Regulation and Accountability

[Morris Gallo]

I have a problem with your "scenario", your data and math, your logic,
and your conclusion.

"Ruth J. Clark" wrote:

>  The discussions over the past week or so have been very valuable and
> I have tried to distill some of it with the following scenario based
> on Tony, Al and other's contributions.
>
> At 01:57 PM 12/5/2002 -0500, you wrote:
>
>> In a message dated 12/5/02 9:13:24 AM Central Standard Time,
>> t-barr at t-barr.com writes:
>>
>>
>>
>> > While Mo is helping in your request Al, what is your point? You
>> > support regulation but not the oversight that is presently
>> > included?
>>
>> Want some with real meaning for the public. After all they are the
>> ones paying the bills.
>>
>> Tony, we are on the same page. I want to see regulations mean
>> something. One way to see is by asking the right questions about how
>> they are working.
>>
>> Al
>
>
> I think what  Al keep trying to bring this back to is Accountability
> for a product at a reasonable, competitive price.  As has also been
> pointed out in various discussions, the cost of prosthetic devices has
> gone up substantially while the 'working life' of said device is
> getting shorter and shorter.  A conscious, built in obsolescence it
> almost seems.
>
> Take an example.
> A mid-level scientist, with 8 years of University conducting award
> winning genetic research, gets a Masters Degree.

In eight years of college most students achieve a Ph.D., not a masters.

> He takes a job with a small firm and continue this work, supervising a
> lab of 4 staff, working on the Avian Genetics.  Salary $85,000 a
> year.  (the other choice was to stay with the University, teach the
> next generation of scientists and maintain a research lab.  Salary
> $75,000).

It is doubtful a lab or university would be interested in a Masters'
level researcher, especially at so high a salary.

> Married with 2 children, he just bought a new van for $22,000 (it has
> a 5 year warrantee and can conceivably last for 8 - 12 years)  On
> vacation, they are driving to a ski hill early one Sunday morning,
> they get hit by a drunk driver (who is a school boy friend of the
> local sheriff).  This 35 year old is now an Above-Knee amputee with a
> capped insurance award from the auto insurance.   Since he often works
> long shifts in the poultry barns, he can not do without a prosthesis.
> There are complications that require 3 revisions, difficulties in
> fitting the socket and within 3 years 90% of their insurance claim has
> been expended.

Your implication seems it is the prosthetist's fault the amputee
required three revisions, has a difficult residuum to fit, and is the
root cause of using most of the insurance claim.  I see no rail against
the "capped" claim, the cost of surgery, medical, etc.  It all seems to
fall to the prosthetist.

> A few new acquaintances have told him that their AK limbs usually need
> to be replaced in less than 3 years and sometimes less than 2.

I have acquaintances who replace their vehicles every two years because
they are worn out, over 100,000 miles.  So making a statement about how
long something lasts without knowing how it is used is foolish.  The
cost of an item will not necessarily insure it has increased longevity.
Oftentimes we pay additionally for comfort or aesthetic preference.  Did
you pay extra for air conditioning, leather seats, fancy wheels, or a
radio in your car?  How do these items extend the useful life

> He now needs to budget $12,000 - $15,000 from his private funds, every
> 3 years for the next 40+ years.

Doesn't your employed researcher have health insurance?

> While at the Prosthetist one day he strikes up a friendship with
> another AK amputee.  This gentleman also follows a trade for which he
> has college training.  He is a brick mason and works on small
> construction sites.

Must be a different country, all the masons I know learned their trade
either on the job or at a trade school, not college.

> Earns $15/hour and must supply all his own tools & transportation
> between work sites.  Since he lost his leg in an accident 8 years
> earlier (no insurance on the job site),

If the mason was an independent contractor workman's comp insurance was
not only his responsibility but in most states working without this
coverage is illegal.

> he has had to learn how to stretch out the life of each of his
> prosthesis.  The limb he had from his last Prosthetist (certified and
> licensed)

Certified and licensed by whom?

> did not fit correctly,

Did he return to the prosthetist for adjustments or simply lament his
bad luck?

> complications set in last year and revision surgery was needed.  (he
> was off work for 5 weeks with no sick leave pay)

Again, are the revision the prosthetist's fault or perhaps were they job
related or the result of poor medical care during amputation?  The guy
sounds like an independent contractor, not an employee, so having
insurance for disability is his own responsibility, no one else's.

> Also, he had wanted a basic safety knee but was talked into a
> different one that cost 2 times as much and the 'fancy' knee caused
> him to fall frequently.

I can't believe a knee module that "caused" his falls would survive in
our litigious society.  Besides, why would a prosthetist use a component
that will only bring grief and complaints to his/her life.

> The construction worker's wife tried to complain but was told that her
> husband was just being unreasonable and expecting too much from his
> prosthesis.

If this happened in a licensed state there would be in place a mechanism
where the complaint could be filed, a state agency would investigate,
and if a problem with competency existed a solution reached.  This is a
major advantage of licensure.

> Being inquisitive the two men learn that the Prosthetist has 3 years
> of  college, is certified and licensed by the State and rumors are
> that he was just enticed to this position with a starting salary of
> $90,000.

Your derogatory implication is that someone with less education is
earning a larger salary.  First, the current requirement for ABC
certification and licensure in most of the states is a Baccalaureate
degree, four years. Before the applicant is accepted to a university
program they must achieve technical experience and then the practitioner
undergoes one year of supervised residency experience.  So a new
ABC/Licensed practitioner has at least six years of training.  This is
not the case for other certification schemes or non licensed states.

> (the owner of the shop took home $85,000 profit at the end of last
> year)

Lets see, I risk my capitol, work like a dog, take all the chances of
failure and you make it sound like a profit of $85,000 is obscene.
Doesn't it seem strange the owner made less then the employee?  Oh I
forgot, this was only based on "rumor".

> The scientist has also looked up the publicly available billing
> schedule and gets hold of some vendor wholesale prices.  It seems that
> the Prosthetist (earning $90,000) does not even make the socket.
> Basic measurements are taken and sent to a Central Fabrication lab
> where a generic size 6 socket is made and supplied, complete, for
> $600.

I have been in the business over 25 years, never have I heard of a
"generic size 6 socket".  Is this again the "rumor" connection?

> He is now being billed over $2500 just for that one component.  An
> over 300 times mark-up.

Three hundred times markup of $600 is $180,000.  If the component cost
$600 and the charge is $2500 then the markup is four times (422%).
Since your scenario doesn't describe the labor and equipment used to
incorporate the component into the prosthesis your markup analysis is a
foolish manipulation of unrelated numbers to lead the reader to a
unsubstantiated conclusion.

>   The construction worker wonders how long he would be able to work in
> his industry if he charged a 300 times mark-up for his products.
>
> These two basic scenarios are true, with minor changes.  We have all
> heard of far too many of these situations, and the number are
> increasing.
>
> Also, a growing number of amputees have limited or no insurance.  Even
> those that do, are facing ever increasing fees for their insurance.
> While certification and licensure are important issues, what will the
> value be of having all practitioners licensed if a minority of the
> amputees can afford their services?  Is the industry becoming
> available for an elite few?  No one will deny that FAIR billing and
> salaries need to be offered, but  the services and product must also
> be offered at a fair price.

What is fair?
In communist countries "fair" is established by the state.  Experience
has shown that it those economies the majority of the population does
without, while of course the politically connected few reap the rewards.

In the socialist economies, like England and Canada, the entire
population pays high taxes to ensure everyone will receive a basic level
of medical service.  This type system stifles innovation but does afford
everyone a very basic utilitarian level of service.
In free trade capitalist economies "fair" is what the consumer is
willing to pay.  If you don't think you receive "fair" return why do you
continue to spend your money with that provider.  If the majority of
consumers find the services and/or prices unfair the vendor will soon go
out of business.  You comment that only the "elite" can afford these
services is by evidence false.  The US is the country where the most
technically advanced devices and services are available.  This expertise
extends to those that choose, or because of economics must settle for,
more utilitarian components.

> There also needs to be easily accessible accountability and
> warrantees.
>
> Many Industries seem to have accomplished this.  Sears, for example,
> offers their Craftsman tools as a mid-range product with a life time
> warrantee that they honor.  The cost of one C-leg (life of 2-3 years)
> would buy you a luxury car (life of 10 - 15 years) and the car has a
> long term warrantee that is honored and enforced by law.

A five carat high quality diamond would cost the same and has a useful
lifetime of millions of years, so I guess the C-Leg and the care are
both overprices?  If you don't like what the C-Leg costs don't buy one.
To me a Testa Rossa is one of the most beautiful cars made, but even if
I could afford one I can't see myself wasting the money on a car.

>    How many people replace their car because the brakes wear out, why
> should you replace your entire  AK limb ($13,000 - $15,000) because
> the locking mechanism (less than $150) for the pin lock has worn our
> after 18 months?

You imply that prosthetists force you to replace the prosthesis when a
minor component wears out, this is BS (Bovine Scat to those of you who
are sensitive).  The fact you quote a price for the replacement part
proves it exists and is available.  Every practitioner I have spoken
with in over more then 25 years in the profession can and does repair
prosthesis.

>
>
> Competent service providers need to be ensured but licensure does not
> guarantee competence.   Licensure is important but it can also act to
> create a 'closed shop'.  With so many of  the components now being
> manufactured centrally, why shouldn't a trained PT provide prosthetic
> care to a Below or Above Elbow amputee with a mature residual limb?

This logic is priceless.  You complain that the certified and licensed
prosthetist is incompetent, gouges you, and is in the practice of
conducting fraudulent business so your solution is to allow a PT, who
has no training or education in prosthetics to provide you with
service.  Are you a PT?  Since you think any moron can do prosthetics
why not let your fictitious brick mason become your prosthetist, he only
makes $15 per hour and brings all his own tools.  You can't hire a PT
that cheap and they both have the same lack of training.

> (You do not expect an Obstetrics Dr. to attend every birth when a
> mid-wife can handle most births successfully) I think Al's proposal to
> have clinics modeled on the VA is a start  to ensure that prosthetic
> assistance remains available to as many amputees as possible.

I think the VA model stinks.  The VA system has been shown to be the
most inefficient of all health care delivery systems.  I have several
acquaintances who sell medical supplies to both the VA and private
hospitals.  They frequently comment that the VA uses a disproportionate
amount of supplies for the number of beds.  Since they sell those
supplies they love having a VA hospital in their territory.  As to the
level of care, I am embarrassed to see the poor care many of our
Veterans receive in the VA system.  Be careful for what you wish.

Morris Gallo, CPO

>
>
> Ruth
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