Thousands of Medicare patients with severe chronic illnesses such as
Alzheimer's would get continuing access to rehab and other services under a
change agreed to by the Obama administration, advocates said Tuesday (Oct. 23)
The proposed agreement in a national class action suit would allow
Medicare patients to keep receiving physical and occupational therapy and other
skilled services at home or in a nursing home so they can remain stable, said Gill
Deford, a lawyer with the Center for Medicare Advocacy.
That's been a problem for some because of a longstanding Medicare policy
that says patients must show improvement to keep getting rehab. Deford's group
and other organizations representing patients challenged it. "If you have
a chronic condition, by definition you are not improving," said Deford,
the lead attorney on the case. "Our view is that Medicare regulations were
intended to allow people to maintain their health status. They don't have to
show they are getting any better. The point is to allow them not to get any
worse, if possible."
The agreement was filed with Chief Judge Christina Reiss of the U.S.
District Court in Vermont. It is expected to affect tens of thousands — maybe hundreds
of thousands — of patients nationally. Those who stand to benefit include not
only people with intractable conditions like Alzheimer's, multiple sclerosis,
Parkinson's and chronic lung disease. Those who are growing weaker because of
advancing age, placing them at greater risk of falls and other problems, could
also be helped.
The impact on Medicare's budget is unclear, partly because program rules
are not always rigidly enforced. Even with a requirement that patients must
continue to show improvement, billing contractors sometimes defer to the
clinical judgment of doctors and therapists. A patient's underlying disease may
be advancing, but therapy might help them keep up strength up and do more to
take care of themselves. Still, that's no guarantee that Medicare will pay. "That's
what the point of this case is," said Deford, adding that his center has
represented many people repeatedly denied coverage for rehabilitation services.
"This will allow them to have access." Advocates say Medicare could
break even financially, if patients don't have to go to the hospital.
In court papers, Medicare denied that it imposes an inflexible standard
that patients must continue to improve to keep receiving rehab services.
Indeed, there is no such requirement in law. Medicare said other factors come
into play, such as the patient's medical condition and whether treatment is
reasonable and necessary. Government lawyers called the policy change a
clarification. "This settlement clarifies existing Medicare policy,"
said Erin Shields Britt, a spokeswoman for the federal Health and Human
Services department. "We expect no changes in access to services or
costs."
Nonetheless, the Medicare policy manual will be changed to spell out
that coverage of rehabilitation services "does not turn on the presence or
absence of a beneficiary's potential for improvement from the therapy, but
rather on the beneficiary's need for skilled care," according to the
proposed settlement. Deford said it could be several months before the
settlement is finalized in court, and perhaps another year before Medicare
formally completes the policy change. But patients may start seeing a change
sooner. "I'm hoping the new coverage rules will de facto take effect
before they are formally revised," said Deford.
Most of the immediate beneficiaries will be the parents of the baby boom
generation and younger disabled people, who are also entitled to Medicare
coverage. But the change could have its greatest significance for the boomers,
many of whom are expected to try to live independently into their 80s and 90s. The
Medicare change was first reported by The New York Times.
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