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.”

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

  1. Dev Rogers says:

    Bravo! A well-selected case to illuminate the need for therapies for functional gain while living with a chronic condition.

  2. Dawn Reel says:

    Thank God for this new legal clarification. So many seniors, like my dad, have been denied physical therapy just because they won’t walk again. They shouldn’t spend the rest of their lives in bed, watching their limbs wither & cause tightening & pain. This will save a lot of money on pain meds, and needless suffering. Way to go MS Society, et al.

  3. Mary Durlak says:

    Denial of therapy put my mother in a nursing home. She was diagnosed with Parkinson’s Disease and, when she broke her hip and they put it together, she didn’t “make progress.” We were told by the rehab facility that she had to show progress, and Ispecifically we were told that Medicare held old people (she was 84) to the same standards of progress as a healthy 18-year-old.*

    Perhaps it’s not coincidental that the facility had a nursing home attached?

    They would not provide therapy even when I offered to pay for it.

    Eventually, my mother was able to walk a suitable distance with a walker, but there was no place other than a nursing home to put her between discharge from therapy and her regaining the ability to walk. (This was back in 2000, when there wasn’t anything in Western New York between “assisted living” and nursing home. To qualify at that time for Assisted Living you had to be able to do, as I recall, four out of six so-called “activities of daily living” independently. )

  4. aidel says:

    I’m happy about the progress but still concerned about those of us who are the “invisible” disabled. I’m talking here about people who are disabled due to mental illness. If you are disabled due to mental illness and wish to work part time, for example, the medicare people push you go work more and get off medicare. The problem is that maybe you can handle working in a shop a few hours a week, but, if you are a professional, this is not your profession and you should not be required to settle for a lesser job that comes with no insurance and probably doesn’t pay enough to cover rent. I worry about how the people on medicare and medicaid will suffer if Romney is elected (god forbid). And I sure do wish prescription drugs were covered. Thank you, Laura, for thinking of the patients. You are in the minority.

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