Oct. 23, 2012 at 1:48 PM ETBy Ricardo Alonso-Zaldivar, AP
WASHINGTON - Thousands of Medicare patients with severe chronic illnesses like Alzheimer's would get continuing access to rehab and other services under a change agreed to by the Obama administration, advocates said Tuesday.
The proposed agreement in a national class action suit, filed with a federal judge in Vermont, would allow Medicare patients to keep receiving physical and occupational therapy and other services at home or in a nursing home so they can remain stable, said Gill Deford, a lawyer with the Center for Medicare Advocacy.
That's been a problem for some because of a longstanding Medicare policy that says patients must show improvement to keep getting rehab. Deford's group and other organizations challenged it.
"If you have a chronic condition, by definition you are not improving," said Deford, the lead attorney on the case. "Our view is that Medicare regulations were intended to allow people to maintain their health status. They don't have to show they are getting any better. The point is to allow them not to get any worse, if possible."
The agreement is expected to affect tens of thousands — maybe hundreds of thousands — of patients nationally. Those who stand to benefit include not only people with intractable conditions like Alzheimer's, multiple sclerosis and chronic lung disease. Those who are growing weaker because of advancing age, placing them at greater risk of falls and other problems, could also be helped.
The impact on Medicare's budget is unclear, partly because program rules are not always rigidly enforced. Even with a requirement that patients must continue to show improvement, billing contractors sometimes defer to the clinical judgment of doctors and therapists. Even if a patient's underlying disease is advancing, therapy might be able to help them keep their strength up and do more take care of themselves. Still, that's no guarantee that Medicare will pay.
"That's what the point of this case is," said Deford, adding that his center has represented many people repeatedly denied coverage for rehabilitation services. "This will allow them to have access."
Administration officials would not comment because the settlement is still pending.
Deford said it could be several months before the settlement is finalized in court, and perhaps another year before Medicare formally completes the policy change.
"I'm hoping the new coverage rules will de facto take effect before they are formally revised," said Deford.
Most of the immediate beneficiaries will be the parents of the baby boom generation and younger disabled people, who are also entitled to Medicare coverage. But the change could have its greatest significance for the boomers, many of whom are expected to try to live independently into their 80s and 90s.
The Medicare change was first reported by The New York Times.
Copyright 2013 Thomson Reuters.