Medicare expected to pay more costs of chronic ailments
Should the federal government cover the costs of many kinds of treatments for patients who aren’t going to get any better?
It didn’t, for many years. But after the settlement of a landmark class-action lawsuit this week, Medicare will soon begin paying more often for physical, occupational and other therapies for large numbers of people with certain disabilities and chronic conditions like Alzheimer’s disease, multiple sclerosis and Parkinson’s disease.
The two questions patient advocates were left with this week were just how many people may benefit from the clarification of the regulations and how quickly.
The settlement, if approved by a federal judge, would end a lawsuit that accused Medicare of allowing the contractors who process its claims to use an “improvement standard” over the last few decades. To the Center for Medicare Advocacy and the many other organizations that joined the suit, that standard seemed to call for cutting off physical, occupational and speech therapy and some inpatient skilled nursing for many people who had reached a plateau in their treatment.
Medicare is supposed to pay for reasonable treatment of an illness or injury as long as a doctor has prescribed it. For the sort of inhome care that this week’s settlement may affect the most, a doctor must have certified that you are, in fact, homebound and have prescribed treatment that only a skilled practitioner can provide. (The “skilled practitioner” rule keeps Medicare from paying for assistance with everyday activities like bathing and dressing.)
But for people who advocate for patients with particular diseases, having treatment cut off for lack of improvement was intensely frustrating.
“The idea that you would have to show improvement when you have a degenerative disease is blatantly absurd,” said Amy Comstock Rick, chief executive of the Parkinson’s Action Network. In her world, holding steady or degenerating more slowly than you might otherwise is often the definition of success.
Over the years, however, the Medicare contractors that process claims started to see things differently than patients and many healthcare professionals. And for
family members of the sick, the denial could be quite abrupt. “It was like falling off a cliff in that there was no longer any access to Medicare to help with even small, maintenance types of things, like range of motion,” said Maureen Conte, a Falmouth, Mass., scientist, recalling the six years her father lived after having a stroke. “Multiple times he was back in the hospital for things that I thought were preventable.”
Many other patients, however, may not have even received certain kinds of treatment because their doctors figured that prescribing it would be pointless. “Once it becomes clear what Medicare will and will not pay for, you end up changing your practice pattern based on what it covers,” said Peter Thomas, a lawyer in private practice who is the outside counsel for the American Academy of Physical Medicine and Rehabilitation.
The settlement agreement takes pains not to describe itself as an expansion of Medicare coverage. But it does promise that the Centers for Medicare and Medicaid Services will revise the manuals its contractors use to make clear that coverage “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.”
Moreover, the settlement specifies that skilled care can qualify for Medicare coverage even if it merely maintains someone’s condition or prevents or slows further deterioration. Certain patients who have had claims rejected will be able to resubmit them.
Representatives of several patient advocacy groups expressed hope this week that Medicare would soon pay for many forms of therapy that it did not always cover before.
For people with cerebral palsy, physical therapy to maintain muscle mass is one possibility. For multiple sclerosis patients, there may be more approval for treatments for spasticity and gait training to prevent falls.
The biggest question mark may be for the large numbers of people who suffer from dementia. According to Robert Egge, vice president of public policy for the Alzheimer’s Association, there are many benefits that come from delaying the long-term progression of dementia.
Leslie Fried, director of policy and programs at the National Council on Aging, said there had been a particular Medicare claims bias over the years in applying
the improvement standard to people with dementia and other forms of cognitive impairment.
“I think the settlement opens coverage up to pretty much any condition that creates functional impairment,” Thomas said. In this way, he added, it is similar to the Americans With Disabilities Act, which did not confine itself to particular diagnoses. “In that respect, it’s probably a more expansive settlement than some people might think.”
It could be a couple of months before the judge approves the settlement, which everyone I interviewed this week expected her to do. Then it could be a year or more until the Medicare billing contractors get the newly clarified manuals.
Even so, some patient advocates see no reason for people not to demand coverage that maintains their condition or slows deterioration right now, given that Medicare was supposed to be paying for it all along.
“We will be urging beneficiaries and advocates to bring the agreement to the attention of contractors,” said Gill Deford, the director of litigation for the Center for Medicare Advocacy. “There is no reason why they can’t be urging contractors to make the right decisions now.”
Rick of the Parkinson’s Action Network questions how that will go over. “I do encourage people to advocate for themselves as hard as they can,” she said, acknowledging that time is of the essence for so many people with degenerative diseases. “But I would be uncomfortable as a contractor reading a settlement agreement and trying to figure out what that means.”
Erin Shields Britt, a spokeswoman for the Department of Health and Human Services, did not want to comment, given that the settlement was not yet final, on how patients could best use the settlement to their advantage when trying to get Medicare to pay their claims.
But it cannot hurt to try. The worst that will happen is that you will get a denial, at which point you will need to decide whether you want to appeal and whether you can pay for the treatment yourself.
For all of the improved access to care that may result from this settlement, crucial money questions linger. People who wondered whether any improved Medicare coverage might reduce the need for long-term care insurance will be disappointed to find that the planning challenge remains. While the settlement might improve coverage for certain kinds of inpatient skilled nursing care, you may still have to pay for years in a nursing home when you can no longer handle basic tasks of daily living and staying in your home is no longer practical.
On a more macro level, there are costs to Medicare for all of these treatments, though Medicare does have individual annual limits in certain areas. How much more money might the program spend?
“Under this proposed settlement, Medicare policy would be clarified so that claims from providers will be reimbursed consistently and appropriately, which is always our aim,” Shields Britt said in an e-mail.“Because this proposed settlement would clarify existing policy, we do not expect changes in cost relative to what has been projected.”
That assumes that there is no exploitation of the newly clarified rules — or outright fraud. Nevertheless, there is potential for savings here, too.
“The upside is really important,” said Carol Levine, the director of the families and healthcare project for the United Hospital Fund. “Because if it’s done well, physical or occupational or other kinds of therapy prevents the kinds of hospital readmissions that are costly. And not only are they costly, they really contribute to the deterioration of someone with a chronic condition.”