Little-Known Medicare Lawsuit Can Help Clear Path to Recovery

Brooke Phillips, CWCMS
Editor | Shield HealthCare
08/10/14  11:11 PM PST
Medicare patients can't lose treatment

Medicare patients can’t lose treatment even if they ‘show no improvement,’ says oft-ignored Jimmo v. Sebelius.

Several days after Christmas last year, my 91-year-old mother suffered a stroke. Up until that time, I had paid very little attention to the topic of Medicare. But in the days that she spent at a San Antonio hospital several months ago, I began mapping out a plan for my mother’s treatment. What I’ve learned along the way about how health care providers manage Medicare-covered patients – and how they regularly violate a federal court order that provides very clear instruction in this regard – has angered me and should trouble us all.

My mother suffered a left-brain stroke, which impaired her ability to speak and swallow. Her neurologist was guarded with his assessment. Any progress that she would make would be “baby steps.” The hope was that she would make enough “baby steps” to regain her ability to eat and speak again. Although he did hold out some hope for my family, he was emphatic: Any recovery would take time – we needed to be patient. We would have a roller coaster of emotions.

Because she could not swallow, the neurologist advised that she have a “PEG” tube inserted so that she could gain necessary nutrition directly through her stomach. The goal was that this would hopefully be temporary while she underwent therapy.

Oddly enough, a few days later, a different doctor entered my mother’s room. He worked for the health insurance company that provides my mother’s Medicare Advantage Plan coverage – essentially, the private company is the administrator of her Medicare benefits. He was very pessimistic. He advised against inserting a PEG tube. He said that Mom was not showing any progress in the brief therapy sessions there in the hospital. His advice was to make her comfortable in the care of a hospice agency.

This was my first exposure to a dirty little secret and a topic that receives scant news coverage: Despite a federal ruling specifically directing the health care industry against doing so, it’s still employing the “Improvement Standard” for patients whose treatment is paid for by Medicare.

The Improvement Standard is pretty much what it sounds like: No progress? No Medicare coverage. In the world of Medicare-funded care, the dreaded term is: “plateau.” No matter that the progress or plateau is assessed in a cruelly subjective manner, clearly intended to avoid the expensive treatment or therapy that patients who suffer catastrophic health events or chronic illnesses commonly require. Stroke patients and their advocates all across the state of Texas encounter this.

Read Full Article by Gabe Quintanilla

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