Which Hospital Must an Ambulance Take You To – Can You Demand a Specific Hospital?
February 13, 2014
The answer is – it depends.
If there is an emergency and you are unable to express your wishes, even if you have advanced medical directives or a health care proxy in place, the Emergency Medical Technicians or Paramedics responding to the call are obligated to stabilize you and transport you to the nearest appropriate hospital. This does not necessarily mean you’ll be transported the closest hospital – for example, if you are severely burned, the ambulance may bring you to the nearest hospital with a specialized burn unit, even if there are other hospitals closer by. Once you have been evaluated, your advanced health care directives can be implemented, including transporting you to another hospital if a transport can be done safely.
In a situation where you are able to express your wishes, an ambulance may take you to the specific hospital you demand. Some ambulances, especially town or municipal ones, may be assigned to a certain “zone,” and are unable to take you to a hospital outside of their assigned region. And, if a hospital’s emergency room is full and not accepting any more patients, an ambulance may not be able to bring you there, even if that is where you wish to go.
It is also important to note that Medicare only covers ambulance services “to the nearest appropriate medical facility that’s able to give you the care you need.” If you demand transportation and are brought to another hospital instead of a closer, equivalent facility, you could be left to foot the bill on your own. An ambulance crew cannot ask you about your insurance, but it is important to know that Medicare may not cover ambulance transport if you demand a specific hospital.
Heard at the Office: “Can’t My Spouse Automatically Speak for Me at the Hospital?”
January 30, 2014
Under the law, no. In real life, sometimes.
Many people think that they don’t need to sign a Health Care Proxy because they assume that the law permits their spouse to speak for them in medical emergencies. The law actually says quite the opposite. Only you or someone you have named in a Health Care Proxy has the authority to make medical decisions for you.
Real life doesn’t precisely follow the law. If hospital staff get the sense that the family all gets along and don’t think anyone in the family will have an issue with the well-spouse being the decision-maker, they will often turn to the well-spouse to make the decisions. But if hospital staff sense any dissent among the family, they will want to see a Health Care Proxy.
But what if you never signed one? Well, the hospital will tell your family that they need to go to court to have a guardian appointed. That costs a lot of money (your money, by the way), and takes a lot of time and emotional energy.
And even if the family all gets along just fine, there are other reasons hospital staff may ask to see a Health Care Proxy (and if there isn’t one, send your family off to court). For example, if you need antipsychotic medications, like anxiety or depression medications, the staff will ask to see a Health Care Proxy. Another common example arises when hospital staff considers inserting or removing a feeding tube, or using or discontinuing use of a ventilator. As you can see, even if your family gets along, the hospital staff still will need to see a Health Care Proxy (or, you guessed it, send your family off to court for guardianship).
Moral of the story? Put a Health Care Proxy in place now. It doesn’t take much time at all.
MOLST – Getting Your End-of-Life Wishes into Your Doctor’s Orders
May 28, 2013
Massachusetts has recently enacted the MOLST program – that’s Medical Orders on Life-Sustaining Treatment. This is a solution to a question that a lot of clients ask: “How do I make sure my kids do what I want with end-of-life care?” Or more typically, clients say, “I want a living will.”
MOLST is better than a living will, and it goes further than a health care proxy. Until MOLST, you might share with your children what kind of treatments and care you do and don’t want as you approach the end of your life, and you might get a chance to talk about it with your doctor, and then you hope for the best as you gradually come to rely on others to make decisions for you.
With MOLST, you have a conversation with your doctor while you are able, and then – this is the key – the doctor turns those into “doctor’s orders.” The MOLST form is a pink sheet of paper, and once that is in your medical record, it’s going to carry a lot of weight.
With MOLST, you get to think about and talk to your doctor about the things that are already on your mind – would you want CPR? Ventilation and intubation? Dialysis? Artificial nutrition and hydration? And then you turn them into medical orders. That means that there is a pretty good chance (though no system is foolproof) that as you decline, your medical providers and family will not only know your wishes, but will honor them. Having them in your record as doctor’s orders makes all the difference.
What about changing your mind? Yes, you can. At any time, you can talk to your medical staff about changing a prior decision in the MOLST.
Family members may ask what to do if a parent or loved one is already at the point where they can’t discuss end-of-life care options themselves with their doctor – the MOLST process permits a health care proxy or guardian to review end-of-life choices with the doctor as well.
For more information, and to see a sample form, see the MOLST site. It’s a well written, easy to read site.
Please note that the MOLST process is meant for people with advanced illness or injuries. If you are healthier, then the best vehicle for sharing your end-of-life wishes is something like the Your Way workbook.
Department of Public Health Survey on Health Needs for People with Disabilities
May 20, 2013
The Nursing Home Stopped Medicare Payments Because my Loved One Stopped Improving, but I Heard that’s Illegal
January 3, 2013
For many years, Medicare has stopped paying for therapies or skilled care once the patient stopped improving, or plateaud. This is not what the regulations say, but somehow that became the practice across the country.
In December, the good folks at the Medicare Advocacy Project fought and won against this trend, and a federal judge ordered that nursing homes must now provide the full 100 days of coverage that patients are entitled to, so long as they need skilled care or therapies, whether to improve, to maintain their conditions, or to stop or slow a deterioration.
So what happens to patients who have received Medicare denials in the past few years, and had to pay out-of-pocket, often impoverishing themselves, so that they (or a loved one) could receive continued nursing home care? Will this federal case help them?
Yes. Denials going back as far as September 20, 2010 can be re-reviewed under the new (old) standard. So if you or a loved one were in a nursing home in the late summer of 2010 or later, and if you had to pay out-of-pocket for skilled care or therapies after a Medicare denial, then dig out your paperwork. As the federal case is implemented, Medicare will create a process for re-reviewing these denials in light of the new (old) standard. Check the Medicare Advocacy Project for updates on this process.
If you have a loved one currently in a nursing home and they receive a Medicare denial, if you think they need continuing skilled care or therapies in order to maintain their condition or to stop or slow their deterioration, then appeal. It will take some time for the appeal process to get up and running, but you want to make sure you appeal on time.
P.S. These rules also apply to home care and outpatient therapies.
Has the Nursing Home Told You that Medicare Coverage is Ending Because the Patient is No Longer “Improving”?
December 27, 2012
Every day, families of nursing home patients are told that Medicare coverage will be ending in a day or two, because the patient is no longer “improving.” Well, that has never been what the Medicare regulations say, but somehow, that has become the common practice across the country.
The good folks at the Medicare Advocacy Project brought these infractions to court and won. A federal judge in Vermont, whose order applies to the whole country, clarifies that nursing homes can no longer cut off Medicare just because a patient has “plateaued.”
Instead, the (old) new law is: so long as the patient needs skilled care, whether to improve, maintain her condition, or prevent or slow deterioration of her condition, she is entitled to Medicare payment for up to 100 days. Period. Looked at another way, if the patient needs skilled care on a daily basis, or if she needs physical, occupational, or speech therapy five days per week, then she is entitled to Medicare coverage for the full 100 days.
The doctor is the most important person for you to work with. If she agrees that the patient needs daily skilled care or therapies, then a written statement from her will help you win the full 100 days of Medicare coverage.
See here for a further understanding of the end of the “improvement standard,” and then review the self-help packets. These are straight-forward, easy to read packets that will help you explain to the nursing home administrator that the rules have changed (many of them haven’t heard yet), so that she will feel comfortable submitting the claim to Medicare and continuing the patient’s coverage.
P.S. These rules also apply to home care and outpatient therapy, as well.
Thank you, Medicare Advocacy Project!
Medicare Long-Term Care Payment Structure Changing
October 23, 2012
Medicare payment structure will be changing. Historically, even though Medicare is supposed to pay for anyone needing skilled care, they’ve been cutting patients off when they “plateau” – so if therapy is no longer going to help you improve, Medicare stops paying (even though their regulations say otherwise). Now, this class-action law suit out of Vermont will change things. Medicare will pay for people who need skilled care (just like their regulations say) regardless of whether the patient is actually improving. This is huge news for elders and disabled individuals who need long-term skilled care. Very exciting stuff. Stay tuned for implementation.
Settlement Eases Rules for Some Medicare Patients
Published: October 22, 2012
Under the agreement, which amounts to a significant change in Medicare coverage rules, Medicare will pay for such services if they are needed to “maintain the patient’s current condition or prevent or slow further deterioration,” regardless of whether the patient’s condition is expected to improve.
Federal officials agreed to rewrite the Medicare manual to make clear that Medicare coverage of nursing and therapy services “does not turn on the presence or absence of an individual’s potential for improvement,” but is based on the beneficiary’s need for skilled care.
Judith A. Stein, director of the nonprofit Center for Medicare Advocacy and a lawyer for the beneficiaries, said the proposed settlement could help people with chronic conditions like Alzheimer’s disease, multiple sclerosis, Parkinson’s disease, stroke, spinal cord injuries and traumatic brain injury. It could also provide relief for families and caregivers who often find themselves stretched financially and personally by the need to provide care.
“As the population ages and people live longer with chronic and long-term conditions,” Ms. Stein said, “the government’s insistence on evidence of medical improvement threatened an ever-increasing number of older and disabled people.”
In many cases, she said, the denial of coverage led to a denial of care because most people cannot afford to pay for these services on their own.
Neither she nor Medicare officials could say how much the settlement might cost the government, but the price of expanding such coverage could be substantial.
Dr. Lynn Gerber, director of the Center for Study of Chronic Illness and Disability at George Mason University in Virginia, called the settlement “a landmark decision for Medicare recipients with chronic illness and especially those with disability.”
“Disability frequently accompanies many chronic conditions,” Dr. Gerber said, “and we often have no cures, so people are likely to experience progressive disability. Rehabilitation, physical and occupational therapy and skilled care are incredibly important in maintaining a person’s functional ability, performance and quality of life.”
The lead plaintiff, Glenda R. Jimmo, 76, of Bristol, Vt., has been blind since childhood. Her right leg was amputated below the knee because of blood circulation problems related to diabetes, and she is in a wheelchair. She received visits from nurses and home health aides who provided wound care and other treatment, but Medicare denied coverage for those services, saying her condition was unlikely to improve.
Another plaintiff, Rosalie J. Berkowitz, 81, of Stamford, Conn., has multiple sclerosis, but Medicare denied coverage for home health visits and physical therapy, on the ground that her condition was not improving. Her family said she would have to go into a nursing home if Medicare did not cover the services.
The proposed settlement, negotiated with lawyers from the Justice Department and the Department of Health and Human Services, was submitted last week to Christina C. Reiss, the chief judge of the Federal District Court in Vermont. If she approves it, as expected, she would have authority to enforce it for up to four years.
Asked about the proposed settlement, Robert D. Reischauer, a public trustee of the Medicare program, said: “Unquestionably that would increase costs. How much, I can’t say.” Other independent experts expressed similar views.
While the settlement is likely to generate additional costs for the government, it might save some money too. For example, physical therapy and home health care might allow some people to avoid more expensive care in hospitals and nursing homes.
Charles S. Miller, a Justice Department spokesman, and Erin Shields Britt, a spokeswoman for the Health and Human Services Department, said government lawyers had no comment.
The changes will apply to the traditional Medicare program and to private Medicare Advantage plans. They apply to people 65 and older, as well as to people under 65 who qualify for Medicare because of disabilities.
The Obama administration initially urged the judge to dismiss the lawsuit. Medicare officials denied that they had a formal policy requiring beneficiaries to show their conditions would improve.
However, in a separate lawsuit in Pennsylvania, Medicare officials argued the reverse. In order for Medicare to cover skilled nursing care, they said in a legal brief, “there must be an expectation that the beneficiary’s condition will improve materially in a reasonable and generally predictable period of time.”
The same standard, in nearly identical language, is found in guidelines used by some Medicare contractors, which review and pay claims on behalf of the government. In a typical case, Medicare terminated coverage of skilled nursing care and physical therapy for an 81-year-old woman because she had “exhibited a decline in functional status.”
Under the settlement, the federal court in Vermont will certify a nationwide class of more than 10,000 Medicare beneficiaries whose claims for skilled nursing and therapy services were denied before Jan. 18, 2011, when the lawsuit was filed. Many of them will have an opportunity to have their claims re-examined under the revised standards.
Plaintiffs in the case include the National Multiple Sclerosis Society, the Parkinson’s Action Network, Paralyzed Veterans of America and the National Committee to Preserve Social Security and Medicare, an advocacy group.
Neither the Medicare law nor regulations require beneficiaries to show a likelihood of improvement. But some provisions of the Medicare manual and guidelines used by Medicare contractors establish more restrictive standards, which suggest coverage should be denied or terminated if a patient reaches a plateau or is not improving or is stable. In most cases, the contractors’ decisions denying coverage become the final decisions of the federal government.
A version of this article appeared in print on October 23, 2012, on page A1of the New York edition with the headline: Accord To Ease Medicare Rules In Chronic Cases.
Bring It with You
March 6, 2012
Do you have a Health Care Proxy, HIPAA Statement, and advanced directive (in my office that would be the workbook called Your Way)? If you are in a hospital or rehab and are being transferred to another medical institution, bring copies with you. Do not assume these will be transferred to the new institution!!
We are living in the beginning of the age of electronic medical records, so you would think it would be a no-brainer that your Health Care Proxy, HIPAA Statement, and advanced directive would go with you to your new medical institution. But even the best computer systems are run by humans, and we all know that medical institutions are understaffed.
Be on the safe side and bring these documents with you. When you get to the new institution, make sure these are placed in your chart. And then tell every nurse and doctor who comes to see you that they can find these documents in your chart.
Have an Advanced Directive? Put it into Language that Doctors Understand
February 21, 2012
If you have an advance directive (in my office, that’s the Your Way workbook), and if you have a terminal or very serious illness, take your advance directive one step further and have your doctor convert it into “doctor’s orders.” If you have been in a hospital, then you know that all care is administered pursuant to doctor’s orders. Frequencies and dosages of medications? Check the doctor’s orders. Which therapies and when? Check the doctor’s orders. Type of diet? Check the doctor’s orders.
Ask your doctor to take your advance directive and convert it into doctor’s orders. That way, in an emergency, hospital staff will look in the chart and immediately see your directives, written in a format that they are used to.
Get Input from Your Doctor to Develop Your Advance Directive
February 10, 2012
I give the “Your Way” workbook to every client who signs a Health Care Proxy. This workbook allows you to spell out to your family what your end-of-life wishes are.
If you have a serious or terminal illness, complete the Your Way workbook in pencil, and then go over it with your doctor or nurse practitioner. They should be able to help you outline wishes based on what they know may lie in your future as your illness progresses.
Have a hard time getting an appointment with your doctor? Or don’t think he gives you the time you need? There’s an alternative. I work with a wonderful geriatric nurse who can sit down with you, discuss what to expect down the road from your illness and what the medical choices will be at various turns in the road. If you would like to meet with her for a private session, so that she can help you articulate educated, thoughtful end-of-life wishes, please call me.