PUMPING IRONY: Medicare Mischief

A recent shift in Medicare reimbursement policies is roiling the home-healthcare industry. It should give pause to folks banking on a single-payer solution to our busted system.

A picture of a stethoscope and a Medicare form

There’s nothing like the promise (or threat) of “free” healthcare to get Americans worked up about an election. But this card-carrying member of Medicare Nation is feeling pretty ambivalent about the whole thing. It’s not so much that I’m opposed to the idea of neutering rapacious insurance companies; it’s just that I’ve seen how the healthcare industry responds to government tinkering, and it seldom favors the patient.

Because Medicare (and Medicaid) reimburses hospitals and clinics at a lower rate than private insurance companies, healthcare providers serving patients covered by these government programs often attempt to trim their services as much as possible without violating federal quality-of-care standards. The most recent example of this dynamic is now roiling the home-healthcare industry.

Prior to this year, Medicare paid providers of in-home healthcare based on a fairly straightforward formula: The more services the company provided its clients, the more dough it received from the government. That allowed SpiriTrust Lutheran, a Pennsylvania-based senior-services company, to offer a full complement of therapists to assist people like Anthony Holloway.

Diagnosed with ALS (amyotrophic lateral sclerosis) in 2017, Holloway, 59, can’t walk or get out of bed; he breathes with the aid of a ventilator. He had been receiving three hours of physical therapy, two hours of occupational therapy, and one hour of speech therapy each week, plus a biweekly visit from a nurse. Then, last November, SpiriTrust notified him and his wife, Deloise, that it was discontinuing all services, explaining that Medicare would no longer pay after January 1.

As Judith Graham reports in Kaiser Health News, Holloway and thousands of others who depend on Medicare for home healthcare services have seen their lives disrupted due to Medicare’s new Patient-Driven Groupings Model (PDGM). Sparked by a dramatic increase in home-healthcare costs since 2016, the policy doesn’t consider the need for specific therapy at all. Rather, it calculates reimbursement based on a more “holistic” — meaning, subjective — assessment:

SpiriTrust and other service providers are now rewarded for assisting clients recently released from a hospital with conditions such as postsurgical wounds who require fewer than 30 days of therapy. And they’ve been quick to terminate care for people like Holloway, who need extensive, long-term help. “It’s totally inhumane to do something like that,” Deloise told Graham. “I can’t verbalize how angry it makes you.”

PDGM is not going over very well with the folks who are providing the care, either. Graham cites a National Association for Home Care and Hospice survey that found a third of its 1,500 member agencies intended to cut therapy services as a result of the policy change. Widespread layoffs have already begun throughout the industry.

As you might expect, federal officials are monitoring the situation, while warning companies about short-changing patients. In an email to Graham, a spokesman for the Centers for Medicare & Medicaid Services delivered this dollop of PR pablum: “We do not expect home health agencies to under-supply care or services; reduce the number of visits in response to payment; or inappropriately discharge a patient receiving Medicare home health services as these would be violations of [Medicare] conditions of participation.”

But, as I often remind myself when ruminating on the vagaries of corporate capitalism, everybody’s gotta make a buck. And SpiriTrust and its ilk are generally going to respond to shifts in government policies by protecting their bottom line well before they start looking out for their employees and patients. Which makes me question whether “Medicare for All” and its various iterations might fall a bit short of the utopian vision some politicians are peddling.

I was heartened, however, to learn that Holloway and his wife were eventually able to find another agency willing to provide a portion of the weekly services SpiriTrust had withdrawn. It’s not ideal, certainly, but it will keep him out of a nursing home for the time being. Considering the capricious nature of Washington policymakers and the survival mechanisms of our healthcare industry, that may be the best outcome a guy can expect.

is an Experience Life deputy editor who explores the joys and challenges of aging well.

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