Physical therapists Can Fight the Medicare Improvement Standard with Patient Stories

Bob and Joanne are near the end...

Joanne can no longer care for Bob, who is increasingly weak and debilitated and is facing institutionalization despite a strong will to work hard, stay in his home and a loving spouse who supports him.

It didn't have to be this way...

Bob was discharged Jan 5th, 2010 from outpatient physical therapy working on falls risk prevention.

The Congress in 2010 failed to implement the Exceptions Process to the arbitrary $1,870 "PT cap" on Physical Therapy services in a timely manner and the patient elected to discontinue services (self-rationing) rather than risk hitting the cap with no Exceptions Process.

In January, Bob was not demonstrating measurable progress in a timely manner but had obvious deficits in mobility, self-care, safety and daily activities which limited his independence and caused a burden on his spouse, Joanne.

The Exceptions Process was finally implemented March 23rd with the signing of the PPACA but Bob and Joanne were lost to follow-up at that point and didn't get word.

Bob returned to outpatient physical therapy Nov 10th, 2010. At this time, we are able to document a measurable DECLINE in function, less strength, slower walking, greater use of assistive devices, higher (quantitative) falls risk and greater dependence on his spouse.

Click on ABC Functional Progress Graph to enlarge

We believe, and the patient believes, that the informal, non-statutory, widespread insistence on the Medicare Improvement Standard has led to a denial of physical therapy care and a greater risk of disablement, future institutionalization, chronic pain and future falls risk.

Bob has indicated a willingness to tell his story, in his own words - further, Joanne will describe the additional burden caused by the Medicare Improvement Standard and its financial corollary, the arbitrary cap on physical therapy services.

We can provide evidence of the patient's decline in in function from January to November 2010 - the period he self-rationed his care because of the Standard. We use multiple, validated measures of function recommended by Medicare and supported by the medical literature.

Bob and Joanne would very much like to spend their time together in their home, in comfort and dignity, rather than an antiseptic institution filled with strangers.

What can we do?

click image to enlarge

The Center for Medicare Advocacy would like physical therapists to provide stories of real patient burden faced by people who are unable to get their needed physical therapy as a result of the Medicare Improvement Standard.

The Medicare improvement Standard is illegal but physical therapists have long been taught by self-appointed Medicare auditors that "maintenance therapy" is not allowed and that patients must "improve" if we are to treat them and get paid. According to the Center for Medicare Advocacy...

"...the Improvement Standard conflicts with the law, it has become deeply ingrained in the system and ardently followed by those who provide care and those who make coverage determinations..."

This situation will continue unless physical therapists larn to speak truth to power and get patients to tell us their stories. Often, we are the ones telling the patient that we cannot see them - because we are afraid of Medicare.

"Beneficiaries are told Medicare coverage is not available if their underlying condition will not improve, if they have "plateaued," are not likely to improve, or if they need "maintenance care only".
As a result it keeps people with debilitating, chronic conditions from receiving the care they need. "

Many times, I have been in the position of telling patients I cannot see them when they've "plateaued" and their chronic condition is not improving - yet, I suspect that they will decline when they get back home and cannot train intensive, functional activities the way we do in the clinic. According to one Federal magistrate...

"An elderly claimant need not risk a deterioration of her fragile health to validate the continuing requirement for skilled care"

If you have a story, please contact the non-profit, non-partisan Center for Medicare Advocacy and share your patients' story.

Also, comment on this blog to increase its appeal for other physical therapists doing natural search - you can help this effort even if you don't have a patient story.

Thank you for all you do.