed that the effectiveness of a spinal stimulator lessened with time; and by agreeing to forgo this surgery I saved Adventist Health (that religious hospital/healthcare corporation) at least $100,000 or even more in associated care.

So, while I thought I was being reasonable I would latter learn from the attorney representing Adventist Health (that religious hospital/healthcare corporation) that he believed my cardiac issue was my own fault for having waited “so long” after my last surgical clearance. I guess he was unaware that like many things in life a surgical clearance has a “life expectancy”, and the generally medical acceptable practice is that a surgical clearance has a life span and that span is dependent on the surgeon and hospital. So the likelihood of a competent and ethical surgeon accepting a surgical clearance that was approximately 2 years old was almost nil and as such I had to start the surgical clearance process all over again.

Once again with no help from Adventist Health (that religious hospital/healthcare corporation), but with expert help from my private insurance and personal physician they referred me to a cardiologist four days after seeing the internal medicine physician. Unfortunately, Adventist Health (that religious hospital/healthcare corporation) was displeased at the pace set by my cardiologist and filed to have me removed from total temporary disability to permanent and stable – their logic seemed to be that I was refusing surgery – the very surgery I couldn’t undergo until I was cleared to have – I guess that’s the logic Adventist Health (that religious hospital/healthcare corporation) uses to save themselves some greenbacks.

More to follow . . .

As you all may know; and in case you didn’t; clearances (not the kind you get at Nordie’s) but the medical kind are as much a part of the surgical process as are the nurses, surgeons and anesthesiologist. So in short you can’t have one without the other, at least for the planned surgical procedures, trauma and emergency situations are another matter entirely. So to deny access to medical clearances is to deny a patient the ability to proceed more safely with surgery.

So with no help or support from Adventist Health (you know that religious, hospital/healthcare corporation); but thanks to my private insurance, patient advocate and doctor, I was able to keep my hematology appointment and ultimately my hematology clearance.

I dutifully submitted a copy of my clearance to my surgeon so he could schedule the internal medicine clearance necessary for my right shoulder surgery. Twelve days after getting the green light from my hematologist my surgeon’s office scheduled my internal medicine clearance. I attended the scheduled February 22, 2016 appointment with the expectation that I would leave with the necessary and mandatory medical “go-ahead” required to schedule my surgery – but that wouldn’t be the case. At that appointment the physician discovered that I had a left branch bundle block, something that would require a cardiology clearance before internal medicine would sign off on the surgery.

Now you’d think that Adventist Health (you know that religious, hospital/healthcare corporation) would take the lead on getting this clearly critical clearance scheduled so their injured worker could get the care they’d need – but again you’d be wrong.

More to follow. . .

Mission and value statements can be very helpful in defining what drives corporate culture, but they can also shed a light on a corporation’s weaknesses. While gathering information on Adventist Health I stumbled on their corporate website (https://www.adventisthealth.org/pages/about-us/mission-vision-and-values.aspx).

After reading their published values I found I couldn’t help but adding my “two cents” to reflect my personal experiences as they relate to Adventist Health values and my journey as an injured worker covered thorough their workers’ compensation insurance – they are self-insured. What follows is taken directly from their website:

Our Values

At Adventist Health, we value:

  • Compassion- The compassionate, healing ministry of Jesus – NOT!
  • Respect- Human dignity and individuality – NOT!
  • Integrity- Absolute integrity in all relationships and dealings – NOT! NOT! NOT!
  • Quality- Excellence in clinical and service quality – NOT!
  • Stewardship- Responsible resource management in serving our communities – NOT!
  • Wholeness- The health care heritage of the Seventh-day Adventist Church – NOT! NOT!
  • Family- Each other as members of a caring family  – NOT! NOT!

You’d think that Adventist Health, you know that religious, hospital/healthcare corporation would do everything in their power to ensure that their employees who suffered a work-related injury would get care in a timely fashion. Unfortunately, that’s not been my experience, especially with what should’ve been my final surgery.

As I posted yesterday, I suffered a full respiratory/cardiac arrest just as the anesthesiologist gave me a nerve block. More than four months later, I’m still waiting for the follow-up care required after such a life-threatening event; but this delay shouldn’t come as a surprise since Adventist Health did nothing to get the medical clearances needed for my shoulder surgery.

After having to go to court to get the Adventist Health to approve my right shoulder surgery, I discovered that Ms. CA decided that before giving the surgeon the go ahead she had to run it by utilization review (UR), in case UR paper-pushers could find a “way-out” of having to provide the very surgery that Adventist Health had agreed in court to provide, I guess. UR, however, green lighted the surgery, including the hematology consult requested by the surgeon. So after this unseen delay, it fell to my daughter and I to make all the necessary appointments to get the requisite medical clearances.

Medical clearances are part in parcel prior to surgery and this is a generally accepted medical practice and standard of care Ah, but not so with Adventist Health. After scheduling the same hematologist that Adventist Health had used for an earlier clearance, I learned one day before my appointment that Ms. CA had denied the clearance. Not only did she deny the approval she told the hematologist’s assistant that my right shoulders wasn’t part of my Workers’ Compensation claim. So with the clock ticking and thanks to the help of Keck-USC where the hematologist practiced we were able to get my private healthcare insurance to cover the consult. Of course the whole point behind Workers’ Compensation is that your employer’s workers’ compensation insurance pays for all the care, direct and related, of the injured worker. Perhaps this isn’t the case with Adventist Health?

To be continued . . .

You’d think that if you surfer a life threatening emergency while undergoing a surgical procedure you’d think that your employer’s Workers’ Compensation insurer carrier wouldn’t question your surgeon’s medical decision – but that didn’t happen in my life-threatening moment. Here’s what happened.

After several years of going back and forth with Adventist Health (who’s self-insured) to get them to approve surgery on my right shoulder I finally got the green light. This process had been very contentious and time consuming, but on August 17th, I arrived at the “hospital” to have my surgery. All was going along as planned until just after the anesthesiologist performed a nerve block. I almost immediately began to experience problems breathing and informed the operating team that I was having severe chest pains and couldn’t breathe. And as they say “all hell broke loose”. I remember the anesthesiologist screaming “I need help over here” and I asked God to please let me live.

I awoke sometime later in the ICU, hooked up to a BPAP and other various monitors and medical personnel. It was then that I learned that not only had I suffered respiratory arrest but a cardiac arrest as well – in short I “died” on the table. After a little more than a day in the ICU, I was discharged home. Not long afterwards I received a letter from Excel Utilization Review (UR), the UR company that my Adventist Health claims adjuster, who shall remain “nameless to protect the guilty” so I’ll just call her Ms. CA. Apparently she thought that my surgeon’s decision to have me admitted to ICU after such a serious medical event required a review and approval of Excel, you know just in case it was an inappropriate and costly decision to admit a patient who’d suffered a full respiratory and cardiac event to ICU. Yeah, you read that right, Adventist Health, a hospital/healthcare corporation, was unsure that my surgeon had made a medically sound and financially correct decision!

Excel denied my admission to ICU! However, in their defense one of the reasons was the failure of my surgeon to send them “appropriate” information, but as a medical professional myself I was rather incredulous that they (Adventist Health and Excel) even questioned the need to admit a patient to ICU – most surgeons don’t just do this on a whim. But this is Workers’ Compensation after all so logic goes out the window and often doesn’t seem to apply.

Sometime later I received another letter from Excel that approved my ICU stay – whew! The irony was that Excel actually commented that the average ICU stays in a case such as mine was just less than 5 days, while I stayed just over 1 day. So while Ms. CA thought my stay was possibly inappropriate and costing Adventist Health unnecessary money that turned out not to be the case.

In the meantime, Ms. CA refused to return me to “total temporary disability” (TTD) status as order by my surgeon and have taken no action to discover what might have happened to cause this serious medical event.

Stay tunned for more . . . .