Dealing with Bureaucrats

Sep 3, 2010

Sometimes you just have to shake your head and laugh when a situation gets so ridiculous and absolutely everyone else can see it except the very people who should be able to see it. Yesterday, Dr. Ken Stoller submitted the first part of his series on HBOT (Hyperbaric Oxygen Therapy) and how the treatment for George Visger and Wayne Hawkins has been progressing. When you read Part II today, you’ll realize that Dr. Stoller is now also getting a taste of the typical bureaucratic runaround that retired players have been encountering for years.

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So before you read Part II of Dr. Stoller’s series, let’s kick things off with with an old video clip that came to mind about the frustration of dealing with idiots – Monty Python’s Dead Parrot sketch:
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On Treating Wayne Hawkins with HBOT 1.5 (Part II)

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By K. Paul Stoller, MD, FACHM

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In honor of the John Mackey 88 Plan, which was written into the labor agreement ratified in 2006 and provides up to $88,000 a year for nursing and medical care for ex-players with dementia or Alzheimer’s disease, or $50,000 for home care.

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The $88,000 and the name of the plan are for Mackey’s number: 88. There was no mea culpa in the creation of this plan, not even an acknowledgment that the multiple concussions football players receive has anything to do with getting dementia. This would be no different than BP denying the oil in the breeze coming off the Gulf has to do with their little accident. After all, the government has stated it is almost all gone and dispersed (NOT!). But risk-averse bureaucrats think if they say something stupid, not only will we all believe it, but it will somehow become true.

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“We would describe the goal of the plan … to provide resources to former players and their families for care and treatment of a debilitating disease that affects many elderly people,” NFL spokesman Greg Aiello said in a 2007 press release. “The League and players association both believe this was an area that needed to be addressed because of the growing population of aging former players. It is a matter of addressing a need, without regard to cause or circumstances.”

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“Elderly people…” Right. Tell that to the forensic pathologist who studied the brain tissue of Andre Waters after his suicide in 2006 at age 44 concluded he had brain damage that resulted from multiple concussions during 12 years as an NFL safety. The Boston Globe and New York Times reported in 2007 that 34-year-old Ted Johnson, who spent 10 years as a linebacker with the New England Patriots, already shows early signs of Alzheimer’s.

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But let’s not point fingers or blame anyone because now there is the 88 Plan, after all, for those that qualify, and while many don’t Wayne Hawkins does. After Wayne started getting treated with Hyperbaric Oxygen (HBOT), not only did his short term memory start to return but his whole physiology started to change. He has lost over 100 lbs in less than two months. It was as if he was carrying all this weighty baggage around with him caused by his brain injuries. To know firsthand what is taking place with Wayne Hawkins is nothing short of miraculous, and while it may not sound very professional to say something like this, it’s time to call a shovel a spade here and stop pretending that HBOT is controversial and unproven for treating Traumatic Brain Injuries (TBI). Because it’s not unproven and only controversial to those who want to put their heads in the sand and continue to make others suffer needlessly.

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However, a funny thing happened when Wayne applied to the 88 plan to get his HBOT treatments covered. By way of background, Wayne was referred to the San Francisco Institute for Hyperbaric Medicine (SFIHM) by multiple physicians who all wrote prescriptions for same, he also consulted with me and I wrote him a prescription. One of these physicians is his neurologist, Kulveen Sachedeva, MD, who has diagnosed him with Chronic Traumatic Encephalopathy (CTE) – a known cause of dementia. Wayne Hawkins has had numerous brain traumas and his story is on Brent Boyd‘s blog (click HERE to read Wayne’s story over at Dignity after Football).

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Wayne has made significant improvements in his neuro-cognitive function since beginning therapy with HBOT using the same protocol now being used with the National Brain Injury Rescue and Rehab Project to treat TBI/PTSD in the military veteran population!

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Wayne received an Explanation of Benefits (EOB) on 7/22/2010 showing that his treatments were denied because “The Type of Service is not subject to payment/reimbursement under the 88 Plan (see 88 plan Article 2.2).” What 2.2 says is that payments will not be made to any entity that has not been determined to be “qualified under standards established by the 88 Board.” Nowhere are these standards delineated in the EOB or in the 88 Plan booklet that summarizes benefits to eligible former players who have “dementia” as defined in the 88 Plan – a definition which Wayne clearly meets.

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CIGNA Health Insurance is the administrator of the 88 plan. My nurse, Gayle Link, RN, spoke with Patrick at CIGNA (phone number [570] 496-5897), at the end of July, to determine the exact nature of the denial as Article 2 provides no clarity other than to say that payment of claims is essentially “at the discretion of the 88 Board,” which paraphrased is analogous to saying the 88 Plan will pay for a service if it feels like paying for a service.

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It was Gayle’s impression that Patrick is the Benefits Administrator of the 88 Plan because he seemed to be upset that Gayle was able to reach him directly, which is why I am making his phone number public – I want him to feel the appreciation from others for all that he is doing. Gayle said Patrick told her CIGNA would not authorize reimbursement for non-prescription medications and it was his contention the hyperbaric oxygen was not a prescription drug and denied CTE (Chronic Traumatic Encephalopathy) was an etiology of dementia. After Gayle explained that not only is hyperbaric oxygen a medical procedure that requires a physician’s prescription, Wayne had over three prescriptions but Patrick continued to deny this service for eligibility. Gayle asked Patrick – since he was being so accommodating – if he was going to deny the claim regardless of any clarification she provided and he said that was his intention.

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The 88 Plan Benefits booklet states that it will cover “Physician services and Prescription medication.” There is no controversy that hyperbaric oxygen therapy is a prescription medication or a physician service. CTE is also recognized as one of the modern medical terms for Dementia Pugilistica, which is also called chronic boxer’s encephalopathy, traumatic boxer’s encephalopathy, boxer’s dementia, chronic traumatic brain injury associated with boxing (CTBI-B) and punch-drunk syndrome (‘punchy’) and Chronic traumatic encephalopathy.

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But Article 2 (2.2) gives the 88 Plan administrator(s) the “discretion” to reimburse for eligible services under standards established by the 88 Board. Gayle did not report that Patrick had cited an inability to meet these certain standards. Rather his position was that CTE is not dementia and the HBOT is not a prescription physician service.

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Now, you can only argue with someone if they agree to a common set of facts. Patrick of CIGNA is not operating with the facts the rest of us operate with, so he was quite accurate when he told my nurse that it wouldn’t matter what she said to him – he was going to deny coverage. One can only speculate on what Patrick’s facts are; for example, denying NFL players who qualify for 88 Plan benefits coverage is how he will not only keep his job but advance up the corporate ladder at CIGNA. If I had to guess… that was his set of facts. Just like chronic TBI doesn’t cause dementia and hyperbaric oxygen isn’t a physician service.

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I am one of those people who believe that when a system is broken, you don’t try to fix it, you go around it. It is time to bypass CIGNA and go directly to the 88 Board and hold them accountable. Who is ready to join Wayne in this effort?

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Kenneth P. Stoller, MD, is President of the International Hyperbaric Medical Association, a Diplomat of the American Board of Pediatrics, a Diplomat of the American Board of Hyperbaric Medicine, a Fellow of the American College for Hyperbaric Medicine, Medical Director of the San Francisco Institute for Hyperbaric Medicine, the Hyperbaric Oxygen Clinic of Sacramento, and the Hyperbaric Medical Center of New Mexico. A book by Dr. Stoller’s late son will be published at the end of the year (www.dreamtreaderpress.com).

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4 Responses so far | Have Your Say!

  1. Dave Pear
    September 3rd, 2010 at 6:49 pm #

    Dave Pear
    The NFLPA Leadership AND the NFL make up their OWN rules.

    For 25 years, former NFLPA Director Gene Upshaw stood behind his “imaginary” laws that did NOT exist when he unwittingly said, “You can’t receive a disability benefit and a pension because it is the Law.” When finally asked by Michael Leahy from the Washington Post on Super Bowl Sunday February 3, 2008 if he was sure, Gene said, “Yes.”

    However, his own lawyer Lanny Davis corrected Gene and said, “It is discretionary.”

    Well, the Upshaw legacy is still here. Nothing has changed! The NFLPA Leadership and the NFL continue to use their “discretion” to deny benefits and leave injured retired players in a lurch.

    De Smith – nothing has changed!

    Regards,
    Dave & Heidi Pear

  2. Lionel James
    September 3rd, 2010 at 7:52 pm #

    Lionel James
    OK we started with Dr. “No” but then he lied to 60 Minutes when he stated that there was no long-term Brain Damage due to Concussions from playing Football. The owners wanted to see if it would fly over the masses of the U.S population and they got a resounding NO to Dr. No. So they got together to work up another scheme but could not. Eventually, that poster in all NFL Locker Rooms showing how to wear equipment. But then they went one step further and have been trying to pass it on to the High Schools in our country. That’s a good start but what are you doing to assist the old players who got hurt and were expected to continue playing and are now suffering the consequences? The whole world knew that Dr. No was lying but he said it anyway because he had the Board of Whoever in the NFL Owners Committee backing him. Once they figured out that they couldn’t stand behind his statement, he resigned – or was fired. Or let go. Whichever sounds good to you.

    So now we have retired players who are being denied because of the collusion between a group of professional people who took the Hippocratic Oath to uphold the quality of life with another group – or Board – who knows what the correct treatment is supposed to be for us. But with their big salaries and the ability to hide behind their highly-paid lawyers provided free to them, they have the ability to take a crazy stance like they are taking. I have one question: What are they prescribing to their regular patients who have the same diagnosis as football players but who never played football? I know there’s a Doctor-Patient confidentiality so we may never know. It’s amazing that the Doctors who have the most extensive education would have so many crutches to stand on. Ball players have been known in the past as “DUMB JOCKS,” but in my view they’re the only true players. We have played in so much pain that an ordinary person could not endure and a street doctor (someone outside of Pro sports) would never advise it. We made a decision to be there for our teammates and coaches and now we see that the so called true professionals, our team doctors, and doctors in general are all liars. With that said, if the Owners, Doctors and Lawyers are all in bed together, where will our justice come from?

    Now again I ask: What does Anti-Trust Law mean, how does the 501(c) 3 tax law apply and how does it all tie in to the CBA? There are always crutches in every corner for the owners to lean on.

    Irv Cross, you seem to be knowledgeable when it comes to the legal issues – could you respond to this? I’m sure that there are many more than me who would like to get these answers.

    Lionel James
    San Diego Chargers
    1984 – 1988

  3. Mary Hilgenberg
    September 4th, 2010 at 10:45 am #

    Wally Hilgenberg
    Hi Dave,

    My name is Mary Hilgenberg. I am the wife of Wally Hilgenberg who we thought died from ALS but now we know it was CTE. I keep reading your blogs and Brent Boyd’s blogs.

    I get furious with how the NFL continues to treat the retired players. The NFL denied us any help even though Wally needed 24-hour care. He apparently had to have dementia to be helped!

    I’m fighting to get help for all the players with ALS. If you have any ideas or know of any good lawyers that are working with the retired players please let me know. I don’t want one other family to suffer the way we did.

    Thank You
    Mary Hilgenberg
    for Wally Hilgenberg
    Detroit Lions, Minnesota Vikings
    1964 – 1979

  4. And now, it’s the defending Super Bowl champion New Orleans Saints — but is it worth the price to the players? « Franorama World
    September 8th, 2010 at 1:48 am #

    [...] Raiders and Buccaneers center Dave Pear, who played in Super Bowl XV with a broken neck, has been among the most vocal ex-players with his [...]