There’s nothing like the promise (or threat) of “free” healthcare to obtain Americans worked up about an election. However this card-carrying member of Medicare Nation is feeling pretty ambivalent about the whole thing. It’s not so much that I’m opposed to the idea of neutering rapacious insurance companies; it’s exactly that I’ve seen how the medical industry responds to government tinkering, also it seldom favors the patient.
Because Medicare (and Medicaid) reimburses hospitals and clinics at a lower rate than private insurance providers, healthcare providers serving patients included in these government programs often attempt to trim their services as much as possible without violating federal quality-of-care standards. The most recent example of this dynamic has become roiling the home-healthcare industry.
Prior to this year, Medicare paid providers of in-home healthcare based on a fairly straightforward formula: The more services the company provided its clients, the more dough it received from the government. That allowed SpiriTrust Lutheran, a Pennsylvania-based senior-services company, to provide a full complement of therapists to help people like Anthony Holloway.
Diagnosed with ALS (amyotrophic lateral sclerosis) in 2021, Holloway, 59, can’t walk or wake up; he breathes with the aid of a ventilator. He'd been receiving three hours of physical therapy, two hours of occupational therapy, and one hour of speech therapy every week, plus a biweekly visit from a nurse. Then, last November, SpiriTrust notified him and the wife, Deloise, that it was discontinuing all services, explaining that Medicare would no longer pay after January 1.
As Judith Graham reports in Kaiser Health News, Holloway and thousands of others who depend on Medicare for home healthcare services have experienced their lives disrupted because of Medicare’s new Patient-Driven Groupings Model (PDGM). Sparked by a dramatic increase in home-healthcare costs since 2021, the policy doesn’t consider the need for specific therapy at all. Rather, it calculates reimbursement with different more “holistic” — meaning, subjective — assessment:
SpiriTrust along with other service providers are now rewarded for assisting clients recently released from a hospital with conditions for example postsurgical wounds who require fewer than Thirty days of therapy. And they’ve been quick to terminate take care of people like Holloway, who need extensive, long-term help. “It’s totally inhumane to behave like that,” Deloise told Graham. “I can’t verbalize how angry it can make you.”
PDGM is not going over perfectly with the folks who are providing the care, either. Graham cites a National Association for Home Care and Hospice survey that found another of its 1,500 member agencies intended to cut therapy services as a result of the policy change. Widespread layoffs have already begun throughout the industry.
As you may expect, federal officials are monitoring the situation, while warning companies about short-changing patients. Within an email to Graham, a spokesman for the Centers for Medicare & Medicaid Services delivered this dollop of PR pablum: “We don't expect home health agencies to under-supply care or services; lessen the number of visits in response to payment; or inappropriately discharge someone receiving Medicare home health services because these would be violations of [Medicare] conditions of participation.”
But, when i often remind myself when ruminating on the vagaries of corporate capitalism, everybody’s gotta create a buck. And SpiriTrust and its ilk are generally going to respond to shifts in government policies by protecting their main point here well before they start looking out for their employees and patients. Making me question whether “Medicare for All” and its various iterations might fall a little short of the utopian vision some politicians are peddling.
I was heartened, however, to learn that Holloway and his wife were eventually capable of finding another agency willing to provide a portion of the weekly services SpiriTrust had withdrawn. It’s not ideal, certainly, however it will keep him out of a nursing home for the time being. Considering the capricious nature of Washington policymakers and the survival mechanisms of our medical industry, that may be the best outcome a man can expect.