JustCare

Tag: Physical therapy

  • Medicare coverage of nursing home care is very limited

    Medicare coverage of nursing home care is very limited

    Planning ahead for a time when you may not be able to care for yourself means recognizing that, unless you qualify for Medicaid, you may need to pay out of pocket for nursing home care. Medicare coverage of nursing home care is very limited.

    Unlike Medicaid, Medicare never pays for custodial nursing home care, basic care that does not require treatment from a skilled nurse or therapist. Medicare only covers nursing home care for people needing skilled care who have been hospitalized as an inpatient for at least three days in the 30 days prior to admission in a nursing home. If you meet these criteria, Medicare should cover your care for up to 100 days (the first 20 days in full and the remaining 80 days with coinsurance) if:

    1. You are admitted to a Medicare-certified skilled nursing facility; and,
    2. You need daily skilled nursing services, seven days a week or physical therapy services at least five or six days a week; and your doctor certifies your need for this care.

    Note: Medicare should pay for nursing home care that helps maintain your condition as well as care that improves your condition.

    On admission, it is possible that a Medicare-certified nursing home may tell you that it does not believe Medicare will cover your care and ask you to sign a waiver agreeing to pay for the care you will receive. The nursing home may do so to protect itself financially if Medicare denies coverage because Medicare does not think you meet the coverage criteria.

    If you sign the waiver, you may be financially liable if Medicare does not cover your care.  However, you should make sure that the nursing home still submits the claim to Medicare, along with a letter from your doctor explaining your need for daily skilled services. This is called a “demand bill.” There is a good chance that Medicare may ultimately pay for your care.

    If the nursing facility admits you without asking you to sign the waiver, you are not financially liable if Medicare denies coverage. But, if the nursing home asks you to sign the waiver prior to admission and you refuse, the nursing home is not obligated to admit you.

    Keep in mind that hospitals sometimes admit people as outpatients on observational status and not as inpatients.  Even if you stay overnight for three days and you are admitted as an outpatient, you will not qualify for skilled nursing facility care, regardless of whether you need it. Speak to your doctor about ensuring you are admitted as an inpatient if you are hospitalized.

    Click here to learn about your rights in a nursing home. And, don’t be misled by five-star nursing home ratings.

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  • Question your doctor before getting arthroscopic knee surgery

    Question your doctor before getting arthroscopic knee surgery

    If your doctor recommends you get arthroscopic knee surgery for a meniscal tear, do some homework before moving forward with the operation. A new Johns Hopkins study published in JAMA reveals that even though arthroscopic partial meniscectomies (APMs) have no benefit whatsoever for people over 65, surgeons perform these procedures routinely. And, as with much surgery, there are risks of infection and complications.

    Researchers studied Medicare data on 121,624 knee arthroscopies for meniscal tears that developed with age. It is one of the most common procedures for older adults, performed by 12,504 surgeons. Yet, many clinical trials have shown that the procedure unequivocally has no benefit in treating this degenerative disease in older adults.

    In general, the clinical trials reveal that routine exercise and physical therapy provide additional benefits for meniscal tears in older adults. Surgery, by comparison, offers no benefit. However, for acute traumatic meniscal tears, often resulting from engaging in sports, the APM can be beneficial.

    Notwithstanding the evidence against arthroscopic knee surgery for meniscal tears in older adults, thousands of surgeons continue to perform the procedure, jeopardizing people’s health and driving up health care spending unnecessarily. Perhaps, the surgeons have not seen the evidence or, perhaps, they choose to disregard it. Either way, the question is what is to be done about it.

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  • What Medicare covers

    What Medicare covers

    In order to plan for your care as you get older, it is good to know what Medicare covers and what it does not cover. You can then budget for your out-of-pocket costs. Because Medicare generally does not provide full coverage and does not cover some high-cost services, annual out-of-pocket health care costs with Medicare average $5,500. And, if you need to pay for long-term care services, unless you have Medicaid as well as Medicare, your costs will likely be much higher.

    Services Medicare covers: Medicare Part A–which is generally premium-free if you or your spouse paid Medicare taxes–covers hospital, skilled nursing facility, skilled rehabilitation facility, hospice and other inpatient services. Medicare Part B–which has a standard monthly premium of about $134, though people with higher incomes pay more–covers medical services from doctors, therapists and other Medicare-certified health care providers, along with medical equipment and supplies. (To be enrolled in traditional Medicare or a commercial Medicare Advantage plan, you need Medicare Parts A and B.) Medicare Part D–which has a monthly premium that varies depending upon the plan you choose–covers prescription drugs and is optional.

    Note: People who enroll in a commercial Medicare Advantage plan also have Medicare Part C.

    Click on the links below to learn more about Medicare’s benefits and the services it does not cover.

    Keep in mind that some costly services are expressly excluded from Medicare coverage.

    Services Medicare does not cover:

    If you qualify for Medicaid as well as Medicare, Medicaid may cover some of these services.

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  • Budget deal lowers drug costs for people with Medicare

    Budget deal lowers drug costs for people with Medicare

    Congress’ budget deal lowers prescription drug costs for people with Medicare. Under the budget agreement, pharmaceutical companies must absorb more of the cost of prescription drugs for people in the Medicare Part D “donut hole,” a gap in drug coverage for people with substantial drug costs. The budget deal also ends the donut hole in 2019, one year earlier than planned.

    The donut hole is triggered when your total drug costs hit $3,750. At that point, in 2018, you pay 35 percent of your drug costs until you spend $5,000 out of pocket on covered drugs. The budget deal means that you will pay 25 percent of your drug costs while you are in the donut hole, beginning in 2019. Pharmaceutical companies will absorb 70 percent of drug costs, up from 50 percent.

    These drug discounts for people with Medicare in the donut hole are often off of drugs that pharmaceutical companies are able to price preposterously high. So, out-of-pocket costs for people in the donut hole needing one high-priced drug can still be as much as $5,000. But, until Congress steps in to negotiate drug prices, as every other developed country does, the discounts are better than nothing. The change in the law could save people with high drug costs thousands of dollars.

    With the budget deal, not only are drug costs lower for many people with Medicare, but people with Medicare should see lower Part D premiums because of lower drug spending.

    In other good news, the budget deal ends the limit on physical, speech and occupational therapy. Historically, Medicare has capped coverage for therapy services. The budget deal also permits Medicare to cover a much greater array of telehealth services.

    That all said, the budget deal did not include the CREATES Act, which is intended to speed drugs to market once they are off patent. CREATES would have made it harder for pharmaceutical companies, which lose their drug patents, from keeping generics off the market. They often do not share samples of these drugs, needed to manufacture the generics, with generic manufacturers. Right now, generic manufacturers do not have the right to sue pharmaceutical companies to get the samples of drugs going off patent.

    Furthermore, the budget deal repeals the Independent Payment Advisory Board established through the Affordable Care Act to help Medicare control costs.

    And, the one million people with Medicare with the greatest yearly incomes–individuals who earn at least $500,000 and couples who earn at least $750,000–will see an increase in their Part B and Part D Medicare premiums.

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  • For knee pain, avoid arthroscopic surgery

    For knee pain, avoid arthroscopic surgery

    Kaiser Health News reports that international health experts and patients say that for knee pain its best to avoid arthroscopic surgery. According to the study published in BMJ, people with degenerative knee disease, that is osteoarthritis, or tears to their meniscus, are better off with exercise and therapy than with surgery.

    Years ago, I looked into this after a meniscal tear myself (a meniscus is a piece of cartilage that acts as a cushion between bones in the knee). Injuries to menisci often get better with physical therapy, anti-inflammatory medicine like ibuprofen, and maintaining a healthy weight. More serious injuries such as ruptures of anterior cruciate ligaments (ACL) which I also managed to do, require surgery if one is going to continue in a sports career or participate in an activity that puts torsion on the knee such as skiing.

    But for many of us, again, physical therapy and keeping the muscles strong around the knee and body weight under control may be the better choice, as studies show that those who have surgery have three times the risk of developing osteoarthritis later. As with many studies, there is a caveat. The higher risk of osteoarthritis may be related, as the study cited notes, to repeated injuries, since people who get the surgeries may do so in order to continue in activities that may cause them to re-traumatize their knees.

    To arrive at this recommendation, researchers looked at 13 studies of 1,700 patients who received arthroscopic surgery. They found that the overwhelming majority of these patients neither gained relief from their pain nor improved mobility from the surgery.  The small fraction who did see improvement in function or pain relief a few months following the surgery did not see it last for more than a year.

    In addition, surgery always has attendant risks, including infection.

    Arthroscopic knee surgery entails a few small cuts around the knee that permits the surgeon to see inside with a small camera and remove any damaged tissue or cartilage. It is a common procedure for repairing meniscal and ACL tears.  It is generally not recommended for patients with arthritis since it has not been found to reduce arthritic pain.

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  • Medicare begins rating home health agencies

    Medicare begins rating home health agencies

    Much like surgeons, home health agencies are not created equal. To help people better compare Medicare-certified home health agencies, Medicare just launched Home Health Compare. It’s a web site that helps you see some quality differences among home health agencies in your community rates.

    There are a lot of factors that go into whether a home health agency is good, bad or great. So, you should talk to your doctor and other people you know and trust about home health agencies in your area as well as look at Home Health Compare. The Informed Patient Institute provides good information about health care quality, patient safety and health care costs as well as the usefulness of report cards.

    Right now, Medicare is rating agencies for the quality of their patient care based on nine of 27 process and outcomes measures.

    • Process measures include how quickly the patient received needed care, whether the patient got a needed flu shot and whether the agency educated the patient about his or her medications.
    • Outcomes measures include whether the patient got better at walking, bathing, and getting into and out of bed, as well as whether the patient experienced less pain and shortness of breath.

    Some home health agencies may not offer the full range of Medicare-covered services you need. On Home Health Compare, you can find out which services different agencies provide, including nursing care, physical therapy, speech therapy, occupational therapy, social services, home health aide services.