ADR Decisions - Texas Back vs. India

[tigerpaw75]

A little background - My wife initially hurt her back years ago while working as a nurse. She would go to physical therapy, take anti-inflammatories, and it would improve. Then it would act up again a few months later. More of the same. Finally in Fall 2008 her disc ruptured and was putting major pressure on her sciatic nerve. We believe the final rupture was caused by a chiropractor who must have had no idea what he was going. He performed several aggressive adjustments and my wife left the chiropractor in more pain than when she arrived. 3 days later she had to go to the hospital in an ambulance (she finally could not walk and I worked 40 miles away). Two days after that she had a hemilaminectomy/discectomy that removed the ruptured part of the S1-L5 disc that was pressing on her sciatic nerve. She still has numbness to this day on the top of her right foot and in several of her toes.

She was relieved of pain until July 2009, when the pain returned, although this time it was specific to the spine area and did not involve any extremity pain. She had an epidural steriod injection that relieved the pain until January, when we tried another epidural. This one did not work at all. MRI and X-ray indicated that both S1-L5 and L5-L4 were bad. All her surgeon here at home had to offer was a two level fusion. The dcotor said he didn't recommend it, but fusion was the only procedure he offered. He knew about ADR but was skeptical about it - his only direct experience had been in Europe in the mid-80s, and he was very concerned about revisions due to ADR material failure after a certain number of years.

So that led us to start researching ADR, where we found this website and a number of others (thanks for all the info). We came across Texas Back Institute, who by most accounts appear to be among the leaders in the U.S. with ADR.

My wife and I traveled to Dallas from Alabama to meet with Dr. Blumenthal at TBI in February and he suggested a hybrid procedure - but interestingly suggested it only because of insurance reasons (insurance would pay for the fusion at S1-L5 and then we would pay for the ADR at L5-L4 out of pocket) - he didn't mention that her previous laminectomy would be a contraindication for ADR at the S1-L5 level...is a hemilaminectomy a contraindication for ADR?

Dr. Blumenthal send my wife for a discogram and a post discogram CT scan. It confirmed that the source of her pain is most likely the two bad discs.

Now the only problem was - how to pay for it. Dr. Blumethal said he thought it would be about $20,000 out of pocket for the L5-L4 ADR with insurance picking up the S1-L5 fusion, the hospital, etc. Well we waited weeks and got bounced around to 10 different people at TBI to attempt to confirm this number. Seems it shouldn't have taken more than a day to do the insurance check? Anyway we were very frustrated with TBI because it seemed that no person was handling my wife's case - and she was having to tell different people the same information multiple times. Finally this week they contacted us and said it would be $30,000 out of pocket...that made us reconsider looking at Wockhardt hospital in India and a Dr. Rajakumar. Their price for two level ADR or the hybrid fusion/ADR would be around $16,000 for everything including a 10 day hospital stay and a 7 day hotel stay after that...I'd much rather do it in the U.S....but with TBI's apparent adminstrative disorganization, bad customer service, and almost double the cost.

Dr. Rajakumar has not seen my wife's films yet, but seemed to think that her hemilaminectomy S1-L5 was a contraindication for ADR at that level. He is proposing to use the O-Mav (oblique entry at 30 degrees from direct anterior) disc...any opinions there? I know I saw a paper than said the oblique entry gave a larger chance of misalignment? Dr. Rajakumar likes that the great vessels can be better avoided by the oblique entry...Dr. Rajakumar has done about 200 lumbar ADRs and many more cervical ADRs...

I hope for the best, but I'm still worried about going overseas for surgery. On the surface, it appears that Wockhardt Hospital - Bangalore is world class facilty - it is JCI accredited and has a partnership with Harvard Medical International...so that makes a person feel a little better. And their customer service has been very attentive. The surgery would be set up through the Taj Medical Group....

Does anyone have any thoughts on what type of risk we are taking here? I know one guy on the forum (Piglet) had cervical ADR with Dr. Rajakumar and he said he is OK...but I haven't been able to get much more info on the net on him in particular...

I think I understand the general risk in leaving the U.S. for a serious medical procedure in technically a third world country...but are there any specific things that we should be looking out for here?

Sorry for the long post...appreciate anyone's thoughts/insights.

Tigerpaw75

[Angintx]

Tigerpaw,
I just had surgery 10 days ago with Dr. Blumenthal at TBI. They have been nothing but professional, informative and very through. I would recommend them for your wife's surgery. I had ADR at L5-S1 and have been very pleased with the outcome thus far.
Good luck with whatever you decide.

Angie

[tigerpaw75]

Angie,

Very glad that your surgery experience went well. I wish she just had the single level problem like you - we would have signed up for one of the clinical trials (I think they are doing the Freedom disc now). If you don't mind saying, did you pay out of pocket or did your insurance cover the procedure? If it was out of pocket do you mind saying approximately how much it was? We were quoted about $30K for the ADR at L5-L4 in conjunction with a fusion at S1-L5 that our insurance (BC/BS of Alabama) will pay for. I assume the insurance company would be billed $40-50K just for the fusion, hospital stay, anesthesiologist, etc.

I don't think either me or my wife doubt that the TBI doctors are among the leaders in the U.S. (and the world) and perhaps the best, it was the disorganized and unresponsive way they dealt with our very serious questions regarding the costs. TBI obviously knows that almost all insurance does not cover these procedures, and most folks don't have $20-30K (or more0 laying around to drop on a medical procedure - that's why most folks have medical insurance. So it would seem that they should know prettly closely how much the more common procedures cost, and be able to respond quickly, and perhaps even offer advice to patients to get their ADR claims reimbursed through appeal procedures. Instead we got passed around from one admin person to another and it seemed no one was keeping notes or putting anything in our file, as every time we called to folllow up on a question we talked to someone new who seemed to know nothing about the question we asked the week before that had not been answered.

And not to mention that Dr. Blumenthal was $10,000 off on the price he told us verbally in February ($20K) vs. what we were quoted this week ($30K).

When looking at India, I'm worried, but we are getting the contact info on several other lumbar ADR patients who had surgery with Dr. Rajakumar at Wockhardt Hospital in Bangalore. If all that checks out - is it worth double to go to TBI?

Thanks again for your comments. I am still holding out a faint hope that we will somehow end up at TBI...and find a way to work out the money.

[scduggan]

Dear Tigerpaw,
Welcome to the website. I am sorry for you and your wife. I wish I had some words of wisdom for you about your situation. There are so many people going the medical tourism route. The number of cases your Indian surgeon has is definately a huge plus. One of the most important things to consider is who will care for her here.

I had a one level ADR at TBI about four weeks ago. My insurance does not cover ADR, but I was lucky enough to enroll in the Freedom trial. My experience there was better than I could ever imagine. On the other hand, I get what you are saying about the run around. That is very frustrating and sends a bad message. I wish you could find the name of a Big Cheese there and get the swift attention you deserve.

Hopefully someone will chime in soon about the hemilaminectomy. I am not that familiar with the procedure. I know if there was some bone removed it is usually a contraindication for ADR.

Good luck with your decision making. Both options look good. You guys will probably have some kind of a gut feeling about which is best for you.
CD

[Harrison]

Tiger,

I don’t believe that a hemi is a contraindication, though it could be for certain clinical trials that may have strict(er) selection criteria.

I wonder if your situation is anomalous, as TBI is generally known to be a higher volume operation; so the pricing situation should be more streamlined. It reminds me of what I went through in 2003, which was far worse. A short elaboration follows…

Since ADR reimbursement was nearly impossible in 2003 (before the Oct 2004 FDA approval), I wanted a cash price for the entire ADR procedure. I made a zillion calls to the folks at New England Baptist Hospital, and eventually met with the CFO to plead and beg for some pricing details. But all of this was a waste of my time – I left without a cash price!

Shortly thereafter, I negotiated a “conditional reimbursement” from BCBS Massachusetts: if lumbar ADR was approved in 2004, I would be reimbursed the $20,000 I had to pony up to the hospital before my surgery. I had lumbar ADR surgery in Boston with Dr. Banco in June 2004, who started (with other docs like Dr. Blumenthal) Charite’ lumbar ADR trials in 2000. My outcome was overwhelmingly positive and I made a quick recovery. And yes, I actually got my money back from BCBS, less the $500 co-payment.

BTW, Dr. Blumenthal performed the first ADR in the US in 2000. The first patient had his ADR exactly ten years ago -- happy anniversary Kyle!

My preference then -- and more so now -- is to have any surgery stateside and seek out the best possible care for surgery and follow-up. Also, please note the stories of others who have described their uncomfortable travels and (infrequent but sometimes horrible) outcomes without the benefit of follow-up care.

[Angintx]

Tigerpaw:
I was seeing Dr. Jessica Shellock at TBI first. My insurance would not pay for the ADR only for the fusion so I asked what it would be out of pocket for me and they quoted $20000 for one level ADR. Dr. Shellock took my case to Dr. Blumenthal who said I would be a good candidate for the Axiomed study. Two weeks later I was having the surgery and ended up with the Prodisc instead of the Freedom Disc.
If your wife needed just one level ADR I would say this is definitely the way to go. I know the study will not take patients needing two level ADR.
I guess since I was seeing Dr. Shellock first I never delt with anyone besides her her assitant Dr. Blumenthal and his assistant. They were all great and answered all my questions called me back immediately etc.
I would highly recommend Dr. Blumenthal and his staff. I think there were probably 7 people in my surgery room. They are very thorough with every aspect of the surgery.
I know money is always a concern and I don't know anything about this other surgeon but if I didn't get into the study I would have paid the 20K knowing what I know now having had the surgery.
When you call TBI just ask to leave a message with Dr. Blumenthal's assistant and hopefully she will call you back promptly. This will probably be the best way to get a definite answer on the cost.
I hope this helps.
Good luck and I hope your wife gets relief soon.

Angie

[Angintx]

One more thing:
You might want to check into CareCredit. It's credit especially for medical procedures.

[tigerpaw75]

The hospital (Texas Presbyterian?) told my wife the Prodisc was about $21,500 (discounted) and that the Doctor's fees to TBI woudl be about $8000. Does this sound right? Seems everyone else was around $20,000? I'm trying to understand the difference. This is with the fusion procedure covering the surgical costs and hospitalization ex-ADR.

Thanks,

[tigerpaw75]

Harrison,

thanks for the info. I'm going to try to call TBI back this week and see if I can get closer to talking to the right person...apparently Dr. Blumenthal's assistant (Nancy?) was on vacation much of the time during which my wife was trying to settle on the money. My wife is so frustrated she will not call them any more.

[tigerpaw75]

Just an update, I called the hospital (Texas Health Presby- Plano) today and found out we were misquoted by the hospital - the cost of the Prodisc will be about $12,600, which when you add in TBI's charges of $8000, nets out of about $20,600 ..BC/BS Alabama will be paying for the fusion and all the peripherals. 20K out of pocket was more what we were expecting. Apparently we were erroneously quoted a full, non-discounted price for the Prodisc. Just frustrating it took 6 weeks to get a solid number. We will try to get reimbursement later, but I won't be holding my breath...going to try to max out our Flex Spending Accounts for the rest of the year to help a little...

My wife also got a call from Cheryl at TBI today, who apologized profusely about the runaround that she had gotten. Apparently there are some communication issues between the hospital and TBI, that they are going to work on to fix.

So it looks like we will be going to Dallas in a couple weeks for a L5-S1 ALIF fusion and a Prodisc L ADR at L4-L5...with Dr. Blumenthal.

Any advice on what to do between then and now, questions to ask? She still has to have a few diagnostic tests and go through the psyche test prior to surgery...

No offense to the Indian surgeon we were considering, but I'm glad we don't have to make a 20+ hour flight to Bangalore. But I was ready to go if TBI was going to be $30K+...and I do think folks should check out Dr. Rajakumar at Wockhardt (soon to be Fortis) Hospital in Bangalore. I think it is a world class facility and by all accounts I could find does good work in this area.

Tom