WSJ Article on 1500 Cap

[Guest guest]

From Today's Wall Street Journal - Looks like we continue the good news

that started in PA and continued last week with the change in the CCI.

Let's build the momentum!!!!

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Medicare Caps on Rehab Therapy

Spark Ire From Patients, Families

By LAURIE MCGINLEY

Staff Reporter of THE WALL STREET JOURNAL

ARLINGTON, Va. -- New Medicare caps on rehabilitative-therapy payments are

catching patients and their families by surprise -- and spurring a rash of

protests.

Enacted as part of the 1997 Balanced Budget Act, the restrictions -- $1,500

a year per patient for physical and speech therapy combined, and another

$1,500 for occupational therapy -- weren't the biggest cuts in the federal

health program for the elderly and disabled. But they may have caused the

most outrage.

nsen cries softly as she explains her decision to halt

rehabilitative therapy for her 82-year-old father, a retired steelworker

battling Parkinson's disease and the effects of a major stroke.

A resident of Potomac Center, a skilled nursing and rehabilitation facility

here, her father, Victor Roselli, had been on an intense regimen of speech,

physical and occupational therapy. But in February, Mrs. nsen learned

he already had used up two-thirds of his annual allotment under the new caps.

Reluctantly, she and her father's neurologist agreed to stop the therapy

for fear her father would need it more later in the year. She says she

can't afford the therapy herself. Now, she says, her father's limbs are

becoming more rigid. Is it the disease or the lack of therapy? " I'll never

know, " she says, adding, " The caps are obscene. "

So far, the limits appear to have hurt the frailest and sickest --

particularly those in nursing homes -- the most. The caps don't apply to

homebound elderly receiving therapy at home under Medicare or, for the

first 100 days, to patients in skilled nursing facilities. In addition,

Congress exempted hospital outpatient departments from the limits, figuring

the most critically ill people could use them as a safety valve.

The caps were supposed to apply to senior citizens who live at home and go

to freestanding rehab facilities. But for now, the Medicare agency doesn't

have the computer capability to keep track of how much therapy is being

provided to people who aren't in nursing homes.

Thus, senior citizens who are mobile can go from one rehabilitation agency

to another, racking up as much therapy as they need, while those in nursing

homes don't have a way to circumvent the caps.

" It's crazy, " says Barbara Vogen, owner of Central Rehabilitation Agency in

Des Moines, Iowa. " People with the least problems can get the most help,

while people with the most severe problems can get the least help. "

On April 23, hundreds of people attended an all-day " town-hall meeting " at

the headquarters of the Health Care Financing Administration -- the agency

that runs Medicare -- to gripe about the caps and other nursing-home

issues. Several therapists complained that combining physical and speech

therapy under a $1,500 cap was forcing some stroke victims in nursing homes

to decide whether to learn how to walk or talk.

Many critics acknowledge the need to rein in Medicare spending but say the

caps are a graphic illustration of the worst way to ration health care:

imposing limits that aren't based on medical need. " They're totally

arbitrary and capricious, " says Gail Wilensky, a Republican who generally

favors containing costs in her role as chairman of the Medicare Payment

Advisory Commission, which advises Congress on Medicare issues.

A Republican congressional staffer said the therapy restrictions were

needed because of the rapid growth in Medicare costs over the past several

years. In addition, she said, the caps were intended to be temporary --

until Medicare officials came up with a way to limit therapy based on

diagnosis.

Berenson, a top Medicare official, notes that the Clinton

administration didn't support the therapy-cap provision and now is worried

about its impact. " But how this will be translated into a remedy, I'm not

exactly sure, " he adds.

Medicare used to reimburse most providers for whatever therapy patients

needed, as long as the costs were deemed reasonable. The result: Spending

for therapy grew 18% a year between 1990 and 1996, reaching $1 billion and

raising red flags about possible fraud.

Critics acknowledge the caps are high enough for most people, but they say

they are too low for victims of stroke and Alzheimer's and Parkinson's

disease, as well as for people unfortunate enough to break a hip and an arm

in the same year.

Patients who can go from one therapist to another may be better off than

those in nursing homes, but they still aren't happy. " Switching therapists

is like switching doctors, " says Bonnie Mather, a 71-year-old resident of

Waterloo, Iowa, whose right leg was amputated just below the knee.

Moreover, some residents of rural areas have to travel long distances to

get to another agency or hospital-outpatient clinic.

No one is sure how many beneficiaries will be affected by the limits. But

an analysis by Larry Lane, senior vice president of regulatory affairs for

NovaCare Inc., a rehabilitation provider based in King of Prussia, Pa.,

suggests almost 150,000 people, more than half of them in nursing homes,

may hit the caps.

Faced with angry senior citizens and deluged with complaints from the

rehabilitation and nursing-home industry, Congress and the Clinton

administration are trying to control the damage. Republican Sen.

Grassley of Iowa and Democratic Sen. Harry Reid of Nevada are pushing a

bill that would allow some people to exceed the caps, based on medical needs.

Another option includes exempting nursing-home residents from the therapy

ceilings. Even House Ways and Means Health Subcommittee Chairman

, the California Republican who sponsored the caps, is exploring

legislative ways to ease them. In the meantime, patient advocates and

industry officials want the caps suspended or, at the very least, two

separate ones established for speech and physical therapy.

Medicare's Mr. Berenson reminds nursing homes that, regardless of their

reimbursements, the federal regulations governing nursing homes require

them to provide their residents with all necessary care, including therapy.

Industry officials are skeptical. " Is it realistic to expect people to

provide free care? " NovaCare's Mr. Lane asks.

At Potomac Center, owned by Genesis Health Ventures Inc. in Kennett Square,

Pa., Robin , who runs the therapy department, is trying to stretch

the therapy she provides her patients. Sometimes therapists there provide

group rather than one-on-one therapy. Other times they provide treatment

for which the center won't be paid. But there is a limit, she says.

Take the case of one of the facility's residents, Kathleen , 54, who

has multiple sclerosis and is unable to walk or work. After her illness

flared last fall, Ms. , who had been living independently in an

apartment, was admitted to Potomac Center for speech, physical and

occupational therapy. She made progress and hoped to go home, but earlier

this year her illness worsened. She needed more therapy but was rapidly

approaching the caps.

Ms. asked Medicaid, the federal-state program for the poor and

disabled, to pick up the cost of the therapy. But the program, which pays

the nursing home $91.06 a day for Ms. 's care, declined to kick in any

more. Finally, Genesis agreed to give her the therapy free.

R. Kovacek, MSA, PT

Email Pkovacek@...

313 884-8920

Visit <www.PTManager.com>

TOGETHER WE CAN MAKE A DIFFERENCE !

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