Jean Burgener, Aspirus VP Post Acute Services
For decades Medicare beneficiaries, particularly those with long-term or debilitating conditions and those who need rehabilitation services, have been denied care based on the “Improvement Standard.” This practice has resulted in Medicare coverage for vital care being denied to thousands of individuals on the grounds that their condition was stable, chronic (ongoing), not improving, or that the necessary services were for “maintenance only.”
The use of this “Improvement Standard” standard has had a particularly devastating effect on patients with conditions not expected to improve, such as Multiple Sclerosis, Alzheimer’s disease, ALS, Parkinson’s disease and paralysis.
Jimmo v. Sebelius was a recent lawsuit brought on behalf of Medicare beneficiaries by six individuals and seven national organizations to challenge the use of the Improvement Standard.
Impact for patients
The lawsuit resulted in an important settlement:
Nursing and therapy services are covered to maintain the patient’s current condition or prevent or slow further deterioration safely and effectively as well as when the patient requires the skill of a qualified therapist or a registered nurse, because of the patient’s special medical complications.
The Jimmo v. Sebelius decision impacts Medicare part A and B services delivered in a Skilled Nursing Facility (nursing home), Home Health, Inpatient Rehabilitation Facility and Outpatient Therapy. Read more about the landmark decision here.
Lower cost and better quality
The skilled maintenance nursing and therapy that is at the heart of this settlement is usually low-cost, low-tech care that can prevent patients from declining and requiring more intense, more expensive care.
A recent study makes this point: In one Veterans Administration program, healthcare workers helped the highest cost patients with multiple health needs in their homes. The program operates in more than 250 locations, has more than 27,000 patients on average per day, and has shown savings (where costs are the highest) of 24%. It has reduced hospitalizations by over 60% and has reduced nursing home use by over 80%. Many similar programs show savings on the highest cost patients of 50% or more. At the same time, patient and caregiver satisfaction was high.
