The article grossly misrepresents the premise of physical therapy and therapy services. They are in place to promote independence and are about teaching. Two things must be in place for continued PT. one: medical necessity. Two: a skilled need. The person you spoke of in the article got better on her own. Meaning she was able to go through the exercises and teaching that was provided. PT is not about taking someone through the same exercises or transferring patients. It's about educating caregivers and family to continue the movements TAUGHT to them. Teaching is involved and the patient or caregiver needs to participate in the therapy in order to be effective.
5
The larger issue here is that Americans want Medicare (or any insurance) to pay for everything. There have to be limits on coverage as people age, become debilitated and unable to truly recover. They are then more appropriate for a less costly level of care. We cannot sustain this excrutiatingly expensive care for patients who cannot benefit from it. They often need aid to perform exercise but not a therapist.
Medicare has been ordered to provide unnecessary care just as it was in the 80's when it was deemed that ALL renal failure patients must be given dialysis. That only created a large class of severely ill, costly patients with no quality of life that we pay millions to transport by ambulance for thrice weekly dialysis and often recurring hospital admissions. This is what gave rise to the lucrative dialysis industry.
Decision making and taking responsibility for our health is hard but must be done and we all must live with the consequences of poor health from poor lifestyle or bad luck. No amount of money will change the circle of life.
Medicare has been ordered to provide unnecessary care just as it was in the 80's when it was deemed that ALL renal failure patients must be given dialysis. That only created a large class of severely ill, costly patients with no quality of life that we pay millions to transport by ambulance for thrice weekly dialysis and often recurring hospital admissions. This is what gave rise to the lucrative dialysis industry.
Decision making and taking responsibility for our health is hard but must be done and we all must live with the consequences of poor health from poor lifestyle or bad luck. No amount of money will change the circle of life.
4
So speaks someone who's never been on the receiving end of that cavalier and callous attitude. I hope you're never the one in that dialysis unit someday, RB, since I don't generally wish ill on people, but if you were, you'd probably learn a lot about the value of a person's life.
10
They didn't know! What a crock. They knew but their bosses told them that people are used to getting denied, just do it. They figured for the one or two who complained most would accept it and pay or suffer the consequences. The managers who made these decisions should be jailed!
3
There is abuse in providing rehab services unnecessarily by for-profit companies, especially in SNF. One of the biggest causes is the link between rehab and inpatient stays..that is the bed is subsidized by Medicare when the patient is participating in therapies. The more therapy minutes, the higher the subsidized rate up to 100 days. But regardless of how long therapy is provided, Medicare requires therapy to be SKILLED in nature - even the maintenance aspect. Skilled therapy requires that what is provided must be of a sophistication that requires the skills of a licensed therapist. So if a patient's mobility needs can be met by a personal trainer, recreational therapist or nurse (or nursing aide), the service would not be covered under Medicare. Skilled therapy is generally short term in nature because it is largely instructive (rather than practice) and progressive. Too many people equate therapy with physical activity. Therapy is not physical activity.
6
Millions of essentially worthless people are responsible for untold trillions of dollars in healthcare expenses. People with no chance of meaningful recovery, and certainly no chance of ever contributing anything to society (if they ever did in the first place). Quite the opposite! They're burdens to society.
If healthcare resources are doled out indiscriminately, the majority of expenses will (and do) go to a minority of chronically ill, chronically hospital-/PT-/dialysis-/LTAC-/etc.-dependent patients. In other words, our healthcare resources are being used to sustain the lives of those least valuable to society. It may sound crass, and I don't expect it to be a popular thing to say on The Times' website, but it's the truth. I see it every day. And it's not sustainable.
If healthcare resources are doled out indiscriminately, the majority of expenses will (and do) go to a minority of chronically ill, chronically hospital-/PT-/dialysis-/LTAC-/etc.-dependent patients. In other words, our healthcare resources are being used to sustain the lives of those least valuable to society. It may sound crass, and I don't expect it to be a popular thing to say on The Times' website, but it's the truth. I see it every day. And it's not sustainable.
6
Michael, you seem to incorrectly assume that people with physical disabilities are worthless and unable to contribute to society. Stephen Hawking and many other very accomplished people apparently didn't get that memo! And no one is worthless to those who love them.
15
You must be a real joy to be around. Judgmental much?
10
I think I know who is a burden to society and I don't think it is the individuals being discussed in this article. You might access a mirror for this investigation.
13
Please do not blame the therapist. They are trained that unless they can document improvement that Medicare will NOT pay for claims and do not keep seeing these pts.. My 95 yr old mother was doing well at Physical therapy to improve balance and walking . We were hoping to prevent falls as she became stiffer and frequently lost got wobbly when walking.
Her therapist followed the guidelines he was given by Duke hospital and discharged her after 8 weeks. I told her she has to help him justify his treatment of her and to tell him how much she is improving so he can document it. This worked for awhile but eventually he discharged her and yes she has deteriorated .
Thank you NYT for this information and I will get her back in therapy ASAP.
However remember its the system not the therapist who is denying service.
Her therapist followed the guidelines he was given by Duke hospital and discharged her after 8 weeks. I told her she has to help him justify his treatment of her and to tell him how much she is improving so he can document it. This worked for awhile but eventually he discharged her and yes she has deteriorated .
Thank you NYT for this information and I will get her back in therapy ASAP.
However remember its the system not the therapist who is denying service.
8
I've seen this problem when trying to get outpatient physical therapy for my parents. Medicare covers a few weeks, then the 'plateau' assessment arrives from the PT group and you're done. We have faxed copies of articles detailing that coverage is allowed if necessary to maintain the patient's condition. Didn't work. Also spoke with management, and response is 'the case is closed, the records are confidential and you need a new doctor's order." They made it clear they have no plans to comply.
8
It is sad that some hospitals and nursing homes put most emphasis on making a profit, while providing sub-standard rehabilitation services.
However, in reputable rehab departments, which provide efficient, fair treatment by professional, empathetic PTs, OTs, and Speech Therapists, there are many patients who really do reach a plateau and no longer show progress toward more advanced functional goals.
By this point, therapists have usually instructed the patient, and nursing home staff or family members, in a maintenance program, such as - written and illustrated exercises, assisted transfers and gait, using a transfer/gait belt, and use of daily living assistive devices for dressing,etc.
A real-life logistics challenge is that, if rehab staff members are required to continue providing "skilled" therapy, when in fact, it is "long term maintenance assistance", then the rehab department schedule no longer has sufficient openings for new, more acute patients.
In addition, when patients are discharged home, they and their family helpers may lose motivation to continue doing enough exercises and walking, and their mobility declines.
Also, significant obesity makes all mobility activities much more difficult.
The Times recently had an article about many nursing homes which have accepted severely obese patients. However, daily care tasks require extra staff and equipment and consume so much time, that these facilities stop accepting very obese patients.
However, in reputable rehab departments, which provide efficient, fair treatment by professional, empathetic PTs, OTs, and Speech Therapists, there are many patients who really do reach a plateau and no longer show progress toward more advanced functional goals.
By this point, therapists have usually instructed the patient, and nursing home staff or family members, in a maintenance program, such as - written and illustrated exercises, assisted transfers and gait, using a transfer/gait belt, and use of daily living assistive devices for dressing,etc.
A real-life logistics challenge is that, if rehab staff members are required to continue providing "skilled" therapy, when in fact, it is "long term maintenance assistance", then the rehab department schedule no longer has sufficient openings for new, more acute patients.
In addition, when patients are discharged home, they and their family helpers may lose motivation to continue doing enough exercises and walking, and their mobility declines.
Also, significant obesity makes all mobility activities much more difficult.
The Times recently had an article about many nursing homes which have accepted severely obese patients. However, daily care tasks require extra staff and equipment and consume so much time, that these facilities stop accepting very obese patients.
2
But inside SNFs, the responsibility is typically 'transferred' to the nursing department, which absolutely does not have the time to accomplish this maintenance therapy (never mind if the pt was actually making forward progress and family were promised the patient 'would not be discharged' when they in fact were...). Someone actually has to help old folks maintain their mobility. But there isn't enough money to hire enough staff, so it's just pass the buck and shift the blame. And don't blame the family members--we also have full-time jobs to maintain, to keep our totally inadequate health insurance!
4
Stories like this, combined with articles about profit gouging on life-save medicines such as the Epipen, clearly show the need for taking the profit motive out of our medical system. We need to put the needs of people ahead of profit. Ironically, it is the profit-mad insurance industry, pharmaceutical industry, and hospital and nursing home industries that are providing the clearest evidence of the failure of the current system. They are the ones who make the most convincing case for a true single payer system
15
I couldn't agree more! My husband, who died of cancer last month had every penny of his medical care paid for by the Italian government. That includes two rounds of chemo, radiation, ten days of intensive care and on and on. Every time I read about American health care I thank the heavens that I live in a country with socialized medicine.
8
As a nation, we need to be much more proactive about heading off lifestyle based health issues.
1
Being under 65, I had Blue Cross/ Blue Shield coverage for rehabilitation after a stroke. They used the same "failure to improve" standard mentioned in this article to terminate coverage for the rehabilitation. I did notice that other stroke survivors admitted at the same time who were on Medicare received benefits longer than I did, so I think that private insurers are probably worse about this than Medicare. However, as an encouragement to those who have also found their coverage terminated because of "failure to improve", I found that when I got home and created my own rehab program which included daily dog walking, I made more significant improvement than I ever did through physical therapy at Moss Rehabilitation Hospital.
2
I know Medicare isn't perfect but it was wonderful when my Dad was ill. Yes he had paid in to it over the years plus his taxes but he got much more back. The same with ss.
What concerns me is that Americans under 65 don't get good care, coverage. The Exchanges are expensive and many doctors won't accept the insurance.
What concerns me is that Americans under 65 don't get good care, coverage. The Exchanges are expensive and many doctors won't accept the insurance.
4
Many are missing the point of the story. CMS' position on the improvement standard was not based on statute. It was found incorrect and the courts directed it to rewrite their procedure manual and re-educate providers. They essentially ignored the court and did neither.
9
Don't kill the messenger, but the money is not there. In addition to the currently scheduled withholdings, Medicare and Medicaid needed to set aside $45 Trillion Dollars in 2014 to meet the obligations that existed as of 2014. This is according to the Trustees for the fund--not some conservative website. We are also facing a doctor shortage --roughly 1 physician for each 400 people. God forbid, some states actually take the administration up on its offer to expand Medicaid.
Single payer will not solve either of the foregoing problems. Much of the bureaucratic/administrative expense is incurred at the state and federal governmental level, i.e. that expense will not go away if single payer is enacted. Rationing is coming and no one, except elected officials and their staff, will be able to opt out. The ACA will impose a 40% tax on all decent insurance plans (scheduled 2016, postponed till 2017, now postponed to 2020) or it will collapse even sooner.
We need some people telling the truth and this article doesn't meet that standard.
Single payer will not solve either of the foregoing problems. Much of the bureaucratic/administrative expense is incurred at the state and federal governmental level, i.e. that expense will not go away if single payer is enacted. Rationing is coming and no one, except elected officials and their staff, will be able to opt out. The ACA will impose a 40% tax on all decent insurance plans (scheduled 2016, postponed till 2017, now postponed to 2020) or it will collapse even sooner.
We need some people telling the truth and this article doesn't meet that standard.
3
When our government can pay $1 trillion plus for ONE PLANE, the money is there!
8
When our government can pay $700 billion to the big banks, insurance companies and other Wall Street firms for losses from their own greed and corruption, lying and excessive risk, it (we, the people) can design and pay for a decent health system for the rest of us.
7
I have argued this with my father's nursing home since the law was initially passed. I gave them the links so they could read about this law. I printed out copies in long and in condensed forms and brought the copies to them. They shrugged.
He was a physically healthy person who could walk as well as I can. The nursing home put him in a wheelchair anyway, locked it, and yelled at him every time he tried to stand up.
They refused to give him any and all physical therapy or even just periods of walking with someone because he has dementia and "won't remember" what they tell him.
Now he is permanently wheelchair bound. How can people so dumb, and frankly, cruel, be allowed to make decisions and set policy in any kind of health care facility. This nursing home got Medicare's highest rating.
I assume they based that on the shiny floors.
He was a physically healthy person who could walk as well as I can. The nursing home put him in a wheelchair anyway, locked it, and yelled at him every time he tried to stand up.
They refused to give him any and all physical therapy or even just periods of walking with someone because he has dementia and "won't remember" what they tell him.
Now he is permanently wheelchair bound. How can people so dumb, and frankly, cruel, be allowed to make decisions and set policy in any kind of health care facility. This nursing home got Medicare's highest rating.
I assume they based that on the shiny floors.
11
Ah yes, walk in, ride out. My mother, also. The nursing homes are rated on numbers of falls, so Mom's "rehab" consisted of 23 hours a day not allowed to walk, and one hour of walking practice. No waiver she could sign. No, I could not be the one who walked with her. They kept an eye on her every minute. Why did I not more forcefully intervene?
2
My personal experience has been that Medicare has been a dream compared to private insurance. Private insurance companies (AETNA) delayed paying for my treatment for very painful severe rheumatoid arthritis for six months, until I threatened legal action. Medicare has never denied my treatment, despite there being no cure for RA and that the medications are very expensive. The difference is that the private insurance denied me because they are trying to make a profit, meanwhile Medicare is going bust. This is all very complicated. We have developed wonderful treatments that we really can't afford to give to everybody. I think we need to focus our efforts more on disease prevention.
4
Let's focus our attention on universal medical access for everyone.
7
Our experience with the "failure to improve" criterion came just before the change in regulation. My mother had a severe stroke and was in a rehab hospital for three weeks. My father in law had a fall resulting in brain injury and was eventually hospitalized in the same rehab hospital. Although their injuries and the immediate results of their injuries were different, the course of "treatment" at the rehab hospital was exactly the same: 15 minutes of physical therapy morning and afternoon and 15 minutes of occupational therapy once a day (none on weekends). They would be picked up in their rooms by the therapist, who was usually late, rolled to the therapy room where they would have much less than 15 minutes of treatment, and then rolled back to their rooms. Then with the exception of meals, they would spend the rest of the day in their rooms or in a day room. The actual therapy exercises and daily experiences between my mother and father in law did not differ at all. My mother was discharged for failure to improve after 3 weeks, which was the Medicare limit at the time; my father in law was discharged for failure to improve after about a week. To me, it was no surprise that with the very limited, outdated, and predetermined course of treatment that they received they failed to improve. The personalized treatment plans that they ostensibly received were an illusion to make it sound more acceptable when they "failed to improve." Cookie-cutter treatment plans=lower costs.
18
You are spot on with this analysis of physical/occupational therapy. I observed this as well after my stroke. Although brief, such regimens are still extremely costly to the healthcare system and virtually useless.
3
Good people on both sides can disagree re this specific case.
However there are many other people who are ripping off Medicare...
1-The Billionaire health execs. who are making fortunes off of unneeded treatment and expensive drugs.
2-Outright criminal thieves on all sides both the con artist and the pro.
3- Hypochrons., who bleed the system dry with their 24/7 going to the doctor.
Let's do something about these people first...
However there are many other people who are ripping off Medicare...
1-The Billionaire health execs. who are making fortunes off of unneeded treatment and expensive drugs.
2-Outright criminal thieves on all sides both the con artist and the pro.
3- Hypochrons., who bleed the system dry with their 24/7 going to the doctor.
Let's do something about these people first...
7
Why? There's no reason that people who need care should be denied because there are some who are (allegedly) ripping off the system. Find and prosecute those who violate the law. Provide the care that the court ruling requires. Simple as that.
1
I work for a SNF and I have the responsibility of issuing the Medicare denial notices. In a SNF, these notices are only required to be given 48 hour prior to the last Medicare covered date (which is the day before discharge for short term residents who are in the facility for rehab). We as a facility due our very best to set discharge dates based on the improvement of our residents, taking into account their safety and well-being upon discharge. When I issue a Medicare Notice of Non-Coverage, I do not wait for the required time frame before issuing. If I am given a date 1 week prior to discharge, I give my notification to the resident at that time to ensure that they are aware of their appeal rights and give ample time to file an appeal and receive a decision back from the QIO. I explain how simple it is to file an appeal if they do not agree with the discharge date as the first step for an expedited appeal is only a phone call. If a resident is unable to make their own decisions, I contact their designated representative to explain these rights to that person. On the occasion that a resident is unable to advocate for themselves, and does not have a designated representative to do so, I or their social worker at the SNF will assist them in filing an appeal. The system is not perfect, but those who have the opportunity to make improvements should do so for the benefit of those who require our care.
6
Great article, although perhaps you need to clarify the length of coverage. If my understanding is correct, Medicare only covers the first 20 days at 100%. Days 21 thru 100 are at a lesser percentage; if they have supplemental insurance, it usually covers the difference, if they do not, it is out-of-pocket.
My bigger concern are the Medicare Advantra products, such as Health America and Aetna. They frequently deny any request for skilled nursing! If the patient is able to ambulate 30 - 50 feet with a walker, they say that this is adequate for return home, even if they live alone, in a two story house and are at high risk for falls.
The Medicare 3 day Inpatient rule for skilled nursing is also an injustice. For example, if a patient falls and fractures an arm or shoulder, or even their back, and does not require surgery, they are an Observation patient, and thus will not qualify for skilled nursing. And if the patient is an Inpatient, why do they need the third day to qualify for skilled nursing? A fractured hip or knee that requires surgery is often stable for discharge on Day 2, but we need to justify the third day in order to qualify for skilled care! This is extremely wasteful of Medicare dollars! Much most cost effective to discharge them to skilled care rather than stay in the hospital an additional day.
My bigger concern are the Medicare Advantra products, such as Health America and Aetna. They frequently deny any request for skilled nursing! If the patient is able to ambulate 30 - 50 feet with a walker, they say that this is adequate for return home, even if they live alone, in a two story house and are at high risk for falls.
The Medicare 3 day Inpatient rule for skilled nursing is also an injustice. For example, if a patient falls and fractures an arm or shoulder, or even their back, and does not require surgery, they are an Observation patient, and thus will not qualify for skilled nursing. And if the patient is an Inpatient, why do they need the third day to qualify for skilled nursing? A fractured hip or knee that requires surgery is often stable for discharge on Day 2, but we need to justify the third day in order to qualify for skilled care! This is extremely wasteful of Medicare dollars! Much most cost effective to discharge them to skilled care rather than stay in the hospital an additional day.
9
The 72h notice was given to us to sign as mom was ON the discharge / transport stretcher! " if you believe you are being discharged prematurely....." HA!
7
Well you can tell a lot about a nation the way it treats its elderly.
Perhaps it is time to introduce "new money" into the economy via
funds for Medicare/Medicaid rather than via very large banks.
Perhaps it is time to introduce "new money" into the economy via
funds for Medicare/Medicaid rather than via very large banks.
11
Excellent idea!
2
I have done my best to stay away from the medical system in this country because I feel that patient care has the lowest priority. Now we are forced into having Medicare. Recently my husband broke an ankle which lead to the discovery of a serious health problem. I have been appalled at the treatment he has received, both in our local "5 star" hospital as well as the rehab facility he was released to. I finally brought him home because I felt I could care for him better by myself here. Then I started getting the bills: $609 for a 1 mile ambulance ride, $850 for the ER doctor, $1,700+ for PT to come each day and deem him unable to do physical therapy, $217/daily visit for the rehab doctor who never came and saw him, $20K for the use of the operating room. He spent hours lying in his own urine & feces because there weren't enough hands on care people to help him, given drugs he was allergic to, & a swarm of docs who did not communicate with each other. When I complained about the care he was getting, I was told by his surgeon's nurse that I needed to plan to stay in the hospital with him 24/7 for his next surgery so that I could help take care of him. I wonder if they give a discount for that.
I think I would rather die than go through what he is going through now. Death I can accept. Suffering I cannot.
I think I would rather die than go through what he is going through now. Death I can accept. Suffering I cannot.
39
I wish you had given us the names of the places that caused you so much suffering and expense. They need some attention paid. It doesn't sound legal. I've had excellent care all my life but I've always had expensive health insurance. What other countries have you received medical care from?
It's all very well to rage about the unfairness of Medicare however consider this: too many skilled rehabs are in business to maximize revenue - period. They'll set unrealistic goals for sick elders and then continue to (supposedly) deliver a maximal therapy schedule ad infinitum pretending that a frail 90-year-old who has done little for years but shuffle every so slowly with a rolling walker from bed to table to couch to bathroom and who suffered a setback after a medical illness should have a goal of being a community ambulator, walking hundreds of yards. The goal cannot be achieved yet the therapy cannot be brought to an end. This makes sense? None of us is entitled to treatment that is futile and no provider should be able to deliver and bill for such, yet they do. Eventually they're caught and their fraud exposed.
17
Spot on!!
I've never seen anything like this. Sounds like a bug-house fable.
1
I am a geriatric neurologist. I am also an amateur health care economist, and strong advocate for single-payer, "socialized" medicine. Here's the problem: health care needs are essentially infinite if you broaden the definition to encompass every intervention that could help individuals live better lives, and provide it for as long as it's needed (who determines that?) or wanted. Even if we liberals could get our way on every aspect of the budget (largely defunding military spending and corporate welfare), we STILL wouldn't be able to afford everything that would make the lives of people optimal, or even close to it. "Rational rationing" is a MUST if we are going to succeed as a society. And we're going to have to decide how to spend our limited tax dollars. I would argue that health in the larger sense includes societal health: are we going to support affordable college education for all who want it, a basic minimum income for those who can't work, repairing and improving on America's aging transportation infrastructure, innovating technology to save our planet from catastrophic climate change, or providing all the medical (dental, vision, auditory) care that everyone needs to live independently as long as possible? No society can "have it all," and every special interest group takes the narrow view regarding their issue. What we're missing is the broader budgetary conversation that takes in ALL the costs and asks us to prioritize.
57
Not rational? We give billions to other countries. We give billions in tax deductions to companies who in no way need it or even provide more jobs for our citizens. It is used to line the pockets of obscenely overpaid CEOs. But pay to relieve someone's physical suffering? This country has priorities alright. Telling our citizenry to go to blazes. Somewhere there is a CEO whose wallet needs fattening. Criminal.
16
But the problem is, when elders get sick, someone is going to take care of them. That someone can be a paid caregiver or set of caregivers in a nursing home (expensive), or they can include unpaid family members. I'm a highly, expensively trained STEM professional who, in my day job, handles major taxpayer funded projects that require my cognitive energy, teaches future professionals and citizens; I'm also a mother of a future taxpayer. When I had to care for my ill father (who ultimately but unnecessarily died after being discharged from PT/OT/Speech therapy for 'failure to progress' even when he actually DID progress), those other responsibilities suffered. Not treating people doesn't make the problem go away, it just shifted the public's cost onto my NASA and NSF grants, the state education department and whatever therapy my kid will need in his later years from having a brutalized and exhausted parent (not to mention what he had to see his grandfather go through). There is no free lunch, unless you plan on euthanizing people. It isn't a question of care or no care--and facilitating people remaining as independent as possible reduces costs elsewhere, some of them invisible (and frequently deposited on the shoulders of unpaid, usually female, caregivers).
14
Thank you so much for your comments, which mirror the mistakes in care for my mother's Parkinson's.
1
I'm for Medicare payment for maintenance therapy, but let's be adults about this. It's going to cost a lot of money and the Medicare trust fund is already well on its way to depletion. We are going to have to contemplate a serious increase in the Medicare payroll tax. What politician has the guts and integrity to propose it?
13
So, what is this woman supposed to do? Die? Or, go broke and end up on public assistance? The government would still be paying but a different part of the government is paying. This is a bad system where elderly and/or disabled patients who do not have a medical advocate or the mental or physical wherewithal get shorted.
16
There is plenty of money available for Medicare the only problem is much of it has been diverted to other agencies. You are drinking the cool aide while the insurance business gets fatter and fatter or hey how about one bank give the tax payers back our money.
We have the worst health care system of any developed county. My European friends fly home when they need care or surgery.
Interestingly BCNS paid 100% for surgery done in another country as they saved so much money compared to what the hospitals here would have charged.
We have the worst health care system of any developed county. My European friends fly home when they need care or surgery.
Interestingly BCNS paid 100% for surgery done in another country as they saved so much money compared to what the hospitals here would have charged.
2
FDR
This is one of the least reported issues that affects the most people in medical reporting....and has been underreported since last summer. At least it appearaed here. Should be front page NYT.
17
Perhaps the CMS denied claims, as they so often do, to reduce costs for Obamacare. The elderly are getting stiffed - higher premiums, denied or reduced coverage, and higher bills. But, the billions coming in through other 'fees' collected by CMS and the IRS are going... where? Oh, to subsidize those that buy on the exchanges and to shore up coverage for the medicaid expansion that the fed so generously offers to states, for now.
We need a complete review of CMS, there actions and rules as they implement the ACA (obamacare), and a review of all budgets and salaries across the 100+ new agencies created since 2009.
But, instead readers blame corporations and insurance companies and greedy doctors. Just because the NYTimes fails to disclose the whole story, doesn't mean you have to swallow the kool-aid.
We need a complete review of CMS, there actions and rules as they implement the ACA (obamacare), and a review of all budgets and salaries across the 100+ new agencies created since 2009.
But, instead readers blame corporations and insurance companies and greedy doctors. Just because the NYTimes fails to disclose the whole story, doesn't mean you have to swallow the kool-aid.
3
Please read the article. This has nothing to do with Obamacare; they've been doing it since time began.
17
Given the choice between being confined in a chair or Euthanasia for me there is no contest. Hopefully someday we will be allowed to decide how we want to exit this world and when with the least amount of discomfort possible. IMHO
22
Nonsense. Try it before you decide it's worse than death. The people I've been close to who have been in wheelchairs still got pleasure out of life and wanted to live. "Have you ever been grateful for a gift you didn't deserve?" I asked my mother after hearing that question at church. She answered instantly: "Life! Every day!"
2
a disgrace.
16
I think it's clear that Medicare, like private insurers, rations care. To those readers below who would characterize the problem as being "too many baby boomers" or the "laws of physics,” apparently we have to keep reminding ourselves that the United States – alone among industrialized countries – clings to a structure that makes profit, rather than health, the paramount objective of the health care system. As a result, we spend more on health care than any other industrialized country, and for outcomes that include not only lower life expectancies and higher infinity mortality, but also the constant threat – hanging over virtually everyone on both sides of 65 – of being bankrupted by medical bills in the event of serious illness. Scrap “being bankrupted.” Far too pretty a term. Substitute not being able to pay for essential care or losing life savings to get it. So, no, there's nothing irrational about Medicare being under a legal requirement not to kick the wheelchair out from under those who need one, especially if that's what it takes to make everyone wake up and see the entire system needs to change. We have lots of alternatives out there for universal care to examine, and no choice but to fashion one for ourselves given the share of health care spending paid by the federal government. So let the laws of mathematics commence, if we can still find them buried in the morass of misinformation from industry lobbyists. And let the real political fight be engaged.
29
This article reminds US to consider that “improved,” ( or not,) is not just a linear, binary-based, contextually influenced word, concept, process, goal, judgment,state, outcome, etc.,It is used, as well as misused, accurately and inaccurately, by influential people and systems to achieve realistic as well as unrealistic goals, interests, etc., which in the ever present reality of uncertainty and unpredictably may or may not be measurable given the state of knowledge,technology and relevant available and accessible resources at that time and place.When the targeted PERSON-patient-client was initially assessed to determine a viable intervention-treatment plan were his/her inner resources (somatic,psychological, emotional, cognitive, spiritual,social, etc.)documented in a way that a they could abe engaged and used during the various treatment phases; noting both flaws aand gaps? External resources as well; networks of people, places, systems? By whom, in terms of expertise, disease as well as wellbeing orientation, experience and knowledge?How much time was allotted and how often? When the objective of a medical system’s training of staff and treatment experience is “ cure” and not viable care(ing), levels and qualities of well being- judgmental underpinnings of “either/or,“”success/failure,” being overridden by “ and in addition”-“improvementS” over time, temporary or more permanent, will hopefully be ONE of the acceptable and realistic markers for planned change.
1
Medicare is a single payer system, the kind of single payer advocated by many. All health care systems eventually run into an upper limit of how much spending they can tolerate. In the US, medical care is one sixth of the economy, but in a decade it will be a quarter. Expect more conflict on this topic. Many single payer plans worldwide prioritize children and working people ahead of seniors, in the US it's just the reverse with all seniors covered under Medicare and many children and working age scrambling.
7
I once had an othopedist who couldn't figure out why my arm still hurt a year after a fall. He told me I had developed another bout of a chronic pain disorder and needed to learn to live with the pain. I changed orthopedists. The new one examined me, did an MRI to rule out bone damage, and put me in a brace designed to treat tennis elbow. Between the brace and new anti-inflammatories, I was nearly pain free in six weeks. If I wasn't aggressive about finding a doctor to actually treat me, I might never have gotten the treatment I needed because I had "failed to improve." I just hadn't gotten the right treatment.
35
Not a big deal? wait till it is your father, mother, or maybe you.
19
More American barbarism. The rest of the world is right to be slack-jawed at the gall of a nation like this one lecturing everyone else on human rights. "Human rights?" What about the "human rights" of the taxpaying public in this country? Our worship of capitalism and military power is revolting, as we turn a blind eye to helpless elderly citizens experiencing the modern-day equivalent of being turned out on an ice floe. Every day I feel certain I've finally read the most infuriating, egregious thing I'll ever see in a newspaper, and the following day I'm inevitably proven dead wrong. I wonder what bile-inducing affront to all that is decent a read of tomorrow's paper will bring?
17
When will we accept that Health Care and Profit Do Not Mix?
42
What does this case have to do with profit? Medicare is a non-profit federal government program.
If article illustrates anything, it is not the uncompatibility of compassionate health care and profit motive, but rather the incompetency and lack accountability of government bureaucracy that is set in its ways and keep doing what it was doing despite the lack of legislative mandate and the intervention of the court.
If article illustrates anything, it is not the uncompatibility of compassionate health care and profit motive, but rather the incompetency and lack accountability of government bureaucracy that is set in its ways and keep doing what it was doing despite the lack of legislative mandate and the intervention of the court.
3
And the specter the Republicans were giving us were government death panels. The specter we needed to be afraid of were the shareholder/boardroom death panels. "Well, people who aren't showing 20% improvement in three weeks after transfer aren't receiving enough benefit to make treatment cost-effective. We need to terminate their care to keep up our bottom line."
10
This has nothing to do with profit. This is the Medicare program, which is supposed by many to be the cure for the ills of the health insurance industry. It's never as simple as people think.
2
The demand for health care services for the elderly will increase dramatically in the coming years. The 65-and-over age group will be 20% of the U.S. population by 2030. Policies such as failure to improve are a prudent and sensible way to achieve efficient delivery of medical care to all senior citizens.
People can scream about how unfair that is, but it is doubtful that the supply of health care services can increase to meet the demands of an aging population. Doctors, nurses and physical therapists go through several years of training before working in their profession. They can't be created by waving a magic wand.
This is rationing and we better get used to it.
People can scream about how unfair that is, but it is doubtful that the supply of health care services can increase to meet the demands of an aging population. Doctors, nurses and physical therapists go through several years of training before working in their profession. They can't be created by waving a magic wand.
This is rationing and we better get used to it.
9
The problem comes when medical personnel make flawed determinations of "failure to improve". Whether the flaw is one of incompetence, laziness, or greed does not matter in the end because it costs families money they may not have to try to get care for their loved ones. If they can't get the care their loved one needs, then their loved one's life will be tragically shortened.
Thus we enter into a world where the rich get to live and the poor get to die.
Thus we enter into a world where the rich get to live and the poor get to die.
1
Physical therapy schools are next to impossible to admitted to. They take very few applicants to ensure that physical therapists and occur;national therapists all have work. There is room for so many more therapists and therapy assistants. We do not need to ration. But we do need to do a lot more in preventative care.
This is where we can bulk up on employment after good training in therapy, and wellness.
This is where we can bulk up on employment after good training in therapy, and wellness.
10
No, it is not prudent or sensible. If rehab is required for a patient to maintain a skill, then it is prudent and sensible to provide that care. My mother's nursing home wanted to give up on her after 21 days because they said she had plateaued -- a misreading of the Medicare rules. I brought them copies of the actual rules and insisted they follow them. And they did. When my mother left the facility a month later, she walked out -- and the staff cheered. There is no reason to stop paying for rehab after 21 days if the patient is still benefiting from it, as my mother was.
24
The denial of coverage, just plain cruel!
12
Uh huh ...
Need to gather and publish list of these so-called-Physical Therapists.
I'm sure that Athletes from High School thru Professionals would want to make sure that reaching a plateau is NOT the goal, or a reason to stop.
Need to gather and publish list of these so-called-Physical Therapists.
I'm sure that Athletes from High School thru Professionals would want to make sure that reaching a plateau is NOT the goal, or a reason to stop.
2
Did you ever stop to think that maybe we are doing what we are taught? Or that we feel horrible discharging a patient when they have reached a plateau? Or that a ruling from 2013 may have been buried and not passed along to therapists because they don't really want us to keep patients on longer? Therapy is expensive and every single therapist I know works their tails off to get patients to the highest functional level they possibly can. Don't blame physical therapists for this, I don't have a single co-worker or friend that had heard about this ruling. Blame medicare and insurance companies for continuing to encourage us to discharge patients when they have reached a plateau.
9
Consider the woman in this story. She isn't going to get better. Sad, but true. And no amount of physical therapy will change that - it's an inside job and as a society, we do not force people to engage in healthy lifestyles. Which is probably a good thing as we have the individual freedom to choose, and no one is taught that obesity, kidney failure, diabetes, and lack of exercise is a good thing. But, she still has rights. Needs to go home and be cared for by family.
5
You missed the point- she did get better even after they refused care!!
2
Our law school clinic has prevailed in every Medicare case of denied care we have litigated before CMS. The problem is that there are too few cases that are taken up on appeal. We have seen denial of care notices sent to the home address of our client (who is sick, in the hospital or nursing home), among other serious due process issues. If the patient and family is given notice and understands they have the right to appeal, the records sent to the private contracted reviewing agency, MAXIMUS in our area, are incomplete and limited. I had hoped that with the Jimmo case we would see additional denials of care being appealed. Not so. The system is set up to discourage appeals because the notices advise that the patient may be liable for the care. I do use the Jimmo case, as well as the cases leading up to it, to teach how agency policy, in direct conflict with the actual law, works to wrongly deny benefits unless patients and their families have the wherewithal to cut through the red tape and file an appeal. It is a complicated system for attorneys to deal with, let alone frail and elderly patients.
Melissa Brown, McGeorge School of Law, Elder & Health Law Clinic
Melissa Brown, McGeorge School of Law, Elder & Health Law Clinic
45
My daughter was diagnosed with a brain tumor in 1981 that blinded her. Radiation therapy saved her life but had many side effects, among which one left here wheelchair bound. Physical therapy helped enormously. On one occasion, a therapist who hadn't seen her in a while, praised her for the "enormous progress she had made." Fifteen minutes later, another therapist announced that she had "reached a plateau." My daughter lost all motivation, figuring that she would never improve and never walk again. Since then we have tried a few times, but Medicare limits reimbursement to $1850 per year total, not matter how many problems exist.
Despite her health problems, she has completed a Bachelor of Arts degree, with honors, and is now working on a Master's degree, All of it was paid for by me, because there is no financial aid for part time students. After graduation, we toured the community looking for an employer who would take on a blind, wheelchair bound employee.
Brain injured patients need regular physical therapy just to maintain what they have. To some, this is a "plateau."
The way Medicare treats the disabled is nothing less than abuse.
Despite her health problems, she has completed a Bachelor of Arts degree, with honors, and is now working on a Master's degree, All of it was paid for by me, because there is no financial aid for part time students. After graduation, we toured the community looking for an employer who would take on a blind, wheelchair bound employee.
Brain injured patients need regular physical therapy just to maintain what they have. To some, this is a "plateau."
The way Medicare treats the disabled is nothing less than abuse.
41
I have repeatedly been denied physical therapy from Medicare after a few weeks. I try to continue at home but eventually become steadily worse and my movements, walking, cooking, dressing become more difficult. I asked to continue my therapy so I could maintain my improvements - to no avail. I shall try again. I asked my orthopedist about ;this and he simply said - Medicare won't and shouldn't pay for therapy the rest of your life! I am 80 years old - but I've worked my whole life and now need this help.
28
I agree with you - you worked and paid in for at least the majority of your life. Pity those that are 60 or 65. Their premiums have skyrocketed and they get little today, and less tomorrow.
The government has lied to us all when it comes to medicare, but that's because they take your money and put it into medicaid, or worse, into the 'old' medicare that was corrupt with fraud. The government wants a one size fits all because that's all they know. They should not be in charge of your care, but one would think an 80 year old could get PT once a week in their own home.
It's hard, but hang in there. Go to the gym during the day - there are many that will help you and motivate you. Citizens that are just like you - older and more or less alone when it comes to PT.
The government has lied to us all when it comes to medicare, but that's because they take your money and put it into medicaid, or worse, into the 'old' medicare that was corrupt with fraud. The government wants a one size fits all because that's all they know. They should not be in charge of your care, but one would think an 80 year old could get PT once a week in their own home.
It's hard, but hang in there. Go to the gym during the day - there are many that will help you and motivate you. Citizens that are just like you - older and more or less alone when it comes to PT.
5
J Kurland, Ask your internist or family doctor to authorize physical therapy. It doesn't have to be an orthopedist who does that. And ask them to recommend a better orthopedist; it sounds like yours is a real loser.
9
I work as a consultant rehab medicine physician in a pediatric nursing home. Despite my medical license, I am not allowed to order a new wheelchair or repairs without nursing home finance adminstrator approval. Even after five to seven years in a growing developing child. The nursing home never wants to pay for a chair bc it costs them to do so, and they think the daily payment which covers all costs doesn't cover it, so no incentive. If the child leaves the nursing home, I can write a prescription to order a chair the next day. But most of these children living in this NY pediatric nursing home have no parent advocates.
14
Another illustration of the barbaric U.S. health care system. Turns its back on its own people.
How about a system of good old fashioned humanity and compassion where the right to basic care isn't measured by how much one has to spend?
The government could learn a thing or two from countries where socialized medicine is the norm.
How about a system of good old fashioned humanity and compassion where the right to basic care isn't measured by how much one has to spend?
The government could learn a thing or two from countries where socialized medicine is the norm.
20
U.S. Medicare is a form of socialized medicine.
2
Socialized medicine in EU and other areas you so vehemently love do NOT provide jack to the elderly. You are left in a care center that doesn't even hydrate you (UK) in the hopes that you'll die soon. OR, you just get nothing and get to stay at home - no nursing homes, no semi-private area for receiving chemo, and no biopsies until your turn is up - about 9 months on average.
Socialized medicine is owned /operated / financed by the government. U.S. Medicare is a single payer system. The VHA is owned and operated by the government, therefore it is a socialized system.
1
Denying coverage seems like elder abuse. Much money went into deductions for social security and medicare over a persons life and to then deny them their benefits is a travesty.
34
As everyone knows, when one becomes ill in the good old USA it is terribly important to have a Juris Doctor on call as well as a Medical Doctor.
59
I direct an advocacy (ombudsman) program for nursing home and rest home residents. At every single one of our facilities, this happens far too often. Our advocates do all we can; the families appeal decisions. But it is the facility's medical director who handles appeals. Talk about a conflict of interest. When I meet with directors of PT/OT programs, they tell me that Medicare will not reimburse them or they may lose their licenses. The thinking is antiquated and so unhelpful to patients. On top of it, the facilities make far more money from skilled care than long-term care, so this makes no sense at all. People are sent home unsafely or put into long-term care and plunked into a wheelchair rather than getting continued help with mobility. It is so very simply WRONG! --J.M. Sorrell, Ombudsman Director, Highland Valley Elder Services
67
That makes no sense that the facility's medical director handles appeals... that actually seems illegal to me. KEPRO should be handling all discharge appeals...
2
Dear Dr. Murthy, here's a thought: Instead of encouraging narcotic use and enabling the out-of-control opioid epidemic you love to grandstand on, how about you offer actual reasonable alternatives, say, like Physical Therapy and all its varied modalities which CMS so frequently denies. Oh? That's not convenient enough? Sorry to have bothered you...
6
Guess what, Miss Anthropist - people suffer a wide spectrum of pain and sometimes pain is so severe, unmanagable by any so- called ' reasonable alternatives' and/or 'modalities', and chronic that opioids are the only recourse. Sometimes even opioids don't work. Sometimes surgical procedures will leave a patient in such pain that opioids are the only recourse for a short while the patient undergoes healing.
You don't seem to understand pain and it might be useful to educate yourself. Read up on it. Call pain clinics, talk to pain specialists. They aren't 'writing' doctors, and they do not encourage narcotic use. Scripts are monthly and cannot be refilled, the doctor must write new ones each month, and the only way that happens is for the patients to have monthly appointments for assessment of drug efficacy. Most pain doctors try to understand the origins and reasons for pain and try various means to treat it - not immediately utilization of opioids. Patients are tested monthly for drugs - and not just for opioids. If you can come up with good alternatives that work for such patients, then by all means share.
The interesting thing is that the people with all the righteousness speeches about opioid use to mitigate severe pain never seem to be the ones suffering from it.
You don't seem to understand pain and it might be useful to educate yourself. Read up on it. Call pain clinics, talk to pain specialists. They aren't 'writing' doctors, and they do not encourage narcotic use. Scripts are monthly and cannot be refilled, the doctor must write new ones each month, and the only way that happens is for the patients to have monthly appointments for assessment of drug efficacy. Most pain doctors try to understand the origins and reasons for pain and try various means to treat it - not immediately utilization of opioids. Patients are tested monthly for drugs - and not just for opioids. If you can come up with good alternatives that work for such patients, then by all means share.
The interesting thing is that the people with all the righteousness speeches about opioid use to mitigate severe pain never seem to be the ones suffering from it.
9
I think the point she was trying to make is that a lot of people are using opioids when they do not have severe pain and then become addicted to it. There are hospitals that are discontinuing use of opioids because of significant increase in opioid addiction among the geriatric population. I see patients daily telling me their pain levels are 1-2/10 and then asking for a pain pill. Pain tolerance increases when you allow yourself to feel the pain. If you are constantly popping pills for every ache and pain, minor pain begins to feels severe. I am absolutely not talking about the people that are actually in severe pain and truly need opioids, just the ones that are using it when simple acetaminophen or ibuprofen would work.
2
Miss Anthropist, you have no clue about severe or chronic pain. It's attitudes like yours that cause untold unnecessary suffering,
3
Thank you for this information. As someone that has been taking care of their elderly parents health for a decade - mother diagnosed with ALS in 2006, father with dementia - I've got very used to hearing "no more coverage, because maintenance isn't covered".
The cost of nursing required for my mother was financially damaging, and left us vulnerable when my father's dementia ramping up at the same time. Based on this article it would appear that all the "no" answers I received at the time were based probably on standard practices. And the insurance policies are so complex, it's very hard to argue with a hard NO. At least with this article, I feel like I have some avenue I can pursue. Thank you.
The cost of nursing required for my mother was financially damaging, and left us vulnerable when my father's dementia ramping up at the same time. Based on this article it would appear that all the "no" answers I received at the time were based probably on standard practices. And the insurance policies are so complex, it's very hard to argue with a hard NO. At least with this article, I feel like I have some avenue I can pursue. Thank you.
23
What is the rationale to limiting the appeal process to 72 hours? Its seems totally unkind and arbitrary. The only reason I can think of is to limit the number of people who successfully appeal a decision that denies them care.
How would healthy, active caregivers, let alone sick, disabled and often confused people even realize the clock is ticking down to 72 hours. A sentence at the end of a devastating denial of benefits letter hardly seems enough.
Lets not forget these people have earned the right to be on medicare. Medicare is there to help patients, not to throw up ridiculous roadblocks to something so simple as having a denial of benefits reviewed or reconsidered.
Would the medicare world really crumble if we gave people at least a minimum of a few weeks to appeal an often capricious decision?
How would healthy, active caregivers, let alone sick, disabled and often confused people even realize the clock is ticking down to 72 hours. A sentence at the end of a devastating denial of benefits letter hardly seems enough.
Lets not forget these people have earned the right to be on medicare. Medicare is there to help patients, not to throw up ridiculous roadblocks to something so simple as having a denial of benefits reviewed or reconsidered.
Would the medicare world really crumble if we gave people at least a minimum of a few weeks to appeal an often capricious decision?
53
I think that was re to leave or become private pay, perhaps similar to when a person objects to being discharged from a hospital and there is a short turnaround time.
If things haven't changed, Part B appeals for coverage can be started within 6 months.
If things haven't changed, Part B appeals for coverage can be started within 6 months.
3
Actually the point is that Medicare dictates that we must give a 3 day notice when a patient will be discharging (most often we give them at least a week's notice). Because of this, they now have 72 hours until discharge, so if they want to appeal they need to do it within that time frame so that the appeals process can take place. The process is pretty quick, usually 24-36 hours, KEPRO is an independent company that reviews the case and then decides whether continued therapy is appropriate or not. We see cases win their appeals about 50% of the time. But the point is, we cannot discharge a patient from the facility while they are in the appeals process BUT if they lose the case, medicare will then go back and only cover from the time frame before the original discharge date and they will now have to private pay for room, nursing services, and any therapy that was received.
1
What about quality of life and appropriate end-of-life care policies? Both my parents died in their eighties, my father after a final major stroke. He'd been bed-ridden and mentally incompetent for months, but at the insistence of other family members he was kept on life support for weeks. My mother died after elective surgery recommended by her physician, despite a serious heart condition. The surgeon admitted afterwards that her organs were beginning to fail and she would have died within a few months anyway. In both instances Medicare paid thousands for worse than useless treatments.
43
An equally disturbing phenomenon involves legitimately terminally ill patients who are kicked off of Hospice care because they are "glaciering"-- they presumably don't deserve care because it takes too long for them to die. Many of these are patients with neurological illnesses, which are no less terminal but far more unpredictable than more "conventional" illnesses. This leaves families to pay out-of-pocket for home health aides and other services that previously were being provided by Hospice. In more egregious cases where a patient may be receiving in-home Hospice care, the Hospice organization even sends workers out to take away the patient's bed.
33
I guess it happens, but I've not seen anyone kicked out of hospice. That includes both time in the elder care industry and that of my own mother. Hospice wants that $6K/mo Medicare pays them. Short of outright fraud, the every six month evaluation can almost always find a reason to keep them in the program.
My mother was in hospice for almost two and a half years. The decline and ultimately death was long and slow.
My mother was in hospice for almost two and a half years. The decline and ultimately death was long and slow.
5
Magnificent, this Medicare/Medicaid system. Denying claims from people whose claims clearly merit approval, while at the same time bleeding out tens of billions a year to fraudsters and bill-padders.
Before we make the thing any larger, as has been heartily recommended by various smartest-people-in-the-room types, might we consider fixing these howlingly obvious flaws first?
Before we make the thing any larger, as has been heartily recommended by various smartest-people-in-the-room types, might we consider fixing these howlingly obvious flaws first?
21
Thank you for your observation. Too many readers of the NYTimes, at the Times urging, ask for 'single payer' systems 'like other countries.' Wish you could actually be old in EU to experience that 'free' care. Medicare and Medicaid are run by administrators that are paid for too much to say 'no' to people and 'yes' to fraudsters that know who to beat the system - they make billions. It's been a joke for a while, but the ACA (obamacare) makes it even worse.
1
it seems obvious that individuals like Mrs. Kirby, who would benefit from improved care, should continue to receive it. It's only when we apply that standard to the entire population of the elderly that we run into a math problem. Isn't every old person (myself included) in some stage of decline? Wouldn't each of us benefit from some form of therapy to maintain our current level of function? But who will pay? That's always the question, isn't it?
13
Lucy, my local senior center has free or very low cost classes that help stabilize or improve fitness for the elderly. If yours does not, perhaps you can ask them to do so.
Several years ago my mother was in the hospital for 8 months following complications from open heart surgery. She received limited physical therapy for only a week and then it was discontinued because they said she didn't show improvement. Truly dedicated therapists and health givers should have tried harder not just given up! So I took over moving her arms and legs so that her joints wouldn't stiffen up and tried to help her maintain muscle use. When she was discharged finally she couldn't walk and I was told that she would never walk again because she had been bedridden for so long. I took her to my home and took two months off from my job to care for her. I had her walking within a month.
This experience made me realize that in our health care system if you don't have someone that cares for you, to advocate for you, you will be allowed to wither and die on your own. I go to a gym that specializes in rehabilitating victims of strokes and other neurological problems. I see tremendous improvement in their lives. What those people all have in common is that they have family members that make the effort to bring them to the gym and help them at home.
We have a friend in Britain whose mother had a stroke. Under the NHS, National Health Service, or socialized medicine if you will, his mother gets daily visits from a number of health care assistants. They bathe and dress her, do housework, prepare meals and do physical therapy. Americans deserve the same standard of care!
This experience made me realize that in our health care system if you don't have someone that cares for you, to advocate for you, you will be allowed to wither and die on your own. I go to a gym that specializes in rehabilitating victims of strokes and other neurological problems. I see tremendous improvement in their lives. What those people all have in common is that they have family members that make the effort to bring them to the gym and help them at home.
We have a friend in Britain whose mother had a stroke. Under the NHS, National Health Service, or socialized medicine if you will, his mother gets daily visits from a number of health care assistants. They bathe and dress her, do housework, prepare meals and do physical therapy. Americans deserve the same standard of care!
178
Of course we do, Mary, but as long as Americans keep electing Republicans, we're not going to get it. And you're completely accurate as to the need for personal advocates to make sure patients receive adequate care.
15
How can you decry republicans as a result of this article? It has nothing to do with republicans. It has to do with Obama's appointees at HHS, specifically CMS. Learn a little about what is going on and who does what to whom.
1
Why are there always unlimited resources for military involvements abroad that destroy countless lives, but when it comes to health care, VA benefits, Social Security, public education, and other social services that build society and help people, there is a perpetual lack of resources?
111
THANK YOU STEVE725. I heartily agree.
I sometimes fantasize with moving to Costa Rica, who dismantled their army and provides universal health care.
I think we would get a lot more respect even abroad if we calmed the heck down on military adventures and provided humane services like medicine, social benefits, etc.
I sometimes fantasize with moving to Costa Rica, who dismantled their army and provides universal health care.
I think we would get a lot more respect even abroad if we calmed the heck down on military adventures and provided humane services like medicine, social benefits, etc.
5
Read "Dark Money" for the answer.
It is the old story, wear them down, and they will go away. Shouldn't we expect more from our government?
22
Anyone who actually believes that any government program is there to help them is a sucker. Sorry to be blunt, but I am about to turn 65 and I knew from my first paycheck deduction over 40 years ago that I would never benefit from that deduction in the future. I will continue to work as long as my cognitive abilities hold out, and then hopefully I will die immediately.
7
Thanks for this article. I didn't know the standard had changed, but I remember how infuriating it was that my mother-in-law couldn't continue the therapy that was helping her. Actually, her nursing home seemed to have no provision for therapy outside of Medicare; she could perhaps have afforded it, too.
18
Most rich and super-rich Americans evade paying their taxes (they hide income, they over-state their deductions, they mis-characterize their income, etc.). So, we need to do a much better job on the revenue side before we throw up our hands and say we don't have enough money to pay for Medicare.
47
I find it difficult to believe that CMS does not have a serious rationale for the improvement standard, a rationale which is neither stated nor explained in this article. Of course, for an expectable variety of reasons CMS may not *want* to state or explain its rationale for the old improvement rule, but I'm sure there is one. Is it solely and only to save money? It could well be, but it's rare that government agencies (as opposed to for-profit insurers) are particularly tight-fisted. Is there a CMS perception that providers (nursing homes and therapists) try to manipulate patients for their own benefit when continued treatment truly isn't justified? Are CMS staffers former or future employees of for-profit insurance companies? This subject would appear to benefit from a depth of reportage that Paula Spann hasn't attempted, at least in this article.
5
This "failure to improve" may make sense in cases where the patient is terminal - think Alzheimers, late stage dementia, cancer - but it's exceptionally cruel to do this for anyone in pain or temporarily disabled by a fracture. Keeping someone immobile is a sure and cruel way to spend more care dollars over a lifetime than trying to remediate mobility that enables self-care (i.e. bathing, cooking, etc.).
27
As the huge baby boomer generation continues to age there will be numerous "Mrs. Kirby's." Because of this fact be prepared for Medicare expenses to explode. And you know who will pay for these increased expenses and care: YOU.
9
Classic strength training which can improve strength at any age is not employed by therapists; because the equipment is expensive and they are reimbursed the same for simple movement exercises. No elderly patient should be denied the right to get better because the correct therapy is inconvenient and expensive.
14
Wouldn't losing weight help a lot of people fight the "failure to improve" verdict -- by improving themselves?
Editor’s note: This comment has been anonymized in accordance with applicable law(s).
31
Right, Nick!
Blame the victim!
Blame the victim!
6
Failure to progress is not acceptable rationale any longer. It was an easy way to terminate skilled services when a facility thought they might not get reimbursed. However, it is a complicated situation, based on patient's diagnosis, presence of HMO, details of the Medicare supplemental insurance, and what patient's functional status was at the time they entered the acute care system (usually an ER or hospital stay happens before SNF care)...no matter how much PT and OT you provide, you can't turn back the clock. Also, patient's ability to participate in therapy is a factor...and sometime you can appeal saying that the UTI or whatever that was causing mental status changes is gone so another few days ought to be covered, but that's about it.
2
"But most families don’t persevere, in part because they can’t afford to pay for care while the appeal proceeds. (If they do spend their own money, though, they can appeal for reimbursement.)"
Exactly. Most families don't persevere... because they can't spend money they don't have. Has it ever occurred to the geniuses who set Medicare policy that it is not the ultra-rich who need Medicare?
No, it's all the rest of us. And God help us.
Exactly. Most families don't persevere... because they can't spend money they don't have. Has it ever occurred to the geniuses who set Medicare policy that it is not the ultra-rich who need Medicare?
No, it's all the rest of us. And God help us.
38
I am a retired nurse with good health. I am worried about all the verbiage being tossed about re home health/PT/rehab care. Even this article, though it tries, does not lay out in straight talk what a person is legally entitled to from Medicare. I really dread the time I will have to deal with more than a couple of prescriptions to maintain my health. What an unconscionable morass!
43
People are getting older and living longer. Resources are getting strained and cost is rising. These are standard factors of supply and demand. The court may rule based on the existing laws on the book but it can never override the laws of economics and physics. Nothing comes from nothing and Medicare can't spend more that it can take in. There comes a time everyone needs to compromise and palliative medicine to be practiced.
Understandably, it is difficult. On one hand, how can you put the price on a human life and its quality? On the other hand, a 100,000 spent on one person means a 100,000 less spent elsewhere. Of course, everyone wants one's freedom and choices etc., but what if it comes at the expense of other people's freedom and choices?
Understandably, it is difficult. On one hand, how can you put the price on a human life and its quality? On the other hand, a 100,000 spent on one person means a 100,000 less spent elsewhere. Of course, everyone wants one's freedom and choices etc., but what if it comes at the expense of other people's freedom and choices?
31
You raised many good points, but your conclusion's the false belief in a zero sum game, the 'throw up our hands and moan because we can't possibly afford to take care of everyone' crying game. It's a type of hysteria, on the right & center that's laughable, since resources do exist to solve these problems. Numerous politically feasible and practical policy designs exist, to raise all the revenue needed to fund any current Medicare expenses, and a full Medicare expansion to cover everyone in the U.S., such as taxing the wealthiest just a little more, closing tax loopholes for rich individuals and corporations, and/or creating a value added tax on consumer items (usually, in most countries, it's somewhere between 7-15%, most commonly 10%, and is the most commonly used way to fund universal health care in nearly every 1st world democracy, such as in England, France, Canada, Japan, and the Netherlands. If they can do it easily, we sure can too.) I've mentioned only a few realistic proposals, proposed by politicians in the U.S. this year, on the left, right & center, to solve the funding problems you've cried your crocodile tears fancifully about. There are other practical, feasible solutions, but for brevity, I've only mentioned a few. I'd rather do something practical, that has had plenty of success in our states, and in other countries, than cry in my beer or coffee that there's no solutions, so we just have to get used to dying off from curable illnesses, since that's DUMB.
7
Despite any subsequent denial, Reader Bos is advocating death panels, whether s/he admits it or not.
3
In reply to Bos who said, "These are factors of supply and demand." To say that the supply of money has run out and the person is on their own is myopic. Who says we can build billion dollar warplanes and not take care of people? Who says the life of a billionaire business owner is more valuable than the life of a person who has less money? THAT is loss of freedom. Loss of freedom is an outgrowth of the belief system that money is the measure of all things. Loss of freedom is the outgrowth of a belief system that says scarcity is real. My hope is that the human species survives long enough to look back someday and be astonished that we thought there were "laws of economics" because physics will have confirmed that "reality" is a mental projection and there is only one mind projecting it all.
8
How will this apply to hospice if a dementia patient is discharged from hospice for failure to show disease progression?
12
Originally, hospice was designed to care for terminal patients (say with the life expectancy of 3 to 6 months) but now the technologies are so good that dementia and even late stage alzheimer patients can last for years if not decades, so now we are at an impossible place. This doesn't include more and more people will reach this stage if we as a society (or even as a species, since many countries are facing the same dilemma) try to recognize the situation as it is and retrofit society to make the best for everyone and not just one dementia patient
7
Nobody gets discharged from hospice care. People check in on their way to checking out. I've known of no one who got better in hospice care. It's the last stop on the streetcar. It's where one goes to die with dignity.
1
It actually does apply to hospice. We were told that Medicare would no longer pay because our family member had not died in the required six weeks The physician who admitted our family member to the hospice was admonished by Medicare.
10
Thanks for bringing attention to this: there was a discussion at lunch with some friends last week about how many PT sessions a Medicare patient is allowed, per period, or per event, however it is determined. One person had recent shoulder surgery, the another is about to have both knees replaced. Provision of PT is so instrumental to getting back into your life that it is a bit frightening to think that CMMS would intentionally try to deny it to patients through not so benign neglect of the court order, which looks like a back door way to limit PT costs. I do know that PT has been routinely stopped for nursing home residents because of lack of improvement, yet it is only through PT that many hold on to any physical skills at all.
However, now that I am pretty clear about that court decision, I still don't understand what limits apply to Medicare coverage for the service.
Also - how can a patient without an advocate ever - when weak and under great stress - manage to file an appeal within 72 hours?
Could the President issue an executive order to CMMS to abide by the spirit as well as the letter of the court decisions?
However, now that I am pretty clear about that court decision, I still don't understand what limits apply to Medicare coverage for the service.
Also - how can a patient without an advocate ever - when weak and under great stress - manage to file an appeal within 72 hours?
Could the President issue an executive order to CMMS to abide by the spirit as well as the letter of the court decisions?
137
I don't know about outpatient settings, but the process of initiating an appeal in SNF is user friendly in my experience. As a social worker, I am required to review the potential cut date of services and then provide the 800 phone number for the patient or his/her proxy to call. Once their phone call is made, the facility is then required to submit all of the clinical documentation. The patient or family just needs to make that first phone call.
19
Thank you for this article, Paula. I have experienced things a little differently myself as a social worker in a nursing home. There have been times when we as the provider wish to have a patient stay for continued skilled care; however, their Medicare HMO refuses to pay for it - despite (in these cases) the provider making a case for an appeal. I think it's also important to note that Medicare has an 100 day maximum of SNF coverage per event, so an individual would not be able to stay in a SNF for months on end in a skilled status, regardless of reaching a "plateau." When folks are discharged, we also take a lot of time to develop a discharge plan that continues all of the needed skilled services, just in a less acute setting, e.g. Transitioning from services in a SNF to services from Home Health. So ideally, a person wouldn't be stopping therapy upon discharging from a SNF.
26
We need the full facts. Something does not compute. According to the author:
"For months, physical therapists worked with Mrs. Kirby... trying to help her... go home. Then her daughter received an email... saying, “Edwina has reached her highest practical level of independence.”"
and the article later says
"The Kirbys still didn’t get the full number of days of skilled nursing care and therapy Edwina Kirby was entitled to... As a result, the Kirbys spent about $100,000 out of pocket on the nursing facility and on at-home care afterward."
No matter which way the improvement/maintenance standard is applied, the VT ruling does not change the benefits of Medicare. If Mrs. Kirby was in a skilled nursing facility (SNF) "for months," depending on how many "months," what year, and the Michigan Medicare insurers, the maximum payout from Medicare was still 20 days with no co-pay (maybe worth $6000) plus 80 days with about a $150 a day co-pay (maybe worth $12000). So Mrs. Kirby was responsible for $12,000 at the end of 100 days even if she was improving all the time.
After that, if she stayed in the SNF, the meter is running at about $10,000 a month. If she instead wanted PT or OT at home after spending the first $12,000, the most Medicare would pay -- improvement, maintenance, whatever -- is a couple of grand a year. The rest is on the Kirby's dime.
In addition, the Times reporter should tell us about the supplemental insurance policy involvement. Maybe that is the issue.
"For months, physical therapists worked with Mrs. Kirby... trying to help her... go home. Then her daughter received an email... saying, “Edwina has reached her highest practical level of independence.”"
and the article later says
"The Kirbys still didn’t get the full number of days of skilled nursing care and therapy Edwina Kirby was entitled to... As a result, the Kirbys spent about $100,000 out of pocket on the nursing facility and on at-home care afterward."
No matter which way the improvement/maintenance standard is applied, the VT ruling does not change the benefits of Medicare. If Mrs. Kirby was in a skilled nursing facility (SNF) "for months," depending on how many "months," what year, and the Michigan Medicare insurers, the maximum payout from Medicare was still 20 days with no co-pay (maybe worth $6000) plus 80 days with about a $150 a day co-pay (maybe worth $12000). So Mrs. Kirby was responsible for $12,000 at the end of 100 days even if she was improving all the time.
After that, if she stayed in the SNF, the meter is running at about $10,000 a month. If she instead wanted PT or OT at home after spending the first $12,000, the most Medicare would pay -- improvement, maintenance, whatever -- is a couple of grand a year. The rest is on the Kirby's dime.
In addition, the Times reporter should tell us about the supplemental insurance policy involvement. Maybe that is the issue.
66
You are not computing: why are you deflecting away from the main points of the article?
1
Note that she had rehab after the surgery, then had another hospitalization and then more therapy was prescribed. Timing is everything. Inpatient is different than outpatient. In this short of an article, the breakdown isn't given. The cap applies to outpatient and is annual. It can be overridden fairly easily. The 100 days of SNF coverage depends on getting daily therapy, so if the therapist gave up, the full 100 days wouldn't be possible. The issue went to court, and the patient was proven right. Perhaps the reporter should have use "allowable" rather than "entitled" because he didn't explain that part of it well, as to why she didn't get the full allowance.
As for the supplement, that rarely pays unless Medicare pays, so it wouldn't be a problem with the supplement. That's not a part of the appeal. What could be a problem is that the full price for the PT was charged instead of the Medicare approved amount, once it was no longer covered. That could easily bring the total cost up.
The point is that the cap is an arbitrary number, the therapists in nursing homes still use the "improvement" determination when they should look at maintaining as well, and people are thus living more limited and unhealthy lives and needing more care in the long run because of these PT limits.
As for the supplement, that rarely pays unless Medicare pays, so it wouldn't be a problem with the supplement. That's not a part of the appeal. What could be a problem is that the full price for the PT was charged instead of the Medicare approved amount, once it was no longer covered. That could easily bring the total cost up.
The point is that the cap is an arbitrary number, the therapists in nursing homes still use the "improvement" determination when they should look at maintaining as well, and people are thus living more limited and unhealthy lives and needing more care in the long run because of these PT limits.
16
Nan
The overriding issue in the article is that Mrs. Kirby allegedly needed over $100,000 in medical services to be paid for by Medicare and most of them were not paid for by Medicare because of lack of progress. But the real reason they were not paid was because of poor Medicare benefits--new regulations or old.
Even if Mrs. Kirby was making progress constantly (never mind just maintaining status quo per the new legal ruling), the most Medicare would have paid is around $15,000 of the over $100,000 based on my reading.
Based on your reading, IF some SNF or hospital bureaucrat had known how to split the incidents up correctly in terms of timing them a certain number of days apart (or if they had just luckily happened that way) and IF a physical therapist had known enough to ask for an extension increasing the PT "annual cap" amount to the 66% higher PT "annual threshold" amount, Medicare would have then paid $25,000 of the $100,000 instead of $15,000.
Some supplements would have increased the amounts for which the Kirby's were responsible a little higher if they paid the SNF co-pays.
But the whole article is wrapped around this new ruling and that seems to have little to do with the Kirby's need
(Of course we are also assuming these treatments were medically necessary.)
The overriding issue in the article is that Mrs. Kirby allegedly needed over $100,000 in medical services to be paid for by Medicare and most of them were not paid for by Medicare because of lack of progress. But the real reason they were not paid was because of poor Medicare benefits--new regulations or old.
Even if Mrs. Kirby was making progress constantly (never mind just maintaining status quo per the new legal ruling), the most Medicare would have paid is around $15,000 of the over $100,000 based on my reading.
Based on your reading, IF some SNF or hospital bureaucrat had known how to split the incidents up correctly in terms of timing them a certain number of days apart (or if they had just luckily happened that way) and IF a physical therapist had known enough to ask for an extension increasing the PT "annual cap" amount to the 66% higher PT "annual threshold" amount, Medicare would have then paid $25,000 of the $100,000 instead of $15,000.
Some supplements would have increased the amounts for which the Kirby's were responsible a little higher if they paid the SNF co-pays.
But the whole article is wrapped around this new ruling and that seems to have little to do with the Kirby's need
(Of course we are also assuming these treatments were medically necessary.)
1
What used to be, or naturally might be, one or more persons helping another person in need, is now become a 'system' of profit maximization and dollar extraction, until the poor individual's resources are exhausted.
Those responsible for this ongoing abomination should be punished, much as those among us who cannot receive care are punished, until they die exhausted and pauperized in the name of corporate profit.