Medicare’s ‘improve or you’re out’ rehab policy

I have been meaning to write about the important court order overturning Medicare’s longstanding ‘improve or you’re out’ (of Medicare financed SNF and/or home health) policy for rehabilitation services. Basically, beneficiaries who had plateaued and could at best maintain function could not receive rehab services under these parts of the Medicare benefit package. Medicare has settled the court ruling with plaintiffs to expand the availability of these services, even to patients who cannot show improvement, but only maintenance of function. Several quick points:

  • While this issue has long been on the radar of elder/disability advocates, it never made it into the popular culture as a political issue. Why? I think it is related to the fact that long term care and disability are the underside of the health care system and people don’t like to think about needing rehab just to be able to maintain their ability to swallow, for example. Not an attractive thought.
  • Imagine if Medicare announced that chemotherapy X to treat Cancer Y would only be paid for if you could prove it was extending your life. The internet and the health policy meets political corner of twitter would break. We turn in horror from looking at long term care, but run toward the potential denial of a curative therapy and have a group freak out (sorta like ‘rubber-necking’ at a bad car wreck).
  • It doesn’t bother me and I even like the fact that the question of ‘can/is this person benefiting?’ from rehab services is being asked. It is a policy question as to whether such care should be required to bring about improvement, or simply to maintain function. I think the case has now been rightly decided toward expansiveness of these services. However, the same type of bright lights (does it extend life, improve function, how much does it cost?) should be asked of the entirety of the Medicare program. Not just the parts no one likes to think about.

cross posted at freeforall

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

7 thoughts on “Medicare’s ‘improve or you’re out’ rehab policy”

  1. I see one problem. One aspect of cost containment is the assumption that most people do not like going to doctors, do not like needles, do not like pills, really do not like surgery. Therapy is different. My husband had lots of speech therapy, some paid by insurance and some not. Three times a week, for an hour, an intelligent, usually young, frequently beautiful young woman (never met a male speech therapist) would get my husband to talk and listen with total attention to everything that she had gotten him to say.

    He would have done this 24/7 if he could.

    1. Hadn’t thought of this angle specifically….but do agree the moral hazard for some things (living in a NH, etc.) are much less than for some care.

  2. A big problem is that therapy may require the patient to live in a rehab facility. Medicare doesn’t pay for long-term care, but it will pay living expenses for a person who needs rehab, so there’s a huge incentive for facilities and families to try to keep a person in rehab if he or she can’t live independently. So Medicare polices improvement strictly and goes after faciilities for fraud if they don’t observe the improvement rule.

    We had this issue with my elderly mother, who had a number of horrendous health issues that resulted in six weeks of hospitalization, discharge to rehab, rehospitalization, and then to another rehab facility. By that point, she was unable to walk, stand, or feed herself, and she was suffering from hospital-induced dementia and depression. She refused to cooperate with the rehab therapists and eventually the facility kicked her off Medicare. They had to – if they’d kept her on when she wasn’t showing improvement, they risked fines and penalties.

    Fortunately, our family could afford to keep her in the facility, and after a month or so her dementia improved to the point that she could begin to participate in physical therapy, where she made significant improvements. She’s now living in her own apartment again.

    But if we hadn’t had the cash, she would be in a medicaid-funded nursing home now, still demented and drugged into inactivity. Or, more likely, she’d be dead.

  3. I’d say in general this is a good thing, but I’m not exactly unbiased in the matter.

    My partner has MS and has run up against this limitation because our health insurance follows Medicare guidelines for recurring treatments. What happens is he plateaus, the PT stops for a while, he deteriorates to the point where PT will result in an improvement again, and the process repeats.

    My guess is the old guidelines were written thinking of people with injuries where there might be a limit (short of full recovery) of the functional recovery that can be expected, but the condition won’t deteriorate if PT is stopped, and not those with chronic degenerative conditions. Kind of like when we were looking for a physical therapist within the medical group we use. Almost all of them were focused on people who are basically healthy but have a specific problem such as a joint injury that has been repaired, and were pretty much useless for someone with MS.

  4. We need a saner system than we have.

    When my mother-in-law was diagnosed with small-cell lung cancer last year, she refused chemotherapy. That was her right, of course. But she lived alone and was unable to care for herself just prior to her diagnosis. In fact, the cancer was discovered when they were trying to diagnose the back pain she had subsequent to her fall. Returning her to her home was not an option: the doctors said she required someone with her 24/7.

    Moving her into our house was not a viable option, either. I was working at my University, and I had to be away from home for a minimum of 30 hours/week, between classes (I taught a 12 hour load last term), office hours and committee duties. My wife was teaching at her campus in the midwest.

    Hospice care was what was appropriate, but because it’s classified as an ICF, Medicare and BC/BS would not pay unless her condition was unmanageable in another setting.

    So, she went to a SNF instead. I had one of the most surreal experiences of my life when I met with the social worker there to “plan” her rehabilitation. In the event, she wasn’t there very long before she died. But she should never have been there at all.

    Our system is insane.

  5. These stories provide a glimpse of how incoherent our LTC system is. My family is living this now….transitioning my mother in law this week from a SNF to assisted living…mixed with 3 hosptializations since Nov 29

  6. This issue also applies to non-Medicare insurance. I was on Blue Cross / Blue Shield who paid for basically unlimited chiropractor visits for my neck stenosis. I got switched to United Healthcare and they will only allow 6 visits per request. Apparently as long as my PCP keeps making the requests I can get therapy but it is a pain (in the neck! LOL). The therapy is not going to fix the stenosis but it sure makes me feel better. Given the unclear benefits of surgical correction I would rather continue with therapy.

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