Courtney: Medicare Standard Is an Erroneous Barrier to Care

Posted December 3, 2010 at 10:19am

At the fevered height of last year’s health care debate, Sarah Palin warned of “death panels” and other alarmists said the bill would lead to rationing. Misrepresentations and red herrings dominated the headlines while Americans such as Eileen Prendergast — a constituent in my eastern Connecticut Congressional district — were left to wonder whether long-standing problems would ever be addressed.

Three years after she was diagnosed with Lou Gehrig’s disease, Prendergast, 68, was told that Medicare would no longer cover the home health care that she needed. Her Medicare Advantage plan and home health agency said that she was “stable in her disease state” and that because her condition would not improve, she was not eligible for skilled care.

At that point, Prendergast could no longer get in her wheelchair on her own. She was losing the use of her arms and hands and had also been diagnosed with diabetes.

Prendergast’s underlying condition was incurable, and her health would never fully improve. However, contrary to years of Medicare practice, the possibility of improvement is not a requirement for skilled care. Just as the hyperbole of health care reform infected our national lexicon, over the course of time, the urban myth of an improvement standard has wrongfully emerged as standard practice for health care agencies and the federal bodies that govern them.

For too long, we have seen a standard with no basis in law — one that courts have rejected in two recent decisions — accepted as a barrier to care. The improvement standard is mentioned in neither the Medicare statute nor its implementing regulations. In fact, according to the Center for Medicare Advocacy, it comes from “references in some Medicare manual provisions, which have been refined, simplified, and emphasized in contractors’ internal guidelines over time.”

In other words, people with chronic conditions — Alzheimer’s disease, broken hips and multiple sclerosis — are being denied precisely the care that they need to avoid further deterioration. More disturbingly, they are being denied that vital care based on an incorrect application of the Medicare statute.

Earlier this year, I spearheaded an effort in the House to right this decades-old wrong. Seventeen of my House colleagues joined me in a letter to the Centers for Medicare and Medicaid Services urging the agency to correct the accepted but erroneous interpretation of the law. The CMS must ensure that all parties involved in Medicare decision-making are on the same page; the statutory standard for care is medical necessity, not improvement.

Today, 46 million older and disabled Americans are enrolled in Medicare, and 78 percent of them have at least one chronic condition. If we continue down this road, ignoring the crisis at hand, more Americans will suffer, more Americans will be denied the care they need and it will unnecessarily result in more institutionalized, expensive care.

Like the demagoguery of the health care debate, the Medicare improvement standard is a myth that evolved into reality. From a line in simplified Medicare manuals to an accepted policy, the improvement standard has hurt countless older and disabled Americans. Too many people such as Eileen Prendergast have suffered its consequences. The time for change is now.

Rep. Joe Courtney is a Democrat from Connecticut.