A group of consumers has filed suit against the federal government, claiming that Medicare benefits are being improperly cut for many recipients with chronic conditions.
The suit, filed in federal court in Vermont, is challenging a Medicare requirement that chronic patients must achieve objective improvements in their functioning in order to qualify for services such as speech and occupational therapy, according to an account in The Chicago Tribune. If a patient can't demonstrate improvement, Medicare will often refuse to pay for such services, and the patient's medical provider will stop offering them.
Denial of such services can in turn cause the cancellation of other Medicare benefits, leading to a slippery slope where patients lose many of the services on which they have long relied.
Making matters worse, the vast majority of Medicare recipients are at least potentially affected by the regulation; the suit says that 78 percent of Medicare's 46 million recipients suffer from at least one chronic illness.
Health care advocacy groups join in
The suit was filed on behalf of five Medicare recipients, all of whom hail from New England. Five health care advocacy groups joined the recipients as plaintiffs.
Judith Stein, executive director of the Center for Medicare Advocacy, one of the five groups involved, told the Tribune that the policy “has been and is creating major harm.”
Stein called the policy “illegal and unfair and an inappropriate application of the Medicare law,” and “a major barrier to access to medical care and access to necessary care. This is not just a theoretic problem but one that affects patients every day.”
“Covert rule of thumb”
According to the suit, the policy is a “covert rule of thumb” that isn't explicitly spelled out in Medicare law. Additionally, the suit alleges that the policy has never gone through a federal rule-making process, which would allow comment from the public.
Many of those affected by the policy have serious chronic illnesses, such as Parkinson's, Alzheimer's, and multiple sclerosis (MS).
Indeed, Dr. Nicholas LaRocca, of the National MS Society -- another of the plaintiff organizations -- told the Naples News that the policy prevented many MS sufferers from using physical therapy to improve their prognosis.
“Maintenance therapy can help hold the line and manage those and other effects of chronic MS,” LaRocca said. “Maintenance therapy can really help them lead more productive lives and maintain quality of life.”
The policy has long been a source of controversy. The Naples News, citing statistics from the Centers for Medicare and Medicaid, said that administrative law judges have heard 36,000 appeals from denials of coverage.
Suit follows Congressional probe
The suit, which seeks a permanent injunction stopping the practice, points out that the policy leads to higher costs down the road, since recipients are unable to seek therapy that could improve their condition, or at least prevent it from deteriorating.
The suit follows a letter sent last May, signed by Rep. Joe Courtney (D-CT) and several other lawmakers, declaring the policy illegal.
“Medicare coverage determinations should not be based on whether the patient's underlying condition is likely to improve,” that letter said, as reported in The Hill. “In fact, federal regulation actually states the opposite.”
Ellen Griffith, a Medicare spokeswoman, said the government would wait to comment until it has reviewed the suit.
