Beware the Medicare HMO!

DISCLAIMER: This web site describes my experience with HMOs and the health care system in the state of California. It is not intended to provide any legal or health care advice to anyone. Please consult your own attorney or physician.

This web site is a work in progress. Your feedback is encouraged.

Introduction: Don’t Join a Medicare HMO!

If you are eligible for Medicare and are thinking about enrolling in a Medicare HMO, you had better think twice! That decision could easily cost you your life—it did so for my mother. Like you, she was wined and dined, along with a large group of other unsuspecting seniors, by a big HMO, who told her she could save a lot of money by enrolling in their Medicare HMO. The colorful brochures they gave her with happy looking seniors on the cover told how much better the HMO was than Medicare: only $5 for a doctor visit as compared with a 20% copayment under Medicare; only $400 for up to 90 days in the hospital, compared with $8,400 through Medicare; and only $1,600 for a 100-day nursing home stay, compared with $9,920 with Medicare. The list went on and on. Although it all seemed too good to be true, she signed away her Medicare in favor of the HMO.

For several years after that, she remained healthy and needed only an annual doctor checkup and a few prescriptions from the HMO. But one fateful night she slipped on a wet bathroom floor and broke her hip. Although her hip repair surgery was successful, and she started physical therapy in a nursing home, the HMO bean counters cut off her therapy before she was fully able to walk again, and then attempted to discharge her from the nursing home long before the “100-day stay” promised in the glossy HMO recruitment booklet was up.

Through a state complaint and appeal process, I was able to stop the early discharge from the nursing home, but I could not reinstate the physical therapy she needed to get her on her feet and back home again. Confined mostly to bed in low-bid nursing homes with cut-rate HMO medical care, she inevitably feel victim to all kinds of horrible afflictions, from bed sores, to scabies, to urinary tract infections and pneumonia. And at every turn, there was the HMO, fighting to shave every nickel from the cost of her care, completely callous to her suffering, looking for any way possible to deny her desperately needed treatment, hoping she would die and get off their books. She was tortured for months with scabies, an unrelenting itch caused by microscopic parasites, while I fought the HMO to have it diagnosed and treated. She struggled for breath for days before I forced the HMO to x-ray and treat her for repeated bouts of pneumonia. And so on and on, month after month it went.

Why didn’t she get out of the HMO at that point, you ask, and simply go back on regular Medicare? Because she couldn’t: the powerful HMO lobby got a law passed that “locks in” these Medicare HMO patients until the end of the calendar year. I took her out of the HMO and got her back on Medicare January 1, but, after 9 months of abuse, it was too late. The damage had already been done. On January 3, she died. Her death certificate listed “pneumonia” as the cause, but she really died a death of 1,000 insults and injuries inflicted by the HMO. Had she been in Medicare instead of the HMO, she would be alive today.

I write this, then, to warn others who might fall victim and suffer the same sad fate: if you are eligible for Medicare, DO NOT SIGN UP FOR A MEDICARE HMO! There is absolutely no reason to do so. Almost every enhancement their booklets promise you over traditional Medicare will evaporate in the fine print when you actually try to claim it. Very few people ever get the “100 days” in the nursing home, for example, because the HMO controls the doctor, and the doctor will invariably determine that you either no longer need to be in the nursing home, or that you are no longer making progress in your therapy, and so need to be discharged after an average stay of 2 to 3 weeks. Remember, unlike traditional Medicare, the HMO dictates what doctor you can see. They make sure that they control that doctor and others in the group through financial contracts—if a doctor spends too much HMO money giving patients the tests and treatments they need, that doctor gets fired. Most of them are young interns with medical degrees from offshore degree mills with lax standards, and very vulnerable to the HMOs. One of my mother’s primary care physicians was a young woman from the Philippines with only a high school diploma and a bachelor’s degree. Regardless of their level of experience and training, though, they all have been chosen or coerced by the HMO to ignore their Hippocratic oath and put the profits of the HMO ahead of the patient’s health. In the early days of HMOs, they came under frequent attack for letting administrators make medical decisions. But today, they avoid that criticism by simply buying the doctors and having them do the dirty work, so that it’s all medically justified.

So resist the Medicare HMO sales pitch at all costs! The few bucks you might save on prescription drugs or office visit copayments might very well cost you your life should you have an accident or fall seriously ill and end up in the hospital. Don’t think this can’t happen to you or a loved one. Don’t think that the horrible tragedies Michael Moore exposed in the file “Sicko” were isolated or extreme examples. They weren’t. They are typical of the way the HMOs treat people every day of the year in hospitals and nursing homes throughout the country in pursuit of their only goal, which is corporate profit.

My mother was a healthy 89-year-old, living independently when she had an accident and broke her hip. Once you are in the clutches of the HMO and their low-bid hospitals, third-rate doctors, and grubby, infection-ridden nursing homes, you face an uphill battle to escape with your life. And it wasn’t just my mother. During her sad journey, I saw dozens of others trapped in the same tragic death spiral.

If you’re still tempted to try the HMO, you should at least check out what lies in store for you. Look on their web site or ask their sales people for a list of approved providers—hospitals, nursing homes, and doctors. If you get sick, you will have no other choice but to go to one of these. Look up the nursing home in your area and pay them a visit. Walk down the halls, have a look and smell the place. Ask yourself if you or your loved one would like to live here. Chances are, you will not, because the HMOs select the crummiest, cheapest, third-rate nursing homes and hospitals in order to save a buck. Once you walk into one of these places and get past the plush offices of the site administrators, you will almost surely find a crumbling, aging, stinking facility that is either uncomfortably hot or cold. The tiny rooms are overcrowded, with barely enough room to walk between the beds. Help lights are flashing furiously and patients are screaming for assistance from the few overstretched nursing assistants on duty.

And as you look around, you might ponder whether the president of the United States or some Hollywood celebrity or professional athlete would be placed in this nursing home if they broke their hip. No? Why is that? Aren’t we all humans who need good health care and kind treatment when we get sick? The HMO problem is just one aspect of the messed-up health care system and mixed-up priorities of this country. But that’s another story. Suffice it to say for now that you won’t know what penny-pinching really means until you join an HMO and they go to work on you or a loved one. So don’t do it!

If You’re Already Stuck in a Medicare HMO…

My secondary purpose is to try to help others who have already fallen into and are now stuck in the HMO trap until their “lock-in period” is up. It’s now too late for you—you cannot claim traditional Medicare benefits. Your only alternative to the HMO is your own pocketbook. All you can do is try to survive until you can get out of the HMO and back into Medicare. Let me share with you what I have learned while trying to do that, in the hope that you might avoid from my mother’s sad experience.

Before I get into that, though, let me recommend a very good book, “Fight Back & Win—How to Get Your HMO to Pay Up,” by William M. Shernoff, that will instruct you on how HMOs are set up and function, and how to communicate with your HMO when they start to give you a hard time, as they almost certainly will do when you get sick.

First, if you are the patient, find someone to be your outside advocate—you can’t take on the HMO alone. They know all too well how to take advantage of sick people. If you’re serving as the advocate for a loved one, get yourself a notebook and carry it with you at all times. (In these chapters, “you” and “your” will refer interchangeably to you as patient or you as advocate for a loved one, as appropriate.) From the moment you set foot inside the hospital, you will be hit with all kinds of information that will be essential to the survival of your loved one, information you must write down.

Surviving the Hospital

Most of the time, you enter the medical system through the hospital emergency room, where you will give the receptionist the HMO membership card. Listen carefully to what the emergency room doctors tell you, and write it down afterward, because, unlike almost everyone else you will be dealing with, they are relatively uncontrolled by the HMO. They will normally tell you the truth about your condition. If you write down what they say, you can repeat it later to the HMO doctors if they try to tell you something different. For example, the emergency room doctor might say: “You’ve got a raging bladder infection and are dehydrated, so we’re going to admit you to the hospital for a week or more for antibiotics and intravenous hydration.” After you’re admitted, however, the HMO doctor might come along and tell you you’re doing fine and you’re going to be discharged in two days, at which point you should ask why the emergency room doctor said “a week or more.” Write down the name of any person who comes into your room and speaks to you. Write down the name of any medicines given and the dosage. For IVs, look on the plastic bag and copy down all of the information, including the doctor’s name. Ask them why they’re doing each of the treatments you notice, and then write down their answers.

The next step is usually admission to the hospital and transfer to a hospital room. You will be asked to complete medical history forms, and possibly an “advanced directives” form, which directs the medical staff what to do if you stop breathing. This is important, and you will be approached with the same form when you enter the nursing home. You can check a box marked “do not resuscitate,” (“DNR”) telling them not to try and revive you, or you can direct them to try and revive you. Whichever you select, just remember that, when the HMO doctor comes around, he or she will probably try to pressure you, overtly or subtly, to choose DNR, because they would rather you die than incur the costs of reviving and treating you, whether or not you might survive. So make your own decision, and be wary of the advice your HMO doctor might give you about this. Remember, he or she is working for the HMO, not for you.

It’s also a good idea at this time to give someone you trust general durable power of attorney. You can do this by signing a form from a stationery store in the presence of a notary. The hospital will usually have a notary on the staff. This way, if you become incapacitated and can’t make decisions or sign papers, your representative can do it for you. You can revoke the durable power of attorney later if you want to. Without it, though, it may not be possible for your loved ones to pay your bills or access medical information they might need to help you if you become incapacitated or unconscious. If you have already made an arrangement for your financial affairs in the event you become incapacitated, or don’t want to sign a general durable power of attorney, then you can sign a durable power of attorney for health care decisions only. The hospital will usually provide the form for this.

You should also be prepared to submit a list of all the prescriptions you normally take—name of prescription, dosage, and how many you take each day.

Be Wary of Your HMO Hospital Doctor

After that—and this will again be repeated later in the nursing home—the HMO doctor will do a very tricky kind of “exam/medical history” on you, the purpose of which is to get you to admit to as many “pre-existing conditions” as possible. This is because the HMO is only responsible for getting you back to the “baseline” that existed before whatever brought you into the hospital this time happened. They’ll feel they’ve really hit the jackpot (which might very well be a pay bonus to the doctor from the HMO for cutting off treatment and thereby promoting profits) if they can get you to admit to a pre-existing condition that they can blame for any problem you’re currently having, so that they don’t have to treat that problem. After my mother broke her hip and had repair surgery, she healed quickly but still had some pain and swelling in the knee area. Her HMO doctor tried very hard through tricky questioning to get her to admit to having arthritis in the knee, but she wouldn’t admit it because she never had arthritis before. “Well, everyone your age has some arthritis,” this doctor insisted.

Some people like to talk all about their aches and pains, and the doctor will encourage this at first by pretending to be sympathetic. But it’s best to say the minimum during these tricky HMO interrogations. This is a legal more than a medical process, so you should simply answer the questions yes or no and not volunteer any further information. If you’re not sure if you’ve had some disease, say no, because, for it to be a “pre-existing condition,” a doctor has to have diagnosed it as such—just having the symptoms of it doesn’t count.

Your HMO doctor is, unfortunately, the “gatekeeper” for the tests and treatments you will need, the person the HMO is counting on to find a way to deny them to you. You have the right to dump your assigned doctor and get a different one from the HMO. If you find that your assigned doctor is so bad that you don’t think you could possibly get anyone worse, you should contact your HMO and tell them you want a different doctor. Here are the salient characteristics of a bad doctor, or one who is little more than an insurance agent wearing a stethoscope, and the warning signs that you had better go to the HMO bullpen for a different one:

Stands at the doorway or the foot of the bed during “visits” and avoids examining you, or comes into the room but avoids making physical contact.

Starts pushing for discharge from the very first visit, spending more time sitting at the desk writing in your chart the rationale for discharging you than visiting with you or treating you.

After the initial interrogation to get you to claim pre-existing condition, isn’t interested in hearing how you feel, and dismisses your complaints and questions quickly without serious consideration.

Shows little sympathy for older adults and reflects an attitude that they are not worth spending much time or treatment on, and should simply be made comfortable until they die.

Makes quick, “shoot from the hip” diagnoses, sometimes over the telephone, and prescribes a drug without first ordering available laboratory tests.

After ordering a prescription or other treatment, doesn’t follow up to find out from you or the nurses if it’s working or not, or whether you have had any bad side effects.

Historically, people have generally respected their doctors and trusted them to place the patient’s welfare above all other concerns. But in today’s Medicare HMOs, bad doctors whose top priority is HMO profits seem to be the rule rather than the exception. My mother had only one fairly good doctor at the hospital who was willing to buck the HMO a little bit for her—the rest of them were terrible! You will probably find them unapologetically and brazenly uncaring because they get away with it time after time. So I decided to file a complaint with the state medical license board against one particularly arrogant and unprofessional one, because I felt she had to be held accountable for her behavior. (In California, you can do this by printing out an online form, filling it out, and mailing it in.)

How the HMO Discharges You From the Hospital

Soon after you enter the hospital, your assigned hospital case worker will be contacted and pressured by the HMO to kick you out. Their main tactic is a financial arrangement known as “capitation,” meaning they will pay the hospital only a certain, fixed amount of money for you. In my mother’s case at the low-bid hospital, it was $1,500 per day for everything—room and board, medications, laboratory tests, physical therapy, etc. Using their tremendous financial leverage, the HMOs force the providers to sign these capitation agreements. My mother’s actual bills submitted by the hospital to the HMO ran as high as $30,000 per day, but included “insurance adjustments” for the difference, bringing the total down to exactly the daily fee the hospital agreed to in advance through their contract with the HMO. This capitation arrangement naturally motivates the hospital to get rid of you and fill your bed with someone they’re not going to lose money on. So very soon you will see the HMO and the hospital case worker putting an extraordinary amount of energy—probably more than expended on your actual medical care—into discharging you. Not well enough to leave yet, you say? Not a problem—they will twist the doctor’s arm so that he will find that, despite all appearances, you are in fact well enough to go to a nursing home for recovery and rehabilitation, which costs the HMO only $150 or so a day.

Evaluating a Nursing Home

Unfortunately, despite your brief stay, you very likely picked up one or more nasty souvenirs of your hospital stay, like bed sores, scabies, or infection with an antibiotic-resistant bacteria such as MRSA. The doctors might not tell you about it, but you can look at your chart to see if they wrote it down. Or maybe, like my mother, you had general anesthesia during your surgery, and it’s making you crazy at night, causing you terrifying nightmares and hallucinations. The medical staff knows this is very common in elderly patients, but they routinely ignore it in hopes that you won’t say anything or demand to be treated for it.

In their rush to get you out the hospital door, the case worker usually won’t give you much time to choose which nursing home to go to from a list of the low-bid bottom feeders covered by the HMO. Chances are, they’re all nasty, but you should try to choose the least nasty one. Have your representative walk through each one, or at least read the state inspection reports, which the home must make available to you, and which are also available online. Look at the staffing ratios, and how they compare with the state average. You want the highest number of registered nurses and certified nursing assistants (CNAs) per patient. See how the place smells, how clean or dirty it seems, and how many of the call lights outside the patients’ rooms are flashing. Look for the registered nurses. Are they out dealing with patients, or hiding in a closed office talking on the telephone? Are the patients outside their rooms involved in activities, therapy, or with visitors, or are they lying in bed? This visit will at least give you some idea of which ones to definitely avoid.

How Nursing Homes are Organized

When you or a loved one is transferred into a nursing home, the first person you will probably meet is the admissions director. This person’s job is to try and fill any empty beds, and keep the residents—the home’s customers—happy by seeing that they get the care and treatments they need, while making sure that the home receives payment for them. He or she will give you a packet of papers to fill out, including the advance directive form. During your stay, the admissions director also acts as your case manager, and has authority to request treatment or therapy from the doctor and the insurance. A good one will know how and be willing to present your case to the HMO so that they are more likely to authorize and pay for the care you need. A bad one will hide out in the office all day and refuse your requests out of hand with the excuse that “the insurance won’t pay for it.” A good case manager is worth getting to know, because of his or her thorough knowledge of the health care system, and possible willingness to share with you in confidence what’s really going on behind the scenes with the doctor and the HMO.

The director of nursing is the person who supervises the licensed medical staff (registered nurses (RNs) and licensed vocational nurses (LVNs) and is responsible for making sure your overall medical care plan is carried out each day. This is another good person to know.

The charge nurse is the RN who implements your medical care plan during his or her shift. This person usually sits at the nurse’s station, reading from or writing to the patients’ charts, communicating with the doctors over the telephone, and carrying out the doctors’ orders, so you probably won’t see her that often, except to change an IV or perform some other critical procedure. In most nursing homes, it’s difficult to get the charge nurse’s attention, but you will need to try and do so if some serious problem arises. This is why: the medical staff in hospitals and nursing homes goes almost entirely by measurable indicators, chiefly temperature and blood pressure, which they are required to check every shift (but don’t always do so). This means that, unless your temperature or blood pressure readings are out of the normal range, the medical staff is going to assume you are doing fine. Unfortunately, you could develop a serious medical problem before it affects your temperature or blood pressure, by which time it could be too late to treat in the nursing home! So, if you notice something wrong, don’t hesitate—tell the RN right away. (She’s required to write down your report in the chart). If you’re like me, you don’t want to pester people who are busy trying to keep up with their work, particularly over a possible false alarm. But it can end up far worse for everyone if you wait until the problem becomes serious. Remember that there are long pipeline delays built into the nursing home-HMO system. Even if you tell the charge nurse right away, and she doesn’t forget to respond, she will probably have to check with the doctor before doing anything about your situation. That may take up to a day. Then, if the doctor orders some treatment or medication, it will have to be approved by the HMO, which may take several days. If the medication isn’t on the nursing home shelves, they will have to order it from the low-bid pharmacy, which may take yet another day.

In the meantime, if things are getting seriously worse and you don’t think the treatment is going to arrive in time, you can demand as a last resort to go to the hospital emergency room, and the doctor will normally OK it. It should be a last resort because of the trauma associated with being transferred to the hospital and the risk of catching the infectious diseases rampant in hospitals today. Incidentally, if you do transfer to the hospital, the nursing home will ask you if you want to sign a “bed hold” form before you leave. If you do, they will save your bed for you, but you will have to pay the daily room rate for it even though you are in the hospital. You should do so, though, if the nursing home is full and there’s any chance you will lose your bed while you’re gone. You probably won’t spend much time in the hospital, anyway—the HMO will see to that—and you don’t want the additional trauma of being discharged from the hospital to a different nursing home, most likely not of your own choosing.

The licensed vocational nurse (LVN) is in charge of administering medications, including breathing treatments, and applying or changing dressings on wounds or sores as needed.

The assigned certified nursing assistant (CNA) takes care of the routine personal care, including bathroom/diapers, bathing, applying lotions and ointments, caring for teeth and dentures, eyeglasses, hearing aids, bedding and blankets, bringing meals to the patient, and feeding when necessary. The CNA also checks temperature and blood pressure (“vital signs”) once during each shift. These people have a difficult job at low pay, but one that is very important to the comfort and well being of the patient, so it’s important to try to develop a personal relationship with the assigned CNAs so that they will feel more inclined to treat you or your loved one as they would a member of their own family. A good CNA will make sure the patient is clean and comfortable at all times, will check in several times during the shift, and will report any bed sores or other trouble signs to the charge nurse right away. A bad CNA will do the minimum—not check for wet diapers in order to avoid a change, skip taking vital signs, feed the patient a few spoonfuls at meal time and then run away, feed the patient too fast causing aspiration (food going into the lungs), neglect tooth brushing or denture cleaning, and hide in the break room for long periods of time. You may have to pester the CNA in order to get needed care for yourself or your loved one. The problem can be particularly bad during the night shift when the day-shift management has already gone home for the day, and on the weekends. If you are caring for a loved one, you should try and be around on weekends and at least part of the night shift so the CNAs know that someone is checking on things. If you can’t stay until the night shift, you can leave a note. For example: “To the night shift CNA: Please see that my mother is covered during the night as it gets cold in this room.”

Unlike the RNs, LVNs, and CNAs, all of whom work for the nursing home and are paid for by your daily room and board fee, the physical therapist works for an outside company and bills the insurance extra for your treatment. This is why the HMO tries so hard to kick you off of physical therapy. The physical therapist will work with you for a certain amount of time each day or week, and write the results in your chart after each session. If you don’t make steady progress (which can mean that you have even a single bad day in therapy), the HMO may try to use that as an excuse to discontinue therapy. The HMO doctor is the final decision maker, and will try to twist anything less than a glowing report from the therapist so as to justify discontinuing the therapy. The therapists are under a lot of pressure to keep the costs down so the company will retain its contract with this and other nursing homes. So don’t hesitate to ask your physical therapist how you did each day, and say that you hope you will get a good report.

The speech therapist or speech pathologist also works for an outside company under contract to the nursing home. This person’s job is to evaluate the patient’s ability to speak and to swallow food. Aspiration, where food goes into the lungs instead of the stomach, is a common problem in the elderly and causes pneumonia. The speech pathologist can check if the patient is swallowing food properly. If not, a special diet can be prescribed, usually involving thickened liquids and/or pureed foods.

HMO Interrogation Tactics for Establishing a Low “Baseline” for Treament

Once you’re transported to the nursing home, the same induction procedure as in the hospital will be repeated. The HMO doctor may go over the advanced directive questionnaire with you again, even though you already filed it with the admissions director, and try to pressure you into selecting “do not resuscitate” if you haven’t already done so. Again, make your own decision, because this is the HMO talking.

Then you will get the tricky interrogation designed to establish a low “baseline” so they can quickly discharge you, even if you are not ready. Again, be on your guard. The doctor (and other nursing home “spies” the HMO employs) will ask you about your state of health before the hospitalization occurred. Be sure you tell them everything you could do before going into the hospital, such as walking without a cane or walker, living independently, preparing your own meals, driving a car, etc. You will notice that they will try to push you into saying that you couldn’t do much before, so that they don’t have to rehabilitate you very much. Money is at stake her—if they don’t get what they want during this initial interview, they will usually send another person, perhaps an employee of the nursing home, to ask similar questions, hoping you will give different answers. They will even ask your representatives, relatives, and visitors. In my mother’s case, the staff kept asking all her visitors, “Did she live by herself before?” apparently hoping one of them would say no. The HMO must provide generous rewards to the staff members for such spying efforts! When anyone enters your room and starts asking questions, you should first find out their name and write it down, then say “Why are you asking?”

You will probably see the nursing home HMO doctor only once a week or less, although he or she will spend a lot more time sitting at the nursing station desk going over your chart trying to build a case for discharge. Remember that this is the focus of all your doctor’s efforts, to discharge you and get you off of the HMO’s books, not to help you recover. During the doctor’s infrequent visits to your room, then, don’t volunteer that you “feel fine,” as that will immediately be used as evidence that you’re ready for discharge. If you have pain, tell the doctor, and repeat it until you get an acknowledgement that he or she heard you. In this situation, it is better to overstate your problems than to understate them.

On admission (or readmission) to a nursing home, be sure they get a copy of your medications list right away. Don’t assume that the hospital has sent it to them. I found with my mother that her medications routinely fell through the cracks in the system, and that it took days or a week, with the normal delays, to get the prescriptions started again. I also found that the HMO would periodically conduct an “assessment” of her medications, and selectively discontinue medications without notice. For this reason, it is important to check every medication every day—not an easy task, especially when they come all mixed together in a liquid, for example, or when you have a busy or snotty medications nurse who doesn’t want to take the time to tell you. Don’t assume someone is watching out to make sure the right medicines are being given. Big mistakes occur all the time. In the hospital one day, I checked the label on a bag of IV medication the nurse started on my mother and found that it had the name of another patient on it!

Another reason you should keep track of every medication given and when it was given: you will probably get a bill for it later from the pharmacy or nursing home, either for a copayment, or for the entire amount because the HMO has reneged on its responsibility to pay for it. These bills are frequently in error. My mother, for example, got billed for medications she never received, or for medications some other patient received! By keeping an accurate record, you can respond to bogus billings which, by the way, might occur months or even years later!

The Nursing Home Resident’s Bill of Rights

When you enter the nursing home, they are required to give you a copy of the “Resident Bill of Rights,” a document that lists your rights under state and federal laws. You should read this carefully and keep a copy of it handy. Your rights include:

· access to and copies of your health record (“chart”)

· right to choose the personal attending physician

· being informed of any extra expenses not covered by your insurance

· right to refuse any treatment

· proper hygiene and nutrition

· nurses’ call system

· immediate access to family members

· having visitors of your choosing at any time while critically ill

The Nursing Home Psychiatrist

The nursing home calls in a psychiatrist when a patient seems to be depressed or expresses a desire to die. I found that both nursing homes my mother was in used the same psychiatrist. Unlike the stereotypical psychiatrist who listens to your problems for an hour while you lie on a couch, this one made a very short visit to my mother’s room, did not want any family members present, did not want to hear from any family members, and—of most concern to me—immediately after his first and only 20-minute interview, prescribed powerful mind-altering (non-generic) prescription drugs. Deferring to the psychiatrist, we accepted the prescription. There were no return visits to check on how the drugs were affecting her, and no blood draws or other monitoring of the dosages. After about a week of taking them, my mother seemed to sleep almost continuously, and when I tried to call the psychiatrist about it, it took me several days to reach him. He said he didn’t believe the drugs could cause the symptoms my mother was having. When her assigned medical doctor had no explanation either, we decided to discontinue the psychiatric drugs, which upset the psychiatrist.

I later found out that doctors routinely receive gifts, including free travel, from drug companies for prescribing certain drugs, and wish I had asked the psychiatrist at the time if this was the case for these prescriptions. In any event, caution seems to be in order when a doctor makes a cursory, 20-minute exam, immediately prescribes powerful, name-brand prescription drugs with no follow-up plan to check how they are working.

Some Help in the Struggle for Good Nursing Home Care

If you can’t get the nursing home to do what they should, you can call the “Ombudsman.” This is a person assigned to keep an eye on your nursing home under a federal and state funded program. The Ombudsman’s telephone number should be posted on a sign in the nursing home.

There’s also the Medicare Rights Center, with a website at www.medicarerights.org.

How the HMO Stops Your Physical Therapy

You’ll probably be started on physical therapy, which costs the HMO extra, so they will mount a mighty effort to get that stopped as well. They have a tricky way of doing it: if you don’t show continuous improvement—meaning if you have even one bad day, perhaps due to pain or sleepiness—the HMO doctor will swoop down and order the therapy stopped because you’re “no longer benefiting from it.” On the other hand, if you do well and make normal progress, reaching a state of proficiency, they will claim that you have “plateaud,” so that you no longer need the physical therapy. So, you are “damned if you do and damned if you don’t” make progress. It doesn’t matter what your physical therapist says or writes in your chart. The HMO doctor will come in there and overrule the therapist, and you will be cut off before you’re fully recovered. When they cut off your therapy, they will also cut off your “skilled nursing” benefit—that is, they will say that your stay in the nursing home is now “custodial” only, that you don’t need skilled care anymore. Since Medicare doesn’t pay for custodial care (and remember that the HMOs are really “middlemen” between Medicare funds and the patient), they will refuse to pay for your continued stay in the nursing home.

Appealing Discharge From the Nursing Home

If you’re not fully recovered and you feel you need to stay in the nursing home and have more physical therapy or other treatment, you will have to submit an appeal of the HMO’s written discharge notice, which you will receive unexpectedly in the mail, usually on a Friday (they hit you with it on Friday because you have only until noon of the following day to submit your appeal). The discharge notice they send you must explain your appeal rights. You want the “immediate appeal” option. (The other appeal takes months, and is decided by doctors controlled by the HMO, so it’s a complete waste of time.)

The immediate appeal is with the Medicare “Quality Improvement Organization,” or QIO. Simply call the toll free number on the notice and tell the person you want to appeal the discharge order. They will ask for the patient’s name, HMO, the patient’s identification number in the HMO, and social security number, as well as the phone number of the nursing home, so you should have that information ready. They will explain to you over the phone that your submitting the appeal has stopped the discharge until the appeal is decided, so that you have a few more days of coverage at least. Then the QIO will call the nursing home, tell them an appeal has been filed, and request a faxed copy of your chart. After they have that, they will call you back and ask for your views on the appeal over the phone. You also have a right to submit your views in writing. It’s best to do that in a faxed letter, if you have the time, to be sure that all of the information is before the QIO doctor who will decide the appeal. Also, if you have time, ask the nursing home to show you the chart so you know what they are telling the QIO as the reason for discharging you. They legally must allow you to see it.

When they do call requesting your views on the appeal, be ready to give them the reasons why you shouldn’t be discharged. Explain why you’re not ready, noting all the things you can’t do that you could do before going to the hospital—remember that the HMO must get you back to your baseline. If you picked up a new infection in the hospital, or bed sores in the nursing home, let them know that as well, because that’s the HMO’s problem, not yours. If you’re making progress in your therapy but need more time to get back to your baseline, tell them so, because the doctor may be saying in your chart that you are not making progress.

Within a day or two of the interview, they will notify you of the decision. If you win the appeal, the HMO will have to try again to discharge you. If you lose the appeal, the notification will tell you when your last covered day is, after which you will have to pay for the nursing home out of your own pocket under “custodial” care. You will also have to cover the prescription drug co-payments, just as though you were at home.

I won my appeal in my mother’s case, and forced the HMO to give her the full 100 days of coverage that their glossy promotional booklet promised. At the time they claimed she was ready for discharge, she was so sick she couldn’t eat and had a nasal feeding tube! When the QIO doctor saw that in her chart, he told the HMO to forget it. But this shows that these cheap s.o.b.s will try anything to save a buck if they think there’s any chance they can get away with it.

Because the HMOs control the purse strings, the nursing homes have to kowtow to them as well. But several nursing home staff privately told me that, had my mother been on straight Medicare, continued skilled nursing care and physical therapy would have been authorized.

Medicaid

If after the 100 days runs out—or the HMO succeeds in stopping your skilled nursing home coverage before that—you’re still not ready to go home, you have to pay for custodial care in the nursing home out of your own pocket. Or, if you are completely destitute, you can apply for Medicaid, a federal assistance program for the indigent administered by the states (in California, it’s known as “MediCal”). Unfortunately, if you have $2,000 or more in the bank, you don’t qualify for Medicaid. So you first have to spend down all your money (although, curiously, you are allowed to keep your house, if you have one) before you can be on Medicaid. Once you’re on Medicaid, it pays for your custodial care and prescriptions in the nursing home. Any income you may have, from social security, for example, they take, and leave you only $35 per month. If you have a house, the state will place a lien on it when you die for the amount they have spent on your care.

My mother couldn’t qualify for Medicaid because she had some annuities set aside for her children, even though she derived no monthly income from them. Her total income was only about $800 a month from social security and some stock dividends, and yet she did not qualify for Medicaid because of the annuities. So she was in the process of spending down her savings on the custodial nursing home care, at the rate of about $7,000 per month, when she died.

What to Do With Bills the HMO is Supposed to Pay

All during her hospital and nursing home stays, both skilled and custodial, and even after she died, she kept getting billed by the various providers: pharmacies, ambulance companies, hospitals, medical labs, etc. I soon discovered a standard practice in the medical field: billing the patient for items the HMO is supposed to cover. It must be illegal, because what they send you is usually labeled “statement of services,” and often says “this is not a bill.” But at the bottom it still says “pay this amount,” which is usually for the entire bill, not just the co-payment. These statements would often say “we have billed your insurance, but they have denied the claim.”

I collected tall stacks of these bills for items that the glossy HMO brochures said we would never have to worry about. To provide a paper trail so that these providers couldn’t stick me with the bills the deadbeat HMO refused to pay because I never responded, I did the following: wrote a letter to the provider (pharmacy, ambulance service, hospital, etc.) referencing the bill, explaining that my mother was covered for the expense by the HMO, and attaching a copy of the page from the HMO’s “summary of benefits” showing that it was covered. I would also state that, contrary to the Patient’s Bill of Rights, I was not told that I would have to pay for the medication or treatment beyond any copayment listed in the HMO’s “Evidence of Coverage” book. “Please bill my HMO,” I wrote, and sent the letter by registered mail.

The sad truth is that it’s easier for these service providers to try and bully you, the vulnerable patient or advocate, into paying than to take on the big HMO and make them pay what they owe. And so they take the path of least resistance.

The Hospice Racket

It turns out that the same corporation owned both the nursing home my mother was in, and a hospice company that serviced patients in that same nursing home. Soon after my mother’s admission, the nursing home started pressuring me (and other patients as well) to enroll her in the hospice program. They explained that Medicare (and hence the Medicare HMO) pays for hospice, for which a patient can qualify if they have any one of a number of diagnoses: dementia, for example. The patient does not have to be diagnosed as terminally ill. A slick salesperson with glossy brochures was dispatched from the hospice company and gave a presentation about how it works. Only the patient’s symptoms are treated to keep her comfortable and pain free, she explained. No medical “intervention” is allowed, or any trips to the hospital emergency room. Special nurses and nurse’s aides visit the patient every day, so they get more care than normal.

I turned it down and, in retrospect, am glad that I did. The lady in the next bed was in hospice, and a young man would come every morning from the hospice service to change and wash her, in the same way that the nursing home staff did for my mother who was not in hospice. The parent corporation was in effect “double dipping” Medicare, with the nursing home collecting for this lady’s room and board at the same daily rate as for my mother, but not having to pay staff to provide the services normally covered by the daily room and board charges. At the same time, the corporation’s hospice company was billing Medicare for the hospice guy’s time, to provide the cleaning and bathing that the nursing home was also getting paid for. If the patient were under an HMO, the HMO would go along with the scheme because they know she will never incur expensive hospitalization, and will be permanently off their books the first time she catches pneumonia or some other deadly infection requiring hospitalization.

Thus, what most people would think of as a service for terminally ill patients becomes a racket for double-dipping into Medicare and euthanizing elderly patients who might have a chance of recovering if given treatment the HMO would rather not pay for. I see no reason, then, absent a conclusive diagnosis of terminal illness, to put a patient in hospice.

Be There for Your Loved One

If you want your loved one to get out of the hospital or nursing home alive, you must be there as much as you can, preferably every day, to fight for them, especially if they can’t express or communicate their needs to the staff. Don’t assume that the people on duty will take care of everything—they won’t. Particularly after 5 p.m., when the management goes home and the night crew comes in, and on weekends, patients often receive only minimal attention, with low-wage, poorly-trained staff taking long breaks away from the patients. It’s survival of the fittest in these broken down institutions, and the patients need all the outside help they can get.

In this situation, even with no medical training, you play an important role by just finding out what the patient needs and then communicating that to the staff. “My mother seems to have a rash around her ankle. Can you look at it please?” Once in the hospital, the nurse started an IV in a hurry, and then rushed off to do something else. Within a few minutes, the IV fluid began to “infiltrate” and my mother’s hand swelled up to twice its normal size! Another time, an IV started leaking and saturated half the bed with liquid before I could find a nurse to fix it. Whether due to overwork or just laziness, the staff rarely check back with the patients to see how they are doing. What would have happened without an advocate to keep an eye on things? If you’re like me, you feel uncomfortable pestering people to do things, and some of them will resent it, although the good ones will thank you. Unfortunately, you have to do this because the alternative could easily be tragic.

You can also help a loved one by ensuring they get all the care, treatment, and therapy that they’re supposed to be getting. For example, if physical therapy was promised for a certain day and time, but the therapist doesn’t show up, you can ask the bosses why not. Again, when they get too busy or too lazy, the staff will shortchange the patients, particularly the ones least likely to complain.

The seedier nursing homes and hospitals may not like you checking up on them, and may try to get rid of you. One tactic is through strict enforcement of the visiting hours, some of which are too short anyway. If you feel you need to be there outside of visiting hours, try explaining to the staff why it’s important. “After her surgery and general anesthesia, my mother has been having terrible nightmares, and is afraid to fall asleep at night. I want to be with her until she gets to sleep.” If they refuse you, you can pull out the Patient’s Bill of Rights and show them where the patient must be given immediate access to family members and visitors of her choice. If that doesn’t work, call the ombudsman.

Another tactic used by one nursing home (where there were also signs up asking you not to bother their “busy” nurses) was to remove all the chairs from the patients’ rooms, so there was no place for visitors to sit down! We countered this by bringing our own folding chairs or plastic stools.

In all of these unpleasant situations where you are forced to be assertive, you should try to be as tactful as possible—you don’t wanted ticked off staff members to take out their hostility on your loved one.

Beware the Medicare HMO!

Saturday, February 23, 2008

Another Insurance Company Sued Over Cancellations

Saturday, February 16, 2008

Blue Cross Enlisting Doctors to Help Cancel Your Insurance

Saturday, December 29, 2007

Beware the Medicare HMO!

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