Wednesday February 13, 2013

In a bygone era of home health care it was possible for nurses, therapists and aides to provide services in a Medicare beneficiary's home as long as they were doing some good. The idea of doing good generally meant that the services were needed because the person receiving them would either do worse or end up in the hospital without them.

It seemed like a sensible system. Take care of people in the setting in which they prefer to receive those services and try to maximize their health. Nurses would see some patients for years, making visits once a week or once a month or whatever frequency seemed appropriate. It was not a perfect system, but at least it made sense.

Then along came the politicians and the whole system changed. Our "leaders" in Washington decided that too many unscrupulous home health providers were gaming the system and that the United States was spending too many Medicare dollars keeping people healthy at home or paying for outpatient rehabilitation services.

These changes started happening around the late 1990's and things have never been the same. Home health agencies forced nurses to become bean counters because the Medicare payment system was based on episodes of care and keeping track of payment became critical.

The rules also "seemed" to change and they were being interpreted to mean that patients could only be provided service for limited periods of time and that, in many cases, there had to be an indication that they were making some sort of objective progress.


Advertisement

I worked as a home care nurse for 15 years and the changes were happening just as I moved on to a different kind of nursing. The entire character of home health care was changing and I wanted no part of it. The money flow became more important than patient care and that is when my conscience would no longer allow me to support the new regime.

But things change and sometimes there is hope for better times. According to a Feb. 4 New York Times blog post by Susan Jaffe, "the settlement of a class-action lawsuit last month now means that Medicare is prohibited from denying patients coverage for skilled nursing care, home health services or outpatient therapy because they had reached a ‘plateau,' and their conditions were not improving. That will allow people with Medicare who have chronic health problems and disabilities to get the therapy and other skilled care that they need for as long as they need it, if they meet other coverage criteria."

She went on to explain that, "The settlement is expected to affect thousands, and possibly millions, of Medicare beneficiaries with chronic health problems like Parkinson's or Alzheimer's disease, stroke, multiple sclerosis and spinal cord injuries. It could also help families, as well as the overburdened Medicare budget, delay costly nursing home care by enabling seniors to live longer in their own homes."

"'Under this settlement, Medicare policy will be clarified to ensure that claims from providers are reimbursed consistently and appropriately and not denied solely based on a rule-of-thumb determination that a beneficiary's condition is not improving,' said Fabien Levy, a spokesman for the U. S. Department of Health and Human Services, which includes the Medicare program."

Also critically important is the fact that, "Beneficiaries also often lose Medicare coverage for outpatient therapy because they hit the payment limit. But under the exceptions process Congress continued for another year (something separate from the lawsuit), the health care provider can put an additional code on the claim that indicates further treatment above the $1,900 limit is medically necessary. When treatment costs reach $3,700, the provider can submit medical documentation to support a request for another exception to cover 20 more sessions."

"The lawsuit was filed by the Center for Medicare Advocacy and Vermont Legal Aid on behalf of four Medicare patients and five national organizations, including the National Multiple Sclerosis Society, Parkinson's Action Network and the Alzheimer's Association. A tentative settlement had been reached in October and on Jan. 24 a federal judge in Vermont approved the deal."

If you or a friend or family member is being subjected to a termination of home health or rehabilitation services because there is a lack of progress, tell the service provider they are breaking the law. For more information, contact Vermont Legal Aid at 800-889-2047.

Richard Davis is a registered nurse and executive director of Vermont Citizens Campaign for Health. He writes from Guilford and welcomes comments at rbdav@comcast.net.