Carpal Tunnel Syndrome – Time To Explode The Myth

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There are some 210,000 unnecessary CTS surgeries each year, at a cost of roughly $1.5 billion, much of it covered by workers’ compensation.

Carpal tunnel syndrome (CTS) has caused a firestorm of controversy in recent years. CTS is a perfect example of how popular beliefs are not supported by medical evidence. It is time to set the record straight.

Although the popular belief is that keyboard use causes CTS, the science shows otherwise. Nine studies have reviewed this relationship, including ones by the Mayo Clinic, Harvard Medical School and a Swedish study reported in Orthopedics Today. The scientific research shows that keyboards are safe to use and do not cause CTS. Furthermore, keyboard design had no effect on the incidence of CTS. Symptoms may increase with many activities, including the use of keyboards, but keyboards do not cause CTS.

According to the AMA Guides to the Evaluation of Disease and Injury Causation, “85% of patients who meet the National Institute of Occupational Safety and Health (NIOSH) guidelines and requirements for a diagnosis of CTS would not have a true CTS confirmed by nerve conduction testing.”

What complicates the diagnosis and treatment of CTS is that there are multiple causes of the symptoms. These include: diabetes, pregnancy, use of birth control pills, menopause, various vitamin deficiencies, insufficient water consumption, exposure to cold temperatures, incorrect sleeping positions, smoking, knitting, playing musical instruments, recreational sporting activities and other non-work-related activities.

What complicates the diagnosis and treatment of CTS even further is that there are literally dozens of other diseases and conditions that mimic CTS-like symptoms. These include: tendonitis, bursitis, sprains, fractures, dislocations, gout, rheumatoid arthritis, osteoarthritis, thoracic outlet syndrome, myofacial trigger points, as well as an array of neck, shoulder, back and cervical conditions. In fact, there are 59 medical conditions that have been identified to be associated with CTS-like symptoms.

A common error in diagnosis and treatment is the tendency of physicians to treat a case as if there were a single physical site causing all the problems. In fact, it would be extremely rare for only one nerve location to be involved. This means that pain in the wrist may be the result of nerve entrapment in the neck or shoulder. This is referred to as the “whole-nerve syndrome.”

Even the popular name is incorrect. The correct clinical name is Median Nerve Compression Neuropathy. According to the AMA Physicians Guide to Return to Work, “CTS is actually a condition with a known pathology and not a syndrome, but the name “carpal tunnel syndrome’ has become so well-known that CTS is used.”

Medical studies have shown that as many as 85% of patients who are told they have CTS are misdiagnosed. The overwhelming number of cases are determined to be work-related–a major problem in the workers’ compensation industry for the past two decades–and it has been reported that as many as 70% of those diagnosed go on to receive CTS surgery.

Currently, 250,000 people a year in the U.S. have CTS release surgery. If 85% of those are based on misdiagnoses, that would mean more than 210,000 unnecessary surgeries per year. At a cost of $5,000 to $10,000 per surgery, that’s some $1.5 billion a year spent on inappropriate surgery, much of it paid for by workers’ compensation.

According to a University of Maryland Medical Center study, “CTS surgery does not cure all patients and because it permanently cuts the carpal tunnel ligament, some wrist strength is often lost. A number of experts believe that CTS release is performed too often.”

The good news is that CTS can be diagnosed accurately. In many cases, it can be treated successfully with conservative treatment in a matter of weeks and is easily prevented.

The bad news is that primary-care physicians more often than not misdiagnose CTS. This results in incorrect treatment and unnecessary surgery, which leads to chronic unresolved conditions, no relief to the patient and staggering costs to U.S. employers and insurers

Leading medical experts such as Dr. Peter Tsairis, retired chairman of neurology at the Hospital for Special Surgery in New York, said the biggest concern is the automatic assumption that the clinical problem is work-related. “It is a significant problem, since many of these patients do not have CTS,” he added. He has often seen patients already scheduled for surgery whose primary-care physicians did not perform a thorough physical exam or conduct any electrical diagnostic testing to confirm the CTS diagnosis.

Dr. Ron Safko, a New York-based, board-certified chiropractic orthopedist, has also seen many cases of misdiagnosis by primary-care physicians. “It boggles my mind how physicians do not even consider other underlying conditions and do not even examine other areas, such as the neck, back, shoulder or cervical spine,” he said.

Just because it has become a widely accepted urban myth that CTS is caused by keyboarding and, therefore, a work-related injury, should not give treating physicians the liberty to avoid performing a thorough patient history, physical examination and appropriate diagnostic testing based on widely accepted and evidenced-based medical protocols.

Isn’t it about time the workers’ compensation industry got it right?

Long-Term Health Care – The Financial Impact

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There’s a phrase: “Long-term health care isn’t about dying, it’s about living!” This may seem obvious, but many people do think of long-term health care incorrectly – in terms of death – but it’s really about the exact opposite.

Long-term care services are rendered with the intent of making life easier! Unfortunately, it has an adverse effect on too many individuals and their families because they don’t plan for it in advance, jeopardizing not only their financial assets but also their own livelihoods.

To get the ball rolling, here’s clarification of some common misconceptions around LTC and long-term care insurance (LTCI) before developing the right plan. Here are a few questions for a better understanding of LTC and future plans:

What does long-term care do?

Long-term care is care that generally extends beyond 90 days and is practical in nature, rather than medical.

Long-term care is the assistance or supervision a person may need when they are able to do some of the basic activities of daily living (ADLs) – bathing, dressing, eating, continence, toileting and transferring that can be taken for granted.

Some policies may even cover assistance of household chores such as errands, cooking, bill paying and other daily activities. For some, services include in-home visits that may be weekly or daily; for others, the care required necessitates 24 hour assistance at a nursing facility. Most importantly, LTC is not strictly for the elderly.

Long-term care events can affect anyone — at any age — who requires assistance with normal tasks.

Who pays for what?

If a person expects their health insurer to cover their long-term care needs, there’s a lot more to learn about LTC.

Health insurance covers very limited and specific services restricted to health care following an acute health issue that typically expires after 100 days.

Medigap/supplement policies likewise do not cover care that lasts beyond 100 days (if that). Disability insurance covers only a portion of a working person’s income but does not cover any costs associated with long-term care nor with those who are no longer in the workforce.

What about Uncle Sam?

Medicare focuses exclusively on medically-necessary care (i.e. hospital stays, drugs and doctor visits) for the short-term and not the practical services offered from LTC. Medicaid does pay for some long-term care — on the government’s terms — but comes with exceptionally tight financial requirements (i.e. poverty level income and savings) that make most Americans ineligible.

What about family obligations?

All of this leaves most families reliant on themselves to provide long-term care services. Some people may wish to cover the costs of long-term care for their spouses or even parents (so prepare accordingly); others will provide the care themselves, even if that means leaving the workforce (voluntarily or otherwise).

It’s imperative to have family communication about the expectations around these very real issues that impact families everyday. Thanks to an aging baby boomer population, more and more Americans are seeing their entire life savings depleted from the costs of long-term health care rendered that could have been foreseen and planned. Sadly, this depletion of assets directly affects those left behind – often a spouse or child.

What about additional risk factors to consider?

It’s important to have some grasp of any risk factors when planning appropriately for the future.

For example, someone may not develop Alzheimer’s themselves, even though they lost a parent to the disease; however,   the risk is higher. Knowing this, a person can prioritize their spending now while saving efficiently for future possibilities.

This gives a person more control over their future financial planning from multiple angles.

Is all LTC insurance created equal?

Long-term care policies can help bridge the gap between a person’s assets and the increasingly high costs of care that can continue for years on end. That said, LTCI is a very complex product that requires the skill and understanding of someone who thoroughly understands the product.

The right plan for any given person must take into account multiple factors including their age, health history, retirement savings, future plans, family obligations/expectations and more. LTCI plans are equally as diverse as the people who purchase the policies.

LTCI goes well beyond dollars.

Though a person will be rightly content knowing they have protected their assets, this not the aspect of LTC planning that resonates most with them. In fact, when on claim, it’s known that their loved ones rarely talk about the financial benefits of their LTC financial strategy and policies. Instead, they talk more about how much stress they relieved knowing that their children could continue to work and live according to their own plans without needing to move across the country and care for them in older age. They talk about how fortunate they are that their parents had the insight to purchase the right LTCI policy that allowed them to receive the assistance they needed when they needed it most.

So, long-term care really isn’t about death and dying… it’s absolutely about living! It’s about ensuring that those cared about most will be cared for and those that remain will not be saddled with unnecessary financial burdens. Start this conversation with your family now — while there’s time!

U.S. Finds Many Failures In Medicare Health Plans

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Federal officials say they have overly criticized, and in many cases penalized, Medicare health plans for serious deficiencies, including the improper rejection of claims for medical services and unjustified limits on coverage of prescription drugs.

The findings, cataloged in dozens of federal audit reports, come as millions of older Americans sign up for private health plans and prescription drug plans in Medicare’s annual open enrollment period, which began on Wednesday, October 15 and continues through December 7.

About 16 million people, accounting for 30 percent of the 54 million beneficiaries, are in private Medicare Advantage plans, which provide a full range of health care services under contract with the government. An additional 23 million people are in prescription drug plans, which cover only medications.

Federal officials expressed frustration that they were seeing the same kinds of deficiencies year after year. In a memorandum to health plans, Gerard J. Mulcahy, the Medicare official in charge of oversight and enforcement, listed common “areas of noncompliance” identified in program audits.

Medicare officials impose civil fines and take other enforcement actions when they see practices that could harm beneficiaries by delaying or denying access to care. Insurers usually do not dispute the audit findings, but say the care they provide is superior to that in the traditional fee-for-service Medicare program.

The Centers for Medicare and Medicaid Services reported these findings:

In more than half of all audits, “beneficiaries and providers did not receive an adequate or accurate rationale for the denial” of coverage when insurers refused to provide or pay for care.

When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.

•In 61 percent of audits, insurers “inappropriately rejected claims” for prescription drugs. Insurers enforced “unapproved quantity limits” and required patients to get permission before filling prescriptions when such “prior authorization” was not allowed.

Medicare plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.

Several companies have been penalized in the last year for violations, including Medicare’s patient-protection requirements, officials said.

John K. Gorman, a former Medicare official who is a consultant to many insurers, said, “It’s unforgivable that so many Medicare Advantage plans are still struggling with basic compliance issues.”

Insurers often hire companies to manage their drug benefits. “These companies know how to manage drug benefits for working-age people with commercial insurance, but they are confounded by the complex needs of seniors,” Mr. Gorman said. “Many are failing Medicare beneficiaries.”

Federal officials have begun to inform some companies this year that they could not enroll any more Medicare beneficiaries and should stop marketing their Medicare plans.

Mr. Mulcahy, the Medicare official, said the conduct of these companies “poses a serious threat to the health and safety of Medicare beneficiaries.”

“Violations resulted in enrollees experiencing delays or denials in receiving prescription drugs,” Mr. Mulcahy said, also citing the companies for “inappropriate denials of payment for emergency medical services.”

Spokespersons from these companies said they are taking “these matters very seriously” and are trying to fix the problems so the sanctions can be lifted.

The Obama administration has imposed civil penalties of more than $500,000 on one of the companies, saying it found “widespread and systemic failures” in the management of prescription drug benefits for Medicare patients.

“This company failed to provide its enrollees with benefits” in accordance with Medicare requirements, Mr. Mulcahy said in a letter to the insurer. But, a spokeswoman for the company, said the problems “involved administrative issues, not quality, and have long since been resolved.”

In a letter to another California insurer, the federal government said it had discovered “multiple serious violations on almost all files reviewed” in its audit of the company’s Medicare plan.

The severity of this California insurer’s conduct is magnified by the fact that more than 99 percent of its enrollees are beneficiaries who receive the low-income subsidy,” Mr. Mulcahy wrote.

The chief executive of this California company, a nonprofit health plan, said, “We did not disagree with any of the findings about unnecessary delays and inappropriate denials of care.” Many of the problems, he said, resulted from inadequate supervision of the physician networks and its pharmacy-benefits manager.

This California insurer said it was making improvements but could not enroll new Medicare beneficiaries until the government was satisfied that the deficiencies had been corrected.

Federal officials imposed a $180,400 penalty on a company after finding that it improperly restricted access to certain prescription drugs.  The spokeswoman for this insurer, said, “We did not dispute the findings.” The company has paid the penalty and corrected the deficiencies, she said.

An Oregon insurer paid a penalty of $312,300 for violations involving drug benefits, coverage decisions and the handling of consumer complaints. “This is the first time this has ever happened to us,” said a vice president of the company. “We’ve quickly done everything that Medicare asked of us.”