Tag Archives: Surgery

Number 400

Richard’s Note: The following post was taken from an article posted by Michelle Chaffee a few days ago on LinkedIn. I am re-posting it here so that you can chew on it while you are having your holiday dinner. While you are eating and having a good time with family and friends, look around the table and imagine if one of them was in the same situation Michelle was in. How would you answer the question she poses? And think about this carefully, now that the GOP tax bill has passed and 13 million Americans will lose their healthcare, and millions of children will lose theirs. Then tell me that health care is an entitlement.

Is Healthcare a Right or an Entitlement?

Published on December 12, 2017

Michelle Chaffee

Some of you who have followed my posts over the past few years know that I am a cancer survivor. It’s been almost two years since I was very unexpectedly diagnosed with ovarian cancer. I have shared some of what it’s been like to suddenly find myself in the position of being a patient after spending a career caring for people who are sick, believing I wouldn’t find myself on the other side of this equation. I still struggle with the reality that I have had cancer and that I will have to monitor for it rearing it’s ugly head, for the rest of my life. What I haven’t shared is how the costs of healthcare contributed to my situation, delayed diagnosis and increased my chance for a recurrence. I am sharing it now because as I continue on this journey, I am starting to think the current system is discriminatory and I know it needs to change.

When I was diagnosed with ovarian cancer, I hadn’t been to my doctor for my yearly recommended examination for about 20 months. When I called to make my yearly appointment, I was told I had an outstanding bill I had been unaware of because I had moved and they didn’t have my new address. The bill was a result of “coinsurance” that was from a necessary and fairly routine procedure, still it was substantial enough that I had to set up payments over time because I couldn’t afford to pay it in full. I was told I could not see my doctor until there was a zero balance. I felt fine and had no concerns of any illness so I skipped my routine exam that year. Fast forward almost 2 years later when an unusually potent migraine resulted in a suggestion by my neurologist that I get my hormone levels checked. I contacted a new gynecology group because I couldn’t be seen by my regular ob/gyn because of the balance that still remained. On this routine exam, a very large mass was found on my ovary. So large that even though I was assured it was benign, it needed to be removed. During the surgery, the mass ruptured but the doctor told me not to worry because “It’s not cancer.” She told me the rupture was because it was so large that it made it difficult to remove. She called me about a week later to tell me it was in fact, cancer and the rupture, unfortunately complicated the staging and made recurrence more likely. The fact is, if I had gone to my regular appointment, it would have been discovered when it was much smaller and may not have ruptured. I am not blaming the doctor or the organization where I received care but, it wasn’t discovered because I owed the clinic money and they wouldn’t see me until the bill was paid. I don’t let myself think about that too much, but it’s the truth and it’s the way healthcare works in our current system.

The cost of just the surgery to remove the cancer was over $250,000. This included just one night in the hospital and no chemotherapy or radiation treatment. I had a good insurance plan but even with that, my responsibility was over $30,000. I can safely say most Americans would find it a challenge to add that expense to their yearly budget. The ongoing costs of testing for a possible recurrence are approximately $20,000 every year. That is on top of the nearly $10,000 I pay in premiums each year because I am self employed. I can’t afford this so I stretch out the time between scans and labs further than my doctor recommends.

In the back of my mind I know this could mean I don’t detect something as soon as I should again and that it can literally mean the difference between life or death.

I also know that if I owe a balance again at the hospital where I get my testing, they can refuse to treat me and I have been down that road before.

So as I write this, I find myself waiting again to find out if something discovered on a diagnostic test done almost 9 months after the doctor ordered it, is something that could take my life. Not only that, I brace myself for the cost of repeated imaging, biopsies and what may follow and I am angry, frustrated and of course, afraid. I know I am not alone and for many, it has been worse. I have worked in healthcare long enough to remember when people were denied insurance coverage because they had an illness like cancer or diabetes or a heart defect. I heard the desperation of new mothers who were grateful their precious newborn had received life saving heart surgery but had already reached their life time insurance maximum and had no idea how they would pay for the ongoing care their child needed to stay alive. The Affordable Care Act changed some of that, at least we aren’t denied coverage but it costs too much and patients can still be denied care if they owe a system money. So we constantly pray we don’t get sick again and try to find the right balance between what we can afford and what will keep us alive.

For those of you out there who say “Healthcare isn’t a right,” I tell you to save your breath unless you have faced a condition that could take your life or the life of someone you love.

To those of you who say patients should forego a smartphone or daily “fancy” coffee drink in order to pay for healthcare I say, what fantasy world do you live in where eliminating those things would make even a miniscule dent in the healthcare costs millions face?

You can also put aside the delusion that someone is sick because they did something wrong. I hate to break it to you but just because you exercise, eat healthy or have no family history of disease doesn’t mean you are magically immune to a life changing diagnosis. It can happen to anyone and I am walking proof of that reality. I ate right, exercised, never smoked, have no family history of cancer and like millions of others in this country I got sick anyway.
I find it especially ironic as I travel to other nations and collaborate with healthcare leaders to improve delivery of care to their citizens that I, a struggle to access the care I need in the United States of America. So I pose the following to ponder:

Should we get the same rights as prisoners?

Shouldn’t we at least get the same rights that criminals in this country get? The supreme court has held that those under government control must have “ Adequate food, clothing, shelter, and medical care as a component of the protections accorded by the Eighth Amendment and that “Deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain,’… proscribed by the Eighth amendment,” equating this pain with cruel and unusual punishment. Does “Cruel and unusual punishment” only apply to prisoners? It seems pretty cruel to make law abiding citizens suffer because they can’t afford medicine or treatment or to force them to choose between food or medical care.

Are we discriminated against if we are sick?

It used to be that healthcare provided through programs like Medicare, Medicaid and CHIP seemed sufficient to mitigate an accusation that there was discrimination based on a citizen’s ability to pay for adequate healthcare. Unfortunately, over time there has been an increasing group of Americans that don’t meet the criteria to receive these supplementary services but also can’t afford the cost of the healthcare available to them. I don’t consider myself poor but I can’t afford $30,000 a year or more for basic healthcare. Do I have the same rights to life and general welfare as anyone else? If treatment to save my life is available, should I be denied it because I don’t have the ability to pay? Did the founders of our country mean to make good health only available to the wealthy? It isn’t just what used to be considered the poor or elderly who can’t afford basic healthcare or medication anymore. Hard working people who have made contributions to their communities and are necessary to our countries security and growth can’t afford necessary care. This is a problem for all of us.

Where do we draw the line?

For those of you who continually argue that the government doesn’t pay for our car insurance or life insurance I will explain the difference. Driving a car isn’t necessary for survival, neither is providing an inheritance for your heirs. These things aren’t the same as access to professional healthcare services that prevent you from dying. Suggesting these things as examples of why healthcare isn’t a right, is a faulty argument and insulting to anyone who is sick. Our founding fathers and leaders were concerned for the health and welfare of our citizens. Franklin D. Roosevelt even tried to enact a “Second bill of rights” that included access to adequate medical care and the opportunity to enjoy good health. They couldn’t have imagined how costly healthcare would become as the model ushered in with the advent of health insurance, has progressed and costs have skyrocketed. I am not even insisting the government cover the cost. Even making it affordable, meaning something I can pay for that doesn’t consume my entire grocery budget for a year is a good place to start. At the very least, insuring people with truly life threatening disease have an opportunity to take advantage of the treatment we can provide seems reasonable to me and maybe it’s time to make it an undeniable right of every American.


“Florida, We Have a Problem”

Tuesday, Judge David Langham, Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims and Division of Administrative Hearings, wrote a rather lengthy post about the differences between cost-shifting and case-shifting in workers’ comp.

Much of what the Judge wrote were subjects that I already discussed in a number of previous posts about cost-shifting and case-shifting, so I won’t go into it here. I am only focusing on the parts that relate to Florida workers’ comp. You can read the entire article yourselves.

But what caught my attention was what he said about Florida and what the Workers’ Compensation Research Institute (WCRI) reported in some of their studies on these issues.

As Judge Langham wrote this week, he wrote a post two years ago that asked the question “Why Does Surgery Cost Double in Workers’ Compensation?”

Judge Langham noted in that post that Florida employers have been documented paying almost double for shoulder or knee surgery that is paid for under workers’ compensation, compared to group health costs.

The implication of case-shifting in Florida, he says, could arguably be a doubling of cost.

He cited a WCRI report released earlier this year that suggests however that case-shifting is perhaps not as likely in Florida.

According to the report, Judge Langham continues, “as of July 2011, six states had workers’ comp medical fee schedules with rates within 15% of Medicare rates. They were California, Massachusetts, Florida, North Carolina, New York and Hawaii.”

However, Judge Langham pointed out that the WCRI concluded that case-shifting is more likely in states where the workers’ compensation fee schedule is 20% or more above the group health rates, and not in Florida.

Judge Langham stated that this analysis of workers’ compensation fee schedules does not appear to include analysis of the reimbursement rates for hospitals, and that It also seems contradictory to the assertions that Florida workers’ compensation costs for various surgeries have been documented as roughly double the group health rates (100% higher, not 15% higher).

Injured workers who missed work in the Florida workers’ compensation system could be compensated in 2016 at a rate as high as $862.51 per week, the “maximum compensation rate.”

So, if recovery from such a “soft-tissue” injury required ten weeks off-work, he wrote, the case-shifting to workers’ compensation might add another four to nine thousand dollars to the already doubled cost of surgical repair under workers’ compensation.

This could be directly borne by the employer if the employer is self-insured for workers’ compensation; or, if the employer has purchased workers’ compensation insurance, the effect on the employer would be indirect in the form of potentially increased premium costs for workers’ compensation following such events and payments, Judge Langham states.

According to WCRI, the Judge quotes, “policymakers have always focused on the impact (workers’ compensation) fee schedules have on access to care as well as utilization of services.

This has been a two-part analysis, he says:

First, fee schedules have to be sufficient such that physicians are willing to provide care in the workers’ compensation system; and second, the reimbursement cannot be too high, or perhaps overutilization is encouraged.

Lastly, Judge Langham points out that the disparity between costs has also been noted in discussions of “medical tourism.”

The last question he posits is this, “might medical decision makers direct care to more efficient providers, across town, across state lines?”

What about national borders?

I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Blog is now viewed all over the world in 250 countries and political entities. I have published nearly 300 articles, many of them re-published in newsletters and other blogs.

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Follow-up Visits After Surgery: Telehealth, Medical Travel and Workers’ Comp

One of the questions posed to me when I have discussed the idea of medical travel in workers’ comp is what to do with follow-up care.

In an article this week from Reuters, Andrew Seaman wrote that people may happily, and safely, forgo in-person doctors’ visits after surgery by opting instead for talking with their surgeons by phone or video. Seaman said this was the result of a small study of U.S. veterans.

The study, conducted by researchers in JAMA Surgery, said most patients preferred the virtual visits and that the doctors didn’t miss any infections that popped up after surgery.

Lead author Dr. Michael Vella, of Vanderbilt University Medical Center in Nashville said, “These kinds of methods are really important in the climate we’re in now,”…”So I think anything you can do to save money, see more patients and improve access to care is really important.”

Vella and his colleagues also wrote that there is interest in so-called telehealth to increase access to healthcare while also decreasing the costs associated with traveling to office visits.

Past research has found that telehealth visits may be useful in the treatment of chronic conditions and after surgery, but less is known about patients preferences for these types of visits, they added.

The study team evaluated data collected over several months in 2014 from 23 veterans, Seaman reported, and all but one of them were men, who were seen three times after a simple operation that would require only a night or so in the hospital. One visit was via video, the second was via telephone and the third was an in-person office visit.

The researchers found that no post-operation infections were missed during the video or telephone visits.

Dr. Vella said, “The veterans were very good at describing their wounds,” … “There was one patient who thought they were having problems, we brought them into clinic and there was an infection.”

Overall, the study found that 69 percent of the participants said they preferred a telehealth visit over the traditional in-office visit. Those who preferred the telehealth visit tended to live farther away from the hospital than those who would rather come into the office.

“I think (the study) challenges the paradigm that we need to see all patients back for visits,” Vella said.

Dr. Vella cautioned that the study was small, and they could not say that telehealth visits won’t miss problems. The study also cannot assess how telehealth visits would work for patients who have undergone more complex surgeries, according to Dr. Vella.

An alternative opinion was given by Dr. Sherry Wren, who was not involved in the new study, and also cautioned that not all patient preferences will align with the telehealth model.

“There will be patients who want to be seen, be reassured and want a doctor to check something out,” said Wren, a professor of surgery at the Palo Alto Veterans Affairs Health Care System in California.

Still, she said, many patients will like the option.

“There is a subset of patient that it’s not going to be appropriate for, but I think it’s a great alternative for the vast majority of patients.”

Dr. Vella said future research showing the results of the real-world implementation of telehealth will provide more information on its safety.

“I think it’s just really important that people continue to look at it,” he said.

What does this mean?

It means that when medical travel is ever implemented into workers comp, and that day grows ever closer, after a patient goes home to his/her country, they will still be able to get follow up care from the surgeon who performed the surgery, without having to fly back to the medical travel destination several times.

Will it work for everyone? Both Drs. Vella and Wren indicated that there are people who will not want it, and that there are subsets of patients that it will not be appropriate for, but overall they were both very positive about the future of telehealth visits after surgery.

If it worked for American veterans, it can certainly work for injured workers covered under workers’ comp, Veterans, especially those from our two ill-designed, ill-planned, and ill-conceived wars in Iraq and Afghanistan certainly have wounds more serious than most injured workers would suffer as a result of a work-related injury.

The only thing that stands in the way of introducing telehealth into workers’ comp, with or without medical travel, is what is between the ears of the leaders and “so-called” experts in the industry who have thus far gone and done the same things over and over again, and expect different results.

And you know what that is? Crazy, stupid, ridiculous, without any credibility, and without any traction in logic, which, I suspect is where the stuff between their ears are in.

Knee Surgery in Costa Rica — A Less Expensive Alternative


Richard’s Note: This is probably the last blog post I will write in 2013, so let me take this opportunity to wish all of my readers a very Happy Holiday, and a very Happy New Year. Let’s hope that 2014 will be a year in which medical tourism takes its rightful place as an alternative to high cost, low quality health care. One more thing, 2014 will be the centennial year of the beginning of the First World War, a war in which the leading nations of the world at that time, blundered into, and which ultimately led to an even greater disaster, the Second World War. As globalization brings us closer together, let us remember that one hundred years ago, much of the world was backward and underdeveloped, and being exploited by all major powers; yes, even the ‘good ole USA’, so my hope is that one day, travelling to another country for health care will be as commonplace as going to another city here at home.

Last week, I had a meeting with the C.E.O. of Costa Rica Med Connect, Russell Cuciak. Russell connected with me on LinkedIn in response to my last blog posting. As we are both in South Florida and live in Palm Beach County, we had the chance to talk by phone on a few occasions before arranging a meeting in his office in Boca Raton.

Russell told me that he has been sending patients to Costa Rica for about two years now, and has been very active in taking a hands-on approach towards his clients’ care, which was in evidence during our meeting when he called a former potential client who had weight loss surgery in Florida, instead of in Costa Rica. The client had lost a significant amount of weight from the surgery, but since Russell followed up with him even though the client did not seek his care in Costa Rica, it proved to me that Russell stands by those who come to him for his services, whether they use them or not.

His patients are sent to the CIMA Hospital in Escazú, or its more formal name, San Miguel de Escazú, the capital city of the canton of Escazú in the province of San José in Costa Rica. It is also the name of the district that includes the city, a subnational entity with 14,815 inhabitants. Escazú is 9 kilometers from the national capital of San Jose, which is in the center of the country between the Caribbean Sea and the Pacific Ocean.

Over the past couple of decades Escazú has become an expatriate enclave: several embassies have their residences located here, including the residence of the US Ambassador and the British Ambassador. The past few years have seen a significant influx of newly arrived foreigners from North America, South America and Europe. It is home to many bars and restaurants, especially those of the more chic (and expensive) variety. Rents and prices reflect this and Escazú is the most well-known upscale location in Costa Rica. Here, one can find English movie theaters and even a luxurious country club. There are also many fine restaurants and dining areas in this part of town, with an excellent nightlife. Banks, pharmacies, shops, grocery stores and even an 18-hole championship golf course can be found here, along with one of the biggest and most modern shopping malls in Central America, Multiplaza.

For those of you who have read my blog article, No Back Alleys Here: Medical Tourism Hospitals, Clinics and Networks in Latin America and the Caribbean, you will remember that CIMA — Centro Internacional de Medicina, was one of the hospitals I listed in Mexico, particularly the one in Chihuahua.

I asked Russell to give me a ballpark figure of what the cost of knee replacement surgery would be in Costa Rica, and he quoted me a figure of $13,000, which includes everything except the airfare and hotel. He told me that several of the resorts in the area cater to specific patients having surgery at CIMA, so that there is a resort for patients recovering from plastic surgery, a resort for patients recovering from orthopedic surgeries, etc. It was explained to me that these resorts allow his patients to be around other individuals like them so that they do not feel uncomfortable. One particular hotel, the Holiday Inn, which is next to the CIMA hospital, takes all patients, and has special medical rooms for them.

The cost for a room in some of these resorts are anywhere from $25 a night to $250 a night, so with the cost of surgery for a knee replacement of $13,000, adding the airfare and accommodation would add another $2,000 or $3,000 to the total cost, which when compared to costs in the US of the same procedure, could be double or triple that, depending on the hospital’s bill, the surgeon’s bill, the anesthesiologist’s bill, etc.

Russell told me that in 2012, 40,000 Americans went to Costa Rica for medical tourism. As I said in my No Back Alleys Here piece, Costa Rica is one of the “rising stars” of medical tourism, and Russell’s company is one of at least a half a dozen that I know of, if not more, that are capitalizing on those 40,000 medical tourists.

During our conversation, I discussed what I found in my research paper about the barriers to implementing medical tourism into workers’ compensation, and with medical tourism in general, was the issue of legal liability. Russell told me that he carries $1 million in liability insurance, and I gave him some names of insurance companies that provide medical tourism insurance that I found on my smartphone while talking to him.

I told him of my difficulty in getting the workers’ compensation industry interested in my idea for medical tourism, and he asked me why I thought that the insurance companies had not jumped on this. I told him that there are many people in medical tourism who are asking the same question, and the most logical answer was that it is not on their radar.

We spent more than an hour and a half talking inside and outside his office, and we hope to be able to drum up more interest for medical tourism with individuals, employers, and insurance companies, both in health care and in workers’ compensation.

As uncertainty with the ACA continues, and as the cost of health care keeps rising, despite the drop in health care spending, traveling to a medical tourism destination such as Costa Rica, will become a viable option not only for health care patients, but for workers’ compensation as well. HAPPY NEW YEAR!


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Surgical Shenanigans: How Workers’ Compensation is being ripped off


Now that I’ve cleared the air, and professed the faith of my conviction, I would like to get back to the subject at hand, which is implementing medical tourism into workers’ compensation. In my last post, I asked the following question:

Is there something different about patients who can afford to pay for medical treatment abroad or who have private health plans that do, from those who get injured on the job and have their treatment paid for by an employer or insurance carrier under workers’ comp?

In that same post, I also asked this question as well:

What difference is there if a person injures their hip or knee by engaging in some sort of physical activity outside of their employment, or if the person gets hurt on the job? Are the surgical procedures for these types of surgeries different for a working person than those for a middle-class or upper-middle-class person?

Well, according to a recent study just released by the Workers’ Compensation Research Institute (WCRI), and reported this week by WorkersCompensation.com, there is something different in what hospitals were paid for shoulder surgeries in workers’ compensation and what hospitals were paid by private or group health insurance for the very same surgeries.

The article, Hospitals Were Paid At Least $2,000 More For Common Surgeries For Injured Workers Than The Typical Patient, stated that in half of the study states, hospital outpatient payments for shoulder surgeries in workers’ compensation were at least $2,000 (or 43 %) higher than group health insurance.

The study, entitled Comparing Workers’ Compensation and Group Health Hospital Outpatient Payments, is the first, WorkersCompensation.com says, that compares hospital payments for the same surgical procedure when paid for by group health versus workers’ compensation.

According to Richard Victor, the executive director of the WCRI, “These are large differences in costs in many states. Policymakers looking to contain medical costs in these states may want to ask if the difference is necessary to induce hospital outpatient departments to treat injured workers”.

The WCRI study also found that workers’ compensation payments exceeded group health payments by the most in states where the price regulations were based on a percentage of the hospital’s charges, or had no price regulation.

The study compared outpatient payments made by workers’ compensation and group health insurers for treatment of common surgical cases in 16 large states, which represents 60% of the workers’ compensation benefits paid in the US, and covers outpatient services delivered in 2008.

So apparently, there is a difference between workers’ compensation and group health insurance after all. The only problem is it does not have to do with the treatment received by patients covered under each type of insurance, but rather on how much workers’ compensation carriers paid hospitals for outpatient surgeries. Silly me, all this time I thought it had to do with the type of patient, now I see it has to do with the kind of insurance he is covered under.

So now, my question to the workers’ compensation industry is this:

How long are you going to put up with overpaying for the same surgical procedure for your workers’ compensation claimants, than what group health insurance pays for its patients for the same procedure under their plans?

And my question to the medical tourism industry is this:

If you claim that medical tourism destination hospitals offer lower cost health care than what is available in the US, then why are you not actively pursuing the workers’ compensation market, instead of just pursuing the private or group health care market? Do breast augmentations/reductions, plastic surgery and other common medical tourism procedures make more profit than that of the US workers’ compensation industry, or is it a lack of vision thing?

Do I have to spell it out every time I write an article? The American health care system (and that includes workers’ compensation) is too expensive. Yes, I know there are regulatory differences between health care and workers’ compensation. Yes, I know that in certain cases, there may be different processes involved with the same type of surgery for different patients. And yes, I realize that there are risk and complications; but really, what difference does it make if the patient was injured on the job and needs shoulder surgery, or if the patient was a weekend warrior playing hoops, football, baseball, or a myriad other sports and activities and needs  the same type of surgery? Not much.

The only difference is who pays, and how much, and based on this latest study, it seems the workers’ compensation industry is being hosed, big time. Time to wake up and explore the alternatives to high cost medical care for injured workers. Time to wake up and realize that the rest of the world is catching up to the “good ole’ USA” and providing better quality health care at lower cost.

I am not saying that it will be easy to implement medical tourism, so no one should think reading this that this is what I am advocating. And I am not saying that every destination is up to the task of providing such services. Far from it, but those that can, should be explored. Those that would like to in the future should be encouraged to seek out workers’ compensation carriers, third party administrators and case management firms here in the US for their advice and guidance.

The workers’ compensation industry can take the next step and seriously consider medical tourism, or it can continue to pay at least $2,000 more for the same surgery a group health plan pays. It’s your choice.