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Pat Needs More than Medicare Services

Pat (age 74) had been uncomfortable with a swollen belly for a while, but did not want to see a doctor. One evening, when she acted very confused and did not at all seem like herself, her adult children became alarmed and brought her to the hospital. After a number of tests, they were all sad to learn that she had liver cancer. Several quarts of poisonous fluid were drained from her abdomen (belly) and her oncologist prescribed a chemotherapy (chemo) pill. The pill was expensive, but Pat was on Medicare and able to pay for it through Medicare Part D and EPIC (New York State Elderly Pharmaceutical Insurance Coverage).  (Medicare Details1)

Pat became more comfortable and showed improvement in her ability to think clearly. She wanted to go home, but realized that she was too weak to manage on her own.  None of her children were able to take off time from work for a long period to stay with her. The hospital social worker suggested that Pat be discharged to a Skilled Nursing Facility (SNF), where she could receive short-term rehabilitation2. It would be paid for by Pat’s original Medicare and a supplemental Medigap insurance policy (initially for 20 days with a possibility of extending to up to 100 days, if needed). Everyone was pleased with this arrangement and took comfort in hearing the words “short-term” and “rehabilitation.” This suggested that Pat would get better in a reasonable time.

However, after less than a week in the nursing home, things started to go poorly. The chemo pills gave Pat terrible diarrhea. She remained frail, and her mind was on and off or not clear at all. It appeared that her liver could not rid her body of the poisons that form even in healthy bodies. She was unable to benefit from the therapy offered.

Pat was re-hospitalized for abdominal swelling and delirium a couple of times over the next several weeks. Back in the nursing home, her condition continued to spiral downward. As the disease progressed, Pat rebounded less and less after the removal of waste from her system; she no longer took the chemo pills. Nobody spoke openly about the fact that death was near.  The skilled care services were coming to an end, and Pat’s family worked with the nursing home finance office to apply for Nursing Home Medicaid, so she could be transferred to a long-term care floor.

On admission to her new room, a nurse explained to Pat and her family that Pat would be eligible for hospice services as a long-term nursing home resident. The family finally acknowledged the inevitable and signed Pat on with the hospice organization that had a contract with the nursing home.

Pat died peacefully just a week later. Looking back at events in the months since Pat was diagnosed, the children wished that someone (one of them or Pat herself) had dared asked more forthrightly about prognosis, or that one of the professionals (the hospital social worker, a nurse, or the oncologist) would have been more forthcoming about Pat’s situation. Had they known, they felt they might have been able to make arrangements for someone to stay with Pat during her last months so that she could have gone home.

Editorial Comments:

1Medicare Details:
Without a Medicare Part D prescription drug plan, Pat’s monthly out-of -pocket cost for the cancer medication would have been over $16,000. With only Medicare Part D coverage, Pat would have paid about $700 per month for this medication. With Medicare Part D and EPIC (New York State Elderly Pharmaceutical Insurance Coverage), Pat’s co-payment for a 30-day supply was $20.  (Amounts from 2016)

Had Pat qualified, federal Medicare Part D Low Income Subsidy programs called Extra Help and Partial Extra Help could have reduced or eliminated the Part D deductible and copayments.

Pharmaceutical companies offer patient assistance programs to provide free or low-cost medication to uninsured or under-insured patients who are financially eligible For a comprehensive list of pharmaceutical companies with patient assistance programs, please visit RXAssist or The Assistance Fund.

Medicare Part A covers skilled nursing facility care for beneficiaries who have been hospitalized for at least 3 days. Medicare pays 100% for the first 20 days, then the beneficiary has a substantial co-payment for days 21-100. Some Medicare supplemental or Medigap policies cover the SNF co-pay for days 21-100, and the in-patient hospital deductible.

Medicare Part A covers only one inpatient benefit at a time. Pat could not receive hospice services while in the Skilled Nursing Facility (SNF) for short-term rehabilitation. Medicare will only reimburse for hospice and SNF,  concurrently, when the reason for treatment in the SNF is completely unrelated to the hospice diagnosis. For example, if someone with cancer trips and falls and breaks a hip, Medicare may pay for both hospice and rehabilitation in a SNF.

Medicare is complicated.  For more information as it applies to your specific situation, get free counseling about available benefits from the Senior Benefits Information Center at one of the Westchester Public Libraries that offer this service.  You may also consult one of the other agencies/recourses here.

2Short-Term Rehabilitation:
Short-Term Rehabilitation is often the fallback position when a patient cannot be discharged to home. It is a misleading term.  Short-term only means that Medicare will reimburse for a limited period of time. It is not related to how long the patient actually might need to recover.  Rehabilitation is also often misleading. The expectation is not, in fact, that the elderly patient will be rehabilitated to his or her previous state of health. Just as for Pat, “short-term rehabilitation” is often only a way-station for the elderly, paid by Medicare, before it becomes necessary to find a long-term solution at home or in a nursing home.