Tuesday, February 24, 2009

Utah legislation aims to cover prosthetics like hip replacements in insurance plans

From the Deseret News in Utah:

A bill that would put prosthetics on par with hip replacements in medical insurance plans passed out of a legislative committee with one opposing vote, despite stiff opposition from some lawmakers and the insurance industry who regard HB89 as yet another mandate to a health-care system that is falling apart.

Like a bill to mandate that insurers cover in-home behavior modification therapy for state-employed parents who have autistic children, the prosthetic parity proposal faces an uphill battle for lawmakers votes. An autism-coverage bill (SB43) that several state senators regard as forcing expensive coverage for one well-deserving group by trimming basic coverage to everyone else covered in the state insurance plan received Senate approval this week.

HB89, which is similar to a bill proposed last year, would require accident and health insurers to provide coverage for medically necessary prosthetic devices at the same amount that government insurance pays for surgical procedures such as knee and hip replacements.

A no-new-mandates ban might be overcome, even as state revenues are projected to fall some $300,000 short in 2010. The bill's sponsor Rep. David Litvak, D-Salt Lake, is hoping there is breathing room in the state's $1.5 billion budget gap to add equity in coverage for the 12,500 Utahns who are amputees.

In the 11 other states implementing similar legislation, the annual cost average has been $2 per member per year, said Tami Stanley, (pictured) a Utah amputee who is solely responsible for keeping the issue from getting lost in the rush to balance the state budget.

Colorado, which was the first state to implement this legislation in 2001, saw a net savings of almost $500,000 in medical expenses in it's first year, Stanley told the newspaper. Replacement of hip, knee and shoulder joints are routine and rising and covered by insurance, she said, noting that the average price of single knee or hip replacement in Utah is between $40,000 to $60,000 if there are no complications. The national average for these joint replacement surgeries ranges from $80,000 — $150,000.

Surgery to replace smaller joints such as thumbs and toes disfigured and pain-ridden by arthritis is covered and runs $8,000 to $10,000, she said

"I think most people are not even aware that this problem exists," Staney said. "I didn't, and I knew nothing about the world of limb loss until it happened to me four years ago … there was no reason for me to know, because I never dreamed that I would be living the life as an amputee.

The world of limb loss was made even more devastating when I found out that my insurance would pay almost $1 million to save my leg and then to remove it, but not provide the coverage needed to replace my leg."

The cost for a prosthetic for Stanley, who like most Utah amputees is missing her leg just below the knee, is $12,000.

Between 70 to 90 percent of Utahns with limb loss are able to return to work and function in their home environment with the aid of a prosthetic device, which also will help the significant psychological trauma "that comes from losing forever the way you used to just naturally get around in the world."

Lawmakers are loathe, they say, to telling any business or anyone they must do something, and given the course of health-care related bills so far, especially insurance companies. A plank in the Republican platform states that the part opposes "excessive and restrictive government regulation … unless a convincing case can be made that the collective good is clearly improved by such regulation."

"This is a perfect example of the collective good is clearly improved by such regulation," Stanley said, noting that market forces and health-care system reform efforts that might rectify such problems in the system will simply skate past this small, worthy population. "This is a medically necessary piece of legislation that the private industry and market will not respond to unless we step up and make some policy decisions."