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Another Strategy in the Health Care Reimbursement Game


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American health care has become a gigantic game board with players of all sorts strategizing to win. Winning, of course, means getting more money from payers – government or private. It turns out this medical marketplace game is not all that new. It's just become wilier, as I have shared in a couple of posts over the summer.

An obituary last week for Dr. Rashi Fein, an influential economist with a progressive stripe who laid the intellectual ammunition for Medicare, noted that as far back as 1982 Fein had concerns about the corporatization of health care. Writing in the New England Journal of Medicine, Fein observed: "A new language is infecting the culture of medicine. It's the language of the marketplace, of the tradesman, and of the cost accountant. It is a language that depersonalizes both patients and physicians and describes medical care as just another commodity. It is a language that is dangerous."

Last week, a column in the Kearney (Nebraska) Hub illustrated just how dangerous it can be. Health reporter Mary Jane Skala shared what happened after her 93-year-old mother was abruptly hospitalized for a suspected stroke, which it turned out she did not have. What followed, said Skala, was a "front-row seat to modern American health care, now playing at a theater near you."

Her mother, who lives independently in a retirement complex, woke up one morning feeling dizzy. "Someone saw (or thought they saw) a slight sag on the left side of her face and whisked her over to the nearest hospital," Skala wrote. The next day all the tests came back negative, and her mother was sitting in a chair in her hospital room eating a large portion of stir fry and rice. But Skala's mother wasn’t discharged to go back to her apartment.

Instead, officials at her retirement center sent her to the rehab facility in its complex, where some hospital patients go to recover before returning to their former residence or stepping up to more assisted care. In the last several years, these rehab centers have grown thanks to Medicare reimbursements, which sometimes can be greater than Medicaid payments for nursing home care. Officials told Skala's family that she would be there four to eight weeks.

Was Skala's mother sent to rehab because her retirement facility could collect additional money from Medicare? Keep in mind that the facility still collects monthly rent and other fees from residents during these rehab admissions.

The rehab facility promised physical therapy, and at first the family thought that was a good idea since their mother had sprained an ankle last spring and was still a bit wobbly. Perhaps therapy could help. But soon Skala observed that the facility mostly seemed to be building a record of her mother's condition to document a case for reimbursement.

"They refused to let her walk until they 'evaluated' her, so she was unhappily imprisoned in that wheelchair," Skala wrote. One night after dinner in the guest dining room with Skala, nurses studied her mother's plate and "scribbled down that she had cleaned her plate as if she were four years old." Nurses woke her up in the morning and washed and dressed her even though Skala said that her mother was capable of getting up herself. The staff didn't permit her to do that.

One day at lunch a medical worker came by and "held out two puny pills." He said, "These are for your nausea." Skala's mother protested, saying she didn't have nausea (although she did three days ago when she was admitted to the hospital). She had two choices: she could either take the pills or sign a paper saying she refused them. She signed the paper in her "perfect handwriting," Skala said.

After that came 45 minutes of physical therapy in the morning and another 45 minutes of occupational therapy in the afternoon. Why did she need occupational therapy, Skala wondered since her mother could easily do crossword puzzles, sign her name and do other tasks with her hands and fingers.

After ten days in the rehab facility, she could go home. Medicare paid the bill. Whether it should have is a different story – one Skala may want to dig into someday. The news media has documented how common it is for health care providers to overbill Medicare. "I smell a rat with this rehab place," Skala told me. "No doubt some people need rehab facilities after surgery or procedures, but everyone at her place seemed to be sent there after hospitalizations, for any reason."

And that's reason enough for families in this predicament to be cautious. Question why your relative needs to be there. Document what's going on. Get your relative out as soon as possible if, like Skala, you have doubts whether he or she should be there.

Sit down with the head of the rehab facility and the retirement center staff if necessary and discuss your concerns. They may speak in jargon and throw out a lot of acronyms. Skala said she had a hard time understanding what the center professionals were saying. These facilities hold most, if not all, of the cards, and the process can be very intimidating. If you need more help, contact the Medicare Rights Center in New York City or the Center for Medicare Advocacy in Washington, DC.

More Blog Posts by Trudy Lieberman

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Trudy Lieberman, a journalist for more than 40 years, is an adjunct associate professor of public health at Hunter College in New York City. She had a long career at Consumer Reports specializing in insurance, health care, health care financing and long-term care. She is a longtime contributor to the Columbia Journalism Review and blogs for its website,, about media coverage of health care, Social Security and retirement. As a William Ziff Fellow at the Center for Advancing Health, she contributes regularly to the Prepared Patient Blog. Follow her on twitter @Trudy_Lieberman.

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