How will he heal?

By Jill Tillman, Times Staff Writer
Published February 24, 2008

Steve McCabe, 51, fell in September because of an infection in his artificial hip. A surgery could help him, but his HMO won't pay what doctors ask.
	[Brendan Fitterer | Times]

HUDSON - Steve McCabe was playing horseshoes when his right hip gave out. He collapsed. That was in September.

In some ways, he has yet to get up.

McCabe fell that day because of an infection associated with his artificial hip.

Sounds simple enough. But little about McCabe's situation is simple, and his case raises this question: What happens when your insurance plan says it can't find someone to treat you for what it is willing to pay?

This happens: At 51 years old, McCabe can no longer function well enough to live alone at his Holiday mobile home. Instead, he sits in a wheelchair and lives in a nursing home and waits.

"No one I speak to," he says, "can believe what's going on."

Seven years ago, McCabe had total replacements of both hips because, he says, of a disease that shut off blood flow to his femurs, killing the bone tissue and resulting in hip pain.

Though rare, infections are a serious problem associated with joint replacement. That's because the implants have a coating in which bacteria can hide, said Dr. Henry Finn, a professor of orthopedic surgery at the University of Chicago.

And curing these infections isn't just a matter of treating the patients with antibiotics. "More often than not," said Finn, who is not connected to McCabe's case, "the joint has to be removed."

Complicating matters: McCabe is HIV positive.

Treating the infection, Finn said, "is bad enough for someone who isn't immune-compromised."

* * *

Last September, less than a week after he collapsed, McCabe ended up in an operating room of Community Hospital in New Port Richey.

To treat the infection, Dr. Jennifer Cook removed the artificial hip and put in an antibiotic-coated "cement spacer," which is used to prevent bone-on-bone contact and stabilize the infected joint.

Once the infection is cured, the spacer can be removed and replaced with a conventional prostheses. This procedure of removing one artificial joint and putting in another at a later date is called hip revision.

The surgery is much more complicated than the original hip replacement, so not every orthopedic surgeon performs it.

"Ultimately he will need to have re-implantation," Cook wrote in her report, "and I would refer him to a more tertiary care center for that procedure."

Translation: At some point, there would be a part two to this surgery, and it needed to happen at a bigger, more specialized hospital.

McCabe is insured through St. Petersburg-based Universal Health Care's private Medicare replacement HMO.

Though he is not of Medicare age, he was eligible for Medicare because he has been on disability for about four years.

He said serious spinal pain, along with a mental health disorder, prevented him from continuing his computer network job in Largo. He signed up for Universal's program about two years ago, pleased by its prescription drug benefits, he said.

Over the three-month span after his surgery, McCabe received short-term rehabilitation and continued treatment for his infection as well as for some later fluid buildup. The best he could do was balance on his left side for a short while. He could not walk, could not shower.

And things only got worse. The cement spacer in his hip had started moving around. He could feel it shift, his right leg rotating out.

McCabe's description: "It's almost on sideways."

But he figured the next surgery was not far off, that it would help him have a normal life again. Finally, in January, he got good news: Universal said it had found a surgeon at Bayfront Medical Center to perform the next procedure.

Universal transferred McCabe to Bear Creek Nursing Center in Hudson, where he could get assistance in the two weeks before his scheduled surgery.

But when Bear Creek administrators called to find out what time he needed to be at the hospital, they learned he wasn't on the schedule.

* * *

So what happened? Universal spokesman Bob O'Malley did not name the surgeon but said he wanted to be paid five times the Medicare rate. Universal balked.

"We felt that was extremely excessive," he said, "and taking advantage of the situation."

O'Malley said that doctor was one of only two "ultraspecialists" that Universal had found who might be willing to perform the procedure. The other one is still negotiating for a rate with Universal, he said.

The Medicare rate for hip revisions in this part of Florida ranges from $1,653 to $1,806, depending on whether the physician participates in the program.

O'Malley said Universal is willing to pay above the Medicare rate, but he declined to say how much, citing ongoing negotiations.

"We're going to extraordinary efforts to get the procedure done," he said. "We're not denying the claim. We're doing everything we can."

* * *

Several surgeons not connected with the case who were contacted by the Pasco Times say it's unfair for Universal to blame doctors for the delays. The Medicare rate, they say, hasn't kept up with costs. To perform a complicated surgery on a patient already prone to infection will cost more than the Medicare rate, they say.

Cook, the original surgeon, did not return phone calls seeking comment, but her office sent a Jan. 17 letter to two Tampa surgeons, asking for their help with McCabe.

Complicating the future revision procedure are three factors, the letter stated: Loss of bone, his HIV status and a Hepatitis C diagnosis.

Having a patient who is HIV positive is not an insignificant factor, said Dr. James Stiehl, an orthopedic surgeon at Columbia St. Mary's in Wisconsin. Though there are precautions that any surgeon would take for HIV patients, he said, such a diagnosis "is a pretty darn good excuse if you're not a revision expert."

Stiehl said McCabe may consider this option: Getting a surgeon simply to remove the shifting concrete spacer. No new prosthesis would be put back in. This procedure would result in his having an unusual, locked-hip gait and probably require him to walk with a cane, but it is an acceptable option for some patients, especially older and sicker ones, he said.

But whatever McCabe's decision, Stiehl said that the HMO should be willing to pay whatever it takes to improve his situation.

"If the HMO can't pay for something, what are they here for?" he said. "It's not going to hurt them to pay a boatload to care for this patient."

* * *

So, still at the nursing home, McCabe waits. He wheels himself down the mauve hallways, past the bulletin boards advertising Lawrence Welk night and bingo, and heads for Room 166. On sunny afternoons, he wheels outside, smokes a cigarette and watches the traffic pass on State Road 52.

Staff members at Bear Creek have called surgeons and the insurance company on his behalf and let him set up shop in an administrative office when he needs to make calls of his own.

"They're fighting with me," he said.

But even with their help, McCabe is weary. It is an understatement to say recent years have not been his best.

He went from working a steady computer job to living off disability checks as his health declined. He and his wife split, and he racked up some criminal charges, including a felony charge by St. Petersburg police for purchase of hydrocodone in February 2007. He says he's innocent.

"I was trying to adjust to the HIV thing," he said before suddenly breaking into tears one day. "And now this."

And this: Last week, Universal sent him a letter saying it would not pay for him to continue to stay at Bear Creek. Bear Creek officials say the letter did not contain an alternative offer, such as home health care.

McCabe quickly appealed to a Medicare board and won. But he says he is bracing for more Universal letters. He says he is bracing to be denied.

Times researcher Shirl Kennedy contributed to this report.Jodie Tillman can be reached at jtillman@sptimes.com or (727) 869-6247.

"If the HMO can't pay for something, what are they here for? It's not going to hurt them to pay a boatload to care for this patient."

Dr. James Stiehl, orthopedic surgeon

[Last modified February 23, 2008, 22:24:06]