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The Rest of the Story: More About the New York Times Article

Human-RightsBeing interviewed by a New York Times reporter is a banner day indeed. The writer singled me out from a transcript of a national conference call with Centers for Medicare Services, or CMS. What drew her interest was my position as a patient advocate which was unique amongst the participants of the call.

She basically wanted to know how the recent changes in Medicare standards for rehabilitation therapy (specifically changes in the “improvement standard”) affected my patients. I gave her two examples.

In both cases described to her, extended therapy was granted as a result of our patient advocacy.

One elderly gentleman with a broken hip was able in the extended time frame to develop enough strength and endurance to discharge from the skilled nursing setting to a better long-term living situation. He escaped living the rest of his life immobile for all intents and purposes, stuck in wheel chair whenever he was out of bed. That few weeks of extra therapy got him over the hump and back on his feet.

The retired, blind Catholic nun who needed more therapy after a pelvic fracture was able to extend her therapy long enough to regain confidence and strength to a use a walker semi-independently. She too escaped the all too frequent and tragic fate of consignment to her wheel chair or bed, where immobility becomes permanent.

This happened not only because the “Jimmo-Sebelius” class action lawsuit, which was brought on by the Center for Medicare Advocacy, was won on behalf of Medicare recipients in 2013, but also because there were patient advocates impacting a system that needs to be recalibrated.  Millions of elders are in need of significant therapy accommodations to be able to regain their lives back.

What’s the big deal about a few more weeks of therapy anyway? What real world effect is there when elders who could have gotten back to their pre-injury baseline are discharged from therapy prematurely?

Immobility is what happens.

Often overlooked, immobility is one of the most dangerous co-morbidities faced by elders who often have their lives shortened by related “complications.”

Meet immobility’s ugly twin sisters: pneumonia and deep vein thrombosis.

If it’s true that hope springs eternal, it’s certainly not true in the halls of most long term care facilities when people are unnecessarily denied a chance to meet their maximum rehabilitation potential. It is not true when elders who’ve lost what movement and independence they recently enjoyed become completely dependent on others for their most personal needs.

Waiting too long for someone to take you to the bathroom quickly devolves to incontinence. The only things that spring up in that environment are urinary tract infections and despair.  This whole cycle is exactly why extended therapy for patients in a post-acute rehabilitation situation is so critical. Extended therapy which helps elders maintain their highest level of mobility and maximum independence is not only good for elders, it also cuts costs for Medicare in the long run.

The other side of the story is that while the “sea change” represented by “Jimmo vs Sebelius” filters down from top policy levels to the Medicare payment mechanisms, it is potentially problematic for providers.

How so? At least theoretically, the system is now demanding something that providers may not be reimbursed for in a timely fashion, if at all. Just because the policy makers at CMS have re-written the Medicare manual at post-acute care delivery settings and have done national conference calls and webinars on the changes doesn’t mean the folks in accounts payable department at CMS will get the memo.

On a conference call with CMS, I was the only patient advocate on the line. All others were confused providers quite obviously concerned that they might not be reimbursed for this extended therapy based on the new “maintenance standard.”  Who will be the provider’s advocate when their billing for extended therapy for their patients gets denied because the system hasn’t been updated to accommodate this change?

Both patients and providers need advocacy in this situation. Otherwise everyone will play it safe and unless skilled and timely advocacy is leveraged, providers will continue operating under the default of the improvement standard. The result of that is that the fragile elderly whose one hope is a few more weeks or months of therapy will be denied it and be stuck in the downward spiral of decline.


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