Medicare “Improvement Standard” No Longer Impedes Home Care

By Alicia Gallegos, American Medical News

Physicians are applauding a landmark settlement that will prohibit Medicare contractors from denying health coverage based on a patient’s potential for improved health status.

The agreement, which a federal judge must approve, is the result of a legal challenge by patients accusing the Centers for Medicare & Medicaid Services of using an “improvement standard” to measure a patient’s need for skilled home health care. Doctors and patient advocates said the standard has resulted in denials for necessary therapy and other home services for patients with chronic health conditions such as Parkinson’s disease, Alzheimer’s and multiple sclerosis.

For a long time, physicians have been frustrated with recommending care for patients only to have coverage for those services rejected, said Alberto Esquenazi, MD, president-elect of the American Academy of Physical Medicine and Rehabilitation, a plaintiff in the suit. Often patients refused coverage were forced into nursing homes or went without needed care.

“Patients would call back after receiving news that their medically indicated rehabilitation intervention was declined because ‘it was for a chronic condition,’?” Dr. Esquenazi said. “Rehabilitation specialists had to look for community services to provide some of this care. [The settlement] is excellent news for our patients with chronic disabling conditions.”

The Justice Dept., which represented the government in the case, declined to comment on the settlement. A spokesman for CMS also declined to comment.

The Center for Medicare Advocacy, a patients rights group based in New York, sued the Dept. of Health & Human Services in 2011 in U.S. District Court for the District of Vermont on behalf of a nationwide class of Medicare patients. The center was joined by seven health organizations, including the National Multiple Sclerosis Society, the Paralyzed Veterans of America and the Parkinson’s Action Network. The plaintiffs claimed that Medicare contractors were using an improvement standard to base coverage decisions on whether patients were expected to get better, despite the practice being prohibited by federal law.

The criteria were written into some CMS guidelines, leading to inconsistency among the manuals that provide guidance to contractors on coverage decisions, said Margaret Murphy, associate director for the Center for Medicare Advocacy.

CMS has not admitted that an improvement standard ever was used. However, the settlement clarifies that patients who need skilled care to maintain their health status or prevent health deterioration may receive coverage regardless of their potential for improvement. CMS has agreed to make this fact clear in its manuals, and educate contractors and administrative law judges who make coverage decisions, Murphy said.

“Once the court approves the settlement, people who have been denied Medicare will have a chance to have their claims re-reviewed,” she said. “They’ll get another bite of the apple to get their case looked at.”

Settlement aids patient advocacy

The CMS agreement is a step in the right direction for patients and the health professionals who treat them, said Nicholas G. LaRocca, vice president of health care delivery and policy research for the National Multiple Sclerosis Society. The settlement will enhance the resources available to people with MS and other chronic conditions and allow them to maintain their maximum independence, he said.

“People who have chronic conditions like MS very often are not likely to improve with treatment,” he said. “However, treatment can help them maintain independent functioning, remain in the community and maintain a quality of life. Basically it helps them hold the line as much as possible against further changes.”

The American Physical Therapy Association expressed satisfaction at the settlement, saying it aligns with the group’s long-held belief that determinations of physical therapy coverage under Medicare should be based on the unique conditions and individual needs of each patient. “We strongly believe that allowing Medicare beneficiaries to receive physical therapy in skilled nursing facilities and home- and community-based settings will result in significant cost savings in the long term, as well as help bolster the triple aim of health care reform to improve care for individuals, improve health for populations and lower spending growth,” the association said in a statement.

The agreement allows doctors and medical professionals to support their patients better and ensure that they receive the appropriate care, said Connecticut family physician Kenneth Dardick, MD. He is the husband of Judith Stein, executive director of the Center for Medicare Advocacy.

“For primary care physicians who are the medical home for many of these patients, and [for] specialists, it should be much easier to advocate properly for the patient to have continued care and not feel trapped that a nursing home is the only place they can go,” he said.

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