In 2008, my husband pitched backward down a flight of stairs and suffered a brain injury that cost him his sense of balance. Despite the walker he reluctantly used after that, he often fell, and I was told that if he hit his head again, the blow could be fatal.
For a time, we had a very good therapist who worked on the balance problem with him. But one day she announced that his therapy had to end. He wasn’t getting better, and Medicare wouldn’t pick up the cost unless a patient was improving. She was apologetic. Trying to hold out hope, she told us that Medicare might reconsider if my husband got worse after being deprived of therapy—provided doctors agreed that he was likely to improve at that point if treatment was restored. In other words, he’d have to go downhill for a while before Medicare would weigh in so that he could, perhaps, regain his present, precarious condition.
About a month after we saw the therapist for the last time, my husband fell and again struck his head. He didn’t recover. I couldn’t help wondering whether that fall would have happened if he’d been able to continue with therapy. And it seemed to me that requiring improvement was a nonsensical and infuriating standard to set in an era when 45 percent of Americans have a chronic illness—often more than one. Many of those people need medical help of one kind or another just to maintain their current state of health.
I wasn’t alone in my distress and indignation. For years, the nonprofit Center for Medicare Advocacy in Connecticut handled appeals for people who were victims of Medicare’s so-called “improvement standard,” but its efforts were often fruitless. The center concluded that a lawsuit was the only way forward. In January 2011, it filed a class-action suit on behalf of Glenda Jimmo, a blind 76-year-old whose right leg had been amputated below the knee, and four other patients. The suit named Secretary of Health and Human Services Kathleen Sebelius as the defendant and is known as Jimmo v. Sebelius.
The government eventually agreed to a settlement, and in January 2013, a federal judge approved it. From now on, Medicare—which covers younger people with long-term disabilities as well as elders—must pay for medically necessary skilled nursing and therapy whether patients need it to improve or just to maintain their present conditions. Both original Medicare and the Medicare Advantage programs must comply with the Jimmo settlement, and advocates hope private insurers, which often follow Medicare’s lead, will give up the improvement standard as well.
All this is great news for people who have chronic illnesses, but the word “skilled” is important to note. Medicare still won’t pay for the home health aides so many people depend on to help them with everyday tasks such as eating or using the bathroom.
Some health experts are concerned that Medicare costs will rise dramatically because of Jimmo, but others believe the change will save money in the long run. Patients often get worse when they’re denied the care they need; then they have to be hospitalized at great expense, or they wind up in a nursing home. Skilled nursing and therapy, delivered at home, can save money. For instance, teams from the Department of Veterans Affairs (VA) provide home care each year to 12,000 patients who have chronic conditions. Those patients not only get better care overall but it drastically reduces the number of days they spend in hospital. As a result, their care costs the VA almost 25 percent less than it otherwise would.
The Jimmo settlement is now the law of the land, and health care providers should immediately stop insisting that patients must improve in order to get—or keep—skilled care. Many health care providers may not know that, however. It will take months for Medicare to revise its guidelines; after that, it’s required to mount a nationwide campaign to tell providers about the new rules.
In the meanwhile, if you have a chronic illness and you’re denied Medicare coverage because of failure to improve, you should explain to your provider that the rules have changed. If that doesn’t work, you can appeal. The Center for Medicare Advocacy has self-help packets available to help. Free counseling is available from the Medicare Rights Center (1-800-333-4114) or your local State Health Insurance Assistance Program (SHIP).
The American health care system is good at dealing with medical crises such as heart attacks and strokes, but experts agree that it handles chronic diseases badly. Care is often poorly coordinated and not enough is done to prevent patients from getting worse. The end of the improvement standard is a step in the right direction. I wish my husband had lived to see it.
Flora Davis has written scores of magazine articles and is the author of five nonfiction books, including the award-winning Moving the Mountain: The Women’s Movement in America Since 1960 (1991, 1999). She currently lives in a retirement community and continues to work as a writer.
