General rant about insurance

[evilhime]

My daughter in DE fell Monday and hurt her ankle - she literally heard a "pop" sound. It swelled to twice it's size and is bruised. That evening she went to an outpatient clinic where it was x-rayed. She was told there is no break evident, but she may have torn something and if it is not better or showing real improvement in 2 days to seek further care.

It has not improved, so she went to her regular doctor as the orthopedist was unavailable, and her primary care physician ordered an MRI. Aetna has denied the test saying she should wait six weeks to see if it gets better before getting further testing done.

In the meantime besides not having her injury taken care of, this is her right ankle so she cannot drive. She works, has two toddlers (2 and 4) that need to be picked up from daycare, and now she has to wait until it "spontaneously" heals which it is showing no signs of doing OR 6 weeks to be treated, whichever comes first.

How is this the BEST health care in the world, can someone explain that to me?

Rant done, thanks for reading.

[cbayer]

1. That sounds like pretty standard medical care for a sprain.

I can't imagine why she would need an MRI.

Did they not give her something to immobilize it and some crutches?

Unfortunately, there is not much else to be done except to allow time to heal. And even more unfortunately, it can take months to heal completely.

One of the problems with US medical care is over-utilization of services. I would be interested in why her PCP physician thought she should have an MRI.

[evilhime]

6. But we don't know

if it is a sprain only that it didn't reveal a break initially. There is probably something torn at this point, hence the MRI to ascertain that. The PCP is a DO so has a training in the skeletal system, and from examination of the ankle that was her evaluation.

[cbayer]

11. A tear is a sprain, and if the xray didn't reveal a fracture, there is no reason to

have an expensive test that will show nothing and lead to no change in treatment plan.

This is a big problem in this country.

[sinkingfeeling]

2. And the doctor won't treat without a $3000 test? I wonder how in the world we survived

before MRIs and CTs.

[evilhime]

7. Well more lasting injuries

And FYI, the test is $700, she called and asked because she was willing to pay out of pocket using her HSA. She was told she cannot do that because it violates the provider's contract with Aetna. So she can't get it paid for (approved) by them, and she can't get the test using her own funds either. That to me is denial of service.

[Sekhmets Daughter]

3. Far be it from me to defend the health insurance industry...

But this is the fault of the doctor who ordered the MRI. That's just absurd. Did he then advise her to see the orthopedist? If not, shame on him. She needs to see one because if she has torn something it needs to be treated, and I'd be willing to bet that if the orthopedist requests an MRI, it will be approved. Also, he may be able to fit her with an appliance that will allow her to drive. Best of luck to your daughter.

[evilhime]

8. Thanks for the good wishes

Yes, she was told to go to the orthopedist, (and she tried that first but couldn't get in to see him so went to her PCP as the alternative) ordering the test was to save time until she get an appointment, since specialists can be hard to get in to see. She has managed to score an appt. for Monday - she got lucky on a cancelation.

[littlemissmartypants]

4. Ok, now before you get your hand close to your holster let me try the other perspective...

I may fail but I am giving it a shot...please don't hate me.

But, How persistent and intelligent is your daughter. Was she communicating with the physician as a participant or as a passive listener?

Some physicians will "order" anything to please (aka dismiss) a patient.
Done by CYA?
Done by request?
Or done as "defensive" medicine. (This is the one I have heard the most.)

Sometimes it is possible to find the patient's "sweet spot" and exploit it just to keep the schedule of patients moving.

Physicians also have to think of productivity. Have you never noticed the same quarter hour block with 4 patients scheduled at that same time? Reimbursement for services is a large concern these days.

What the hell is she expecting? Doctors are unskilled and not trained to respond with tenderness and compassion. They are scientists for Pete's sake.

How many years of experience with these issues (bones, sprains, ankles) do your daughter and the direct caregiver (doctor or not) have respectively?

Was the only "care" given a referral?

How did I do?

[evilhime]

9. Not great :)

1. My daughter is very persistent and knowledgeable - she does her homework, and has had orthopedic issues before. Passive listener? Uh........ no.
2. This physician is very caring and very competent IMO. She examined the affected ankle and her determination was another x-ray wouldn't help determine the extent of the damage.
3. The patient in this case wanted nothing more than to find out what was wrong, and get a solution to expedite the healing process so can drive and take care of her kids again. And avoid having a chronic issue down the line resulting from not taking care of it.
4. Sadly productivity is an issue, but I have been with my daughter when she has gone to this doctor and I would say her concern is much more for the patient in the room at the time than with keeping the flow moving.
5. Well I don't know how long the doc is in practice but I'm saying probably 20 years experience as the first line in all issues, including orthopedic ones; my daughter - many as she has two knees with injuries, among other issues.
6. No, the care given included an examination, a wrap to help with swelling and immobilization, and continue with the crutches, ice, anti-inflammatories (ibu) as needed, etc.

[littlemissmartypants]

10. Well

you could have said....EPIC PHAIL...LOL.

Thanks for the feedback.

Love, Peace and Shelter. lmsp

[evilhime]

12. and thanks

for caring enough to read and provide input

[Celebration]

5. there is no way a primary care doctor can treat this

I wouldn't trust even the best primary care doctor to treat an orthopedic problem. She does need treatment, like a boot and maybe crutches, but only an orthopedic doctor would know that. He could probably tell just by a physical exam what is wrong. I would trust that more than an MRI by the primary care doctor.