Please, Can Anyone Explain This To Me?
By Wendy Ford
Many out there are wiser than I. Many have much higher degrees of education than I. Many have long careers in the political arena and federal bureaucracy, certainly arenas of bafflement to me. Others have spent their careers in policy making for the healthcare field succeeding in turning it into an actual “industry”. Policy making and attempting to control spending is admirable and necessary but at the same time perplexing.
Increasingly I find myself feeling as if I am standing under an overpass in the middle of a four-lane highway furiously waving a red flag and pleading, “Excuse me. Pardon me. Could someone help me, please?” All the while everyone is speeding on by, in all four directions, pens poised, in a whoosh of hot air as they go rushing about their business of attempting to stem the tides of flowing funds. The only goal of which all are in apparent agreement is that spending needs to be controlled. Maybe someone out there can explain some of this to me, for after almost 34 years in the healthcare field I am evidently missing some crucial point of understanding.
These are only a few of my endless questions and I am positive anyone working in or dealing with our health care system can add to these. Not one of us is immune to the state that our health care system is in.
Why is it that Medicare and insurance companies will pay hundreds of thousands of dollars to treat a bedsore (decuitus) after it has formed but not pay for the alternating pressure air mattress that would have prevented the formation of the wound in the first place? [That’s a “luxury comfort item”.] If Medicare would pay for this item do they really think every senior is just drooling in anticipation over having the gentle whoosh, thump, whoosh of the air compressor lull them off to dreamland every night?
Why is it that Medicare and insurance companies will pay for someone’s rehospitalization and the sometimes required surgical intervention following the dislocation of a total hip replacement but won’t pay forty dollars for the elevated toilet seat that would have prevented the dislocation in the first place? [That’s a “luxury comfort item”.] If Medicare would pay for this item do they see a river of red ink as every senior rushes right out to have this glamorous item put on every commode in their home?
Why is it that Medicare and insurance companies will pay the tens of thousands of dollars required to fix a broken hip but not the twenty dollars for the grab bar in the shower that may have prevented the fall and fracture in the first place? By the way it is a well-known fact that a fractured hip is among the leading causes of the elderly losing their ability to remain living and functioning independently in their own homes often necessitating placement in a care facility that Medicare will pay tens of thousands of dollars for. Once Medicare funds are exhausted the person pays out of pocket until they are financially destitute at which point state funded Medicaid programs generally take over. Then it is our public funds to the tune of hundreds of thousands of dollars that foots the bill. Another well-documented fact is that life expectancy following a fractured hip is shortened; death frequently occurs within a year following the incident. Of course the cause of death is never the hip fracture but pneumonia or some other medical problem that was exacerbated by the inactivity following the broken hip. [Again the “luxury comfort item” category.] If Medicare were to pay for this item many seniors WOULD have them installed in their homes. The math hasn’t been done but wouldn’t it take an awful lot of grabs bars to equal the cost of paying for just ONE person’s hip fracture?
Why will Medicare pay hundreds of thousands of dollars treating a diabetic foot or leg ulcer often resulting in the ultimate amputation of a leg, then pay for the rehab, the prosthesis, rehabilitation services, equipment and pain management but won’t spend less than four thousand dollars on a home based ultraviolet light treatment device that has been proven to be efficacious in the healing of these ulcers? Once the ulcer is healed it has been clinically shown that the ulcer does NOT recur when treated with ultraviolet light. Diabetics with chronic ulcers will tell you that is NOT the case following conventional treatments.
Additionally this specialized ultraviolet treatment has been proven to actually reverse peripheral neuropathies in the legs and feet that are so common especially in folks with diabetes. These neuropathies can cause intractable pain and untold suffering often requiring very expensive drug management that Medicare does pay for. Another effect of peripheral neuropathies is numbness in the feet leading to the development of ulcers and pressure sores on the feet that don’t heal but Medicare and insurances pay for attempts at getting these often-chronic wounds to heal. The numbness can lead to loss of balance interfering with ambulation and subsequent falls resulting in hip fractures. Please refer to the above-mentioned effects of hip fractures and that completes this scenario.
Peripheral Neuropathies can also occur in the hands causing pain and/or numbness. This can make it difficult for sufferers to manage utensils when eating or writing, managing the fasteners of clothing items, managing doorknobs and faucets. Many sufferers are taking powerful pain medications and require assistance from family, friends or private caregivers to perform the simplest of daily tasks. Yet with the ultraviolet treatment and home unit that cost less than four thousand dollars the neuropathy can be reversed giving relief from pain and restoring functional use of the fingers and hands.
Having personally witnessed the effects of this treatment it is just not within my grasp of understanding to see why reimbursement for a home unit for these folks to be able to continue treatments on their own without the need for the cost of an outpatient treatment should be denied. A wound care clinic called me one day to find out just what treatment we were using on one of their patient’s heel ulcer. The patient had just come in for his weekly appointment and they had measured a 25% reduction in the size of the wound noting for the first time a viable wound bed of granulation tissue (that’s the good red tissue that is indication of improving blood supply and critical for healing to occur). Another patient walked into our clinic with tears of joy streaming down her face. She had just finished writing a letter to her daughter. You see she hadn’t been able to hold on to a pen in over 4 years. A gentleman was able sleep through the night for the first time in years without needing a narcotic for the foot pain. Another lady graduated from using a walker to a cane because for the first time in over 5 years she could feel her feet on the floor with the restored sensation from the reduction of the peripheral neuropathy.
If Medicare were to pay for this item thousands of folks could be spared untold pain and suffering, surgical procedures for wound cleaning and skin grafting could be reduced, many disfiguring amputations could be avoided, extensive rehab time and equipment expenses could be reduced. Quality of life could be vastly improved for many. Yes, it had become a popular treatment and for a time the costs were rising as more and more patients experienced lasting results from the treatments. If the treatments were working, why in the world did Medicare decide to discontinue paying for it? Patients and the manufacturers of the ultraviolet treatment even testified before Medicare with clinical studies showing the positive results being obtained using this cutting edge technology.
Why is it that Medicare and insurance companies will pay for the hospitalization of a patient for their chemo therapy treatments and will pay for the delivery of the treatment in a physician’s office, but will not pay for the drugs if they are delivered in the home setting by qualified personnel? The nursing visit and the intravenous equipment and supplies are paid for but not the very expensive chemotherapy drugs. The already immunocompromised patient must leave their home (often depending on a family member or friend taking time off work or school to provide transportation and then waiting two to three hours during the treatment), struggle to get to the doctor’s office for the treatment then struggle to get back home. If Medicare did pay for the chemotherapy drugs when used in the home setting what do they think would happen? Maybe they figure that it is more expensive to pay for it to be delivered in the home. It sure tugs at the heart to see a patient already weakened by rounds of radiation and chemotherapy struggling with the help of two family members to get into a wheelchair, get in to a car, then struggle to get out of the car and into the doctor’s office, get out of the wheelchair and into the treatment bed or lounge chair then have to reverse the whole laborious process 3 hours later.
Why it is that Medicare and insurance companies are demanding that patients be discharged to care facilities or their homes with such short hospital stays? The home health care field is treating patients in their homes that up until several years ago would have still been in an intensive care unit. Every hospital has on staff social workers whose sole responsibility is discharge planning. Their job is to coordinate the hospital discharges mandated by Medicare and the insurance companies with the physicians and patients to ensure that the patient has appropriate help at home, gets the appropriate medial equipment or assistive devices needed and has an appropriate home environment to go home to. Unfortunately, “appropriate” does not always mean “adequate and acceptable”. Too many emergency calls have been made to home care agency medical social workers by home care personnel requesting assistance with emergency placement for a patient who is not appropriate for home care services following hospital discharge.
Too often home care agency personnel have been sent out for a home care admission on a patient who has been sent home with no one to care for or assist them, with inadequate and unsafe housing or with no means of getting food or paying for prescribed medications.
Medicare regulations state that an agency may not admit a patient to home care whose needs exceed the care the agency is permitted by Medicare regulations to provide. That’s a good regulation to have. However, the hospital, rehab center or nursing home needed to discharge the patient because the Medicare reimbursement guidelines only allow so many hospital, rehab, or nursing home days. Yet the patient does not meet the Medicare reimbursement criteria for continued hospital, rehab or nursing home admission/placement. Huh?
Last November an article was published in this newsletter/social commentary about the Therapy Reimbursement Cap. That is still an issue before the legislature as it was only put on hold at the close of the 2006 session of Congress. It is still possible for a less than two thousand dollar limit to be placed on out patient therapy services.
Medicare is a costly system. It is not going to go away. Costs will continue to climb as more and more of us reach that magical age of 65. What are we to do? The rules and regulations are what they are and who can fight the federal government, right? WRONG!
We need to have a healthcare SYSTEM and not an “Industry”. What really needs to be done is to put the health care system back in the hands of the people who deliver the care and take it OUT of the hands of the pharmaceutical and insurance companies. It needs to be the physicians and healthcare provider professionals making the day to day CLINICAL decisions and not businessmen and women. The HMO Mandate needs to be repealed. You remember, the one that turned healthcare into a profit generating industry.
Each and every one of us can write to our Congressmen and Senators, those of us who are members of the American Association of Retired Persons (AARP) can join in taking action through the resources of that organization. Those of us who work in the health care field can work through our professional organizations. Most importantly we can take our voices to the voting booths and use our fingers to make our wishes known. There is no reason why every single one of us can’t take some kind of action. Come on, folks. Together the American people CAN band together to make our voices heard. Together we CAN form a united front that cannot and WILL not be ignored.
Can anyone explain why this is NOT possible?
May the Lord of Life provide you the light bright enough to see, the discernment accurate enough to recognize and identify and the courage large enough to let you stand up and speak out against injustice wherever it may be hiding and lurking.