Medicare Case a Win For Patients
With Chronic, Debilitating Conditions, Disabilities

Patients on Medicare with chronic conditions and disabilities will no longer have to show improvement to get skilled care and therapy services, according to a proposed settlement of a class action suit, Jimmo v. Sebelius. The settlement clarifies the standard for Medicare coverage, ending the practice of denying coverage to patients deemed no longer able to improve, which was never part of the Medicare statute.  Proponents say that Medicare patients likely to benefit include those with disabling conditions, including multiple sclerosis, Parkinson’s disease, arthritis, stroke, and heart disease.

“We were plaintiffs in this suit,” said David Chatel, Executive Vice President, Government Affairs, National Multiple Sclerosis Society, Washington, DC. Chatel was adamant that this is  “not a new benefit, but a clarification for patients that were inappropriately denied coverage.” Importantly, the Medicare statute never included an improvement requirement. However, patients seeking rehabilitative therapies (speech, physical therapy, and occupational therapy, for example)are frequently turned down because they failed to show progress. Once they fail to show progress, they are put into a “custodial” classification, not covered by Medicare. As a result, the practice has left patients likely to benefit from services abandoned by the system and at increased risk of further deterioration and hospitalization.

The Maintenance Standard

Under the settlement, Medicare must pay for:

  • outpatient therapy,
  • home health care, and
  • skilled nursing

if needed to “maintain the patient’s current condition, or prevent or slow further deterioration.”

Aditya Ganapathiraju sustained a spinal cord injury several years ago. At the time of the accident, he was extremely weak and did not use much physical therapy. “I was in a lot of pain and lost a lot of weight,” he said. “Had I been able to get therapy post injury, I might have made a lot more improvement much earlier. Ganapathiraju says that he has used physical therapy extensively to help him with transferring and strengthening, permitting him to do a host of things he never could have envisioned at the start.  For example, he now drives, went back to school and graduated from the University of Washington Seattle, and is involved in training and research in rehabilitation medicine at the University of Washington. He is also an advocate with a presence on YouTube.

Ganapathiraju added: “The notion of maintenance to prevent further degradation is well founded. You can quickly degenerate quickly post injury.” Among the many benefits that he sees include prevention of contractures [abnormal, permanent shortening of muscle], prevention of surgery, improving seat function, and activities of daily living.”

But what really troubles Ganapathiraju is the notion that a condition prevents people from functioning in day-to-day life. “It’s really a subjective standard and can prove a self-fulfilling prophecy,” he said.

Cost Considerations

Some accounts of the clarification of the Medicare standard claim that it will prove cost-prohibitive. “That’s kind of a red herring,” said Ganapathiraju. “Medicare financing is entirely a political decision. With just a modest increase in the taxes of the very rich, we could really afford Medicare for All.”

  • What’s your point of view? Share it here.

Planning Orthopedic Surgery: Ask Ahead About Aftercare

Don’t make the mistake of thinking that orthopedic surgery will miraculously dispense with your bone problems; aftercare is just the beginning of healing. That’s how two women see it. Each woman has had five or more orthopedic surgeries. They report that sometimes they felt abandoned, as if nobody was in charge, and their questions were not answered adequately, or on time. One woman, “Terry,” a wall artist and jeweler, had neck, shoulder, and hand surgeries in the mid-Atlantic; the other, “Gina,” had hip surgery at a few centers in California. Both women said that some of their surgeries went well and aftercare was not a big issue. But for other surgeries, it was hard to figure out who was in charge, and aftercare procedures seemed non-existent. By telling their stories, they hope, for the sake of other patients, orthopedic programs develop more systematic aftercare procedures.

Gina’s hip surgeries at teaching hospitals began when she was a child. She had many satisfactory surgeries, but one left her with intractable pain. “ I never should have been released when I had a pain score of 10 [the highest score]. They never managed my pain. They would just blame me and tell me about how none of the other kids that they treated had pain. I think, especially in pediatrics, they have to trust the patient.” Gina returned to the hospital as an outpatient for six months because of intractable pain. When it came time to have her final surgery after puberty, she refused to go back to that hospital, even though until that time, she and her family had built up a strong, personal relationship with the doctors and the staff. She and her family traveled to a neighboring, but much less convenient city, and they say that they will never go back to the place where her pain was a long-term nightmare.

“Unfortunately,” said Gina, “I think orthopedists think that once the surgery is done, they are all through, but for the patient, the recovery is only the beginning.” Gina also pointed to a lack of clarity about rehabilitation, including physical therapy and occupational therapy. Gina’s mother recently had a knee replacement and she had occupational therapy after surgery, and her recovery has gone extremely well. Even though she was far more comfortable after her last surgery, she said: “I still cannot bend down to tie my shoes. To this day, I wonder whether I should have been referred for PT or should have been told that this is the best that the surgery could do. Was it up to me to ask for physical therapy?”

Terry’s last surgery, to graft two bones together in her thumb, was by far, her worst, in terms of aftercare. Terry considers herself an easygoing person, but she regrets having gone to a big center where nothing gets relayed back to the doctor. I interviewed her when it was close to three months after her last hand surgery, the point at which she was supposed to be healed. “I think I am healing, but truthfully, I am not sure.” That’s because, whenever she had follow-up appointments, she knew that she had to have all her questions organized and not try to get something answered between appointments. “If I forget to ask a question at the appointment, I have to forget it.” After living through telephone menus, getting put on hold, and never knowing where she is being referred to when she calls from home with a simple question, she feels that she often hit a dead end or a dead-letter box.  “Sometimes they can’t find a hand surgeon or nobody wants to comment if that is not their specialty,” she said. Shouldn’t there be some person responsible for handling these things?”

Pain was hard to tolerate in her last surgery. Terry said that getting pain prescription before discharge was impossible. They told me: “We can’t give you anything because you are leaving tomorrow.” That left Terry with having to recruit her husband to go to the drug store to get her pain medication and a hole in time when her pain was not fully covered. During her three-month recovery period, “sometimes, I would call and they wouldn’t get around to ordering the pain pills until the next day.”

Terry does not feel that she has gotten timely feedback on restrictions in this last surgery either. “I have animals: big dogs and horses. It is not practical for me to have months on end where I cannot take care of them. I have tried to ask, is it going to do harm to walk the dog or get on the horse? People never call me back, or if they do, the answers don’t seem very helpful.”

Concerns that she felt were not addressed included getting someone to tell her whether pressure on her hand was as bad as lifting and how to deal with a lot of pain. Often, she found that, if she got someone to talk to her, their responses seemed more focused on their own liability rather than her needs. For example, she said: “When they tell me three months out to try and rest my hand, I want to say to them, how about patients who just don’t have restful lives?”

What Good Aftercare Might Look Like

Both women felt that relatively simple systems could be put into place that would not have left them with a sense of patient abandonment that put them into a funk. Gina suggested that just being able to send an email and know that your doctor was going to get back to you by the end of the day would be a big help. There also has to be a shift in medical training so orthopedists don’t just walk away and abandon patients after surgery.  Both women think that a written description of what to expect after surgery would be a major plus.

I contacted the American Academy of Orthopaedic Surgery  to reach an orthopedist for comment, but at press time, I had not heard back. Since this article was published, I learned that an  orthopedist will be getting back to me. A response will be published in the comments below.

Have you had a hard time recovering from orthopedic surgery? Was it difficult to reach people who could advise you about mobility, activity restrictions, or pain? Or did things go smoothly because you had your surgery at a place that had good aftercare practices in place. Let’s hear from you. Consider leaving a comment here.