Medicare Quietly Admits: Not Everyone Gets Better

Rubber Stamp - Top SecretRecent changes in Medicare rules may help seriously ill seniors remain independent at home. Prior to last January, supportive services like home care and physical therapy had to be discontinued for people who “plateaued” in their recovery. Now, as reported by Susan Jaffe in the New York Times, Medicare will cover these services to maintain the condition of people with chronic illness and prevent deterioration.

This could be good news for many people with advanced illness, which consists of one or more chronic conditions that are resistant to treatment. By definition, prospects for recovery are poor in these cases. Home health services are essential to prevent hospital and nursing home admissions that are burdensome, costly and avoidable, even in very advanced disease. But by traditional Medicare rules, home health nurses can serve people only for a limited time before they must discharge them. Left on their own, seriously ill people and their loved ones may have no alternative but to call 911 when things go downhill. However, the new rules may permit more continuous home services even when it’s clear that the recipient will not recover and in fact may not survive.

“Advanced Care” is a new kind of care management that brings needed services to people with advanced illness right where they live. This helps seriously ill seniors, who often have trouble getting to the doctor. Without needed care, their condition deteriorates. Resulting crises lead to hospitalizations that become longer and more frequent as the end of life approaches. Advanced Care can prevent these crises, and as an added bonus it can make treatment more affordable for Medicare.

Advanced Care makes use of Medicare-certified home health services, which include skilled nursing, social work and physical therapy. But it has had to adapt them because the Medicare Manual defines the goals of home health as “recovery and patient safety.” The new rules may make it easier to coordinate care among hospitals, doctors’ offices, and home by allowing more straightforward application of home health over longer periods.

The Medicare rule changes were the result of a 2011 class-action lawsuit filed on behalf of people with multiple sclerosis, Parkinson’s and Alzheimer’s disease, as well as other chronic illnesses. The settlement required Medicare to inform health care providers and certain others about the new rules, but the largest stakeholder group was left out: Medicare beneficiaries, including the very patients who could be helped by the rule changes. Anyone told by a provider or Medicare representative that their home care must be stopped because they aren’t improving should obtain a copy of the Medicare fact sheet about the settlement. Further resources are detailed in Ms. Jaffe’s article.