Category: Shoulder

After practicing for 32 years, I have finally had it. People complain all the time about how dysfunctional the health care system is. In many ways it is, with rules and regulations dictating choices caregivers have, and roadblocks for patients to obtain care.

I have a 53 year patient who has fairly significant arthritis of her knee. She injured her knee on the job, and her job requires her to be on her feet most of the day. She has had surgery twice over the past 10 years and needs a knee replacement, but she is too young. She has been able to continue working by using Ibuprofen when her pain increases.

She called about 3 months after her last visit asking for a refill for her Ibuprofen, which costs about $10-12. She did not feel a need to come in for an exam, as it would take time away from her work. She used it occasionally.

We have to submit a form to her Workers comp insurance company for approval rather than just calling in a refill, and the adjustor sent it to another doctor to be “reviewed for medical necessity”. This reviewing doctor denied our request. Said they had called the office twice to try to speak to me.

Our notes: “Mark with Mitchell UR called and said you can speak with Dr. Brooks, reviewing physician, if there is any other info you would like to add to the ibuprofen refill request. Mark said you do not necessarily have to call if there is nothing else to add. They already have the last report.”

So I appealed his decision, thinking this was a mistake. I sent our request to the next level appeal, to the “Independent Medical Review”, a board of reviewers the legislatures passed in 2009, set up as the final word. Kind of like God… you really don’t know what he/she looks like…There is no list of who is on the board, it is a secret, and after all the records were sent for review, to my surprise, it was denied again. The 4 page denial stated the according to the Chronic Pain Guidelines I needed to document that she had failed a trial of Tylenol. (She had Tylenol use documented, just not the statement that it had FAILED.) NSAIDS such as Motrin are not for long term use”… This was the first refill in 3 months. What- they want me to give her Percocet instead?

The problem is the law also states that we cannot ask for a review for 12 months. She will have to pay for it herself.

What did it cost to deny a $10 bottle of Ibuprofen?

Request for refill of Ibuprofen……….$NA
Cost to fill out Request for Authorization form 10 min……….$40
Phone call from physician reviewer to me (2 times)……….$60
UR Reviewer denial estimated fee……….$100
Administrative time to send initial 7 page denial est……….$50
My time to prepare appeal, talk to patient to explain denial……….$125
Filing costs to IMR……….$400
Estimated physician reviewer fee #2……….$100
Phone call to patient explaining denial #2……….$50
Total estimated cost to deny Motrin……….$925

Time away from actually treating patients……….priceless

So let’s see…what happened to common sense for a $10 medication? Why is this happening?

Several years ago, then Gov Schwarzenegger and a few key legislators (called the Gang of 5) put together a bill that required utilization review for all care patients receive in the workers compensation system. (SB 899). This was supposed to hold down the rising cost of premiums for employers, avoid unnecessary tests, surgeries, and use of narcotics. In the big picture, there was some abuse, and some of the tenants seemed reasonable.

Instead, an entire new industry was born- Utilization Review Companies, whose job it is to review requests for medications, crutches, a simple sling to surgery requests and every postoperative need the patient may have. Some of the companies deny as much care as possible to save money for the insurance company and have every request from a sling to Motrin reviewed. A few are reasonable and leave the decision to protocols for the adjustor. Many of the physicians are hired from out of state, are not required to practice here, just have a California license. Many are retired from actively practicing. I met one recently at an Orthopedic meeting who was at least 80 years old, and clearly was not practicing and had in fact denied an anti-inflammatory for one of my patients.

Has this system saved money for the employer and improved care for the injured worker? NO.

One recent study indicated that over 50% of the cost of care for the patient is in utilization review. If a bottle of Motrin can cost $1000, no wonder.

The people getting hurt here are hardworking blue collar workers, many of whom have never had an injury in their work life. Many do not have English as their primary language, and have limited recourse for denials. Or they hire a Workers compensation attorney, and this too can increase costs and complicate the case. As physicians, our main goal is to help heal the patient. 90% of the doctors caring for these patients are doing just that.

Only the legislature who passed this bill can make this better. Will I continue to treat injured workers? For the few companies that have reasonable review, yes. But my no-fly list is getting longer by the month. Maybe, only when access becomes a crisis will anything change.

Lesley J. Anderson, MD

Reprinted from

J Am Acad Orthop Surg 2013;21: 190-192 by David S. Jevsevar, MD, MBA

You have an orthopaedic implant (for example, joint arthroplasty, metal plates or rods) from a previous orthopaedic surgery. A potential complication of these implants is bacterial infection, which occurs in approximately 1% to 3% of patients. These infections require additional surgery as well as antibiotic usage for an extended period of time. Most infections occur around the time of the procedure (within 1 year), but some have occurred much later.

In theory, late implant infections are caused by the spread of the bacteria from the bloodstream to the implant. Unfortunately, there is no clear scientific evidence to support this theory. We know that many patients with orthopaedic implants frequently have bacteria in their blood that does not spread to their implants.

Dental procedures have long been considered a potential cause of implant infections even after the initial orthopaedic postoperative period. This is because dental procedures can introduce bacteria from the mouth into the bloodstream. However, this fact should be considered in the context that eating and performing oral hygiene at home may also introduce oral bacteria into the blood.

Traditionally, antibiotics have been provided before dental procedures in patients with orthopaedic implants to minimize the bacteria that get into the blood. Best evidence, however, does not show that antibiotics provided before oral care help prevent infections of orthopaedic implants. The routine use of antibiotics in this manner has potential side effects, such as increased bacterial resistance, allergic reactions, and diarrhea, and may even cause death.

Patients who have compromised immune systems might be at greater risk for implant infections. Diabetes, rheumatoid arthritis, cancer, chemotherapy, and chronic steroid use are examples that suggest the presence of immunosuppression.

Please discuss your potential for immunosuppression with your physician or dentist. Patients who are immune-compromised might wish to consider antibiotics before dental procedures because of their greater risk for infection. Decisions with regard to antibiotic premedication should be made by patients, dentists, and physicians in a context of open communication and informed consent. See Figure 1, the Doctor-Patient Shared Decision Making Tool.

Our annual meeting of the American Academy of Orthopedic Surgeons (AAOS) was this week in San Francisco.  This meeting brings together almost 30,000 orthopedic surgeons, vendors, and sales people to provide intense education on the “latest and greatest” new technology as well as provide ongoing education for orthopedic surgeons.  It is usually quite a show, taking over all three Moscone Convention Center, with exhibits showing the greatest new plates, screws, biologic materials to help tendon healing, bone graft substitutes, instruments to make our surgeries go more easily, and techniques to implant them. 

One of the reasons I love orthopedic surgery is because there is always something new to learn, innovation has been fostered and through this innovation has brought total knee replacements, total hip replacements, and surgeries to improve the quality of life for millions of Americans.  Today, I am actually taking the day “off” from the Academy and spending time sifting through  what I have been learning and integrating that into some self assessment examinations.  (Yes, at my age, I still have to take tests and questions). 

In the next few blogs, I am going to talk about some of the updates that we learned during this meeting. 

Today, I will just say a few words about smoking.  As you know, smoking is no longer as big an issue that we see in California since laws have restricted ones ability to smoke in most public places and even near public buildings.  So, smoking is much less prevalent here in California, and especially in Bay Area.  So, most of us do not think it as a big issue.

However, it is well established that smoking increases risks of bones not healing (called nonunions), failure of fusions of spine surgery, poor wound healing and increased infections in joint replacement, rotator cuff repair, and has a huge impact on healing.  Many orthopedic surgeons refuse to operate on a patient for a spinal fusion or a cervical spine fusion if they are smokers.  I insist my patients that are smokers to stop before I will perform rotator cuff repair since it has been established that there are higher incidences of failure of healing of these tendons.  In my next blog, I am going to speak about osteoporosis and some of the new controversies surrounding that.  This is one of the current “hot topics” in orthopedics.  So, stay tuned in the next few weeks.

– Lesley J. Anderson, MD