Denials of care are getting more common. Suppose you hear about a new treatment and your doctor agrees to try it. But, your Medicare Advantage insure will not cover the care. What do you do?
As I have written before the patient needs a patient advocate to get good care. A recent article in Forbes again proves the point. The Aetna Medical Director admitted in a lawsuit that he did not review denials of care. Nurses reviewed the files and made the decisions. The case in point involved a rare condition that the doctor did not know the treatment protocols and did not review the patient’s medical record before denying care. Obviously the nurses did not either and the treatment was denied over the patient’s doctor recommendation. You can read the article here.
The moral is clear. When you receive a denial of care, advocate with your doctor. If your doctor agrees that the denial is wrong go up the appeal ladder with your doctor’s support. Eventually the appeal process requires review with the patient’s doctor and that often results in approval.
I have written often on the need for an elder to have a patient advocate to get the best care. But, what should the advocate do besides be in good communication with the doctor? I read an interesting article by Dr. George G. Ellis, Jr. In it he identifies the most common causes of medical mistakes that lead to legal claims by patients. While it is always good to avoid mistakes, take note that when a mistake arises to a legal claim a patient has had a bad outcome. You can read Doctor Ellis’s article here.
According to Dr. Ellis, here are the two most common medical mistakes and how you can prevent them.
When the doctor prescribes, or administers, a medication the side effects and interaction with the medications the patient is already taking must be considered. According to one study 100,000 people die each year due to adverse drug interactions, making it the fourth leading cause of death. The study found 350,000 cases of serious adverse drug reactions in nursing homes each year. Read more here
The failure to recognize adverse side effects and interactions was fatal for Michigan attorney Jean Hannah’s mother. She wrote how her mother who was an active 83 year old woman died in 63 days in a nursing home from this problem. She wrote about it in her book “Taking Charge: Good Medical Care for the Elderly and How to Get It.”
Seasoned social worker Diane Sasson, of Sasson Senior Services who has helped many seniors with problems of aging, reports that online.epocrates.com is an excellent, free resource for checking medication side effects and interactions. To check on the effects of alternate medications, such as herbal remedies, one will need an annual subscription.
Moral: The patient advocate must know all the medications the patient is taking and their side effects and interactions with the patient’s other medications.
This mistake is made of two parts: one, the tests do not happen either because the order was not executed so no tests were scheduled or the patient did not show up for the tests. The second part occurs when the test reports an abnormality and the physician does not follow up. Sometimes the lab performs the wrong test and the physician does not notice. Then the untreated medical condition becomes much more serious.
One study found that perhaps 25% of all medical malpractice claims involve the failure to follow up on tests. See “No News Is Not Always Good News.”
One can easily find many malpractice case reports based in this error. Malpractice attorney Jules Olsman reported an $850,000 settlement for a 64-year-old man who died as a result of a medication error when the patient was discharged from a rehabilitation center without anticoagulants that were specifically ordered by his physician’s assistant, causing him to suffer a blood clot and die.
To read a full case report involving this error see “Failure to follow up . . . leads to $150,000 award”
For some practical advice to the patient advocate, listen to the podcast interview of Dr. John Hickner, professor of family medicine at the University of Chicago in the New York Times Wellness blog
The moral for the patient advocate is no news is not always good news.” Monitor the medical practice at every step. Be sure tests ordered are completed. Be sure the lab performs the right test. Get a copy of the lab report. And finally, check with the doctor to learn the results of the test.
Conclusion
With simple vigilance the patient advocate can help an aging parent avoid the majority of serious medical errors.
A short note: I heard a program about retirement planning the other day. I won’t identify the fellows since almost all retirement planning advice carries the same assumptions and the same blinders.
The authors had the usual advice about savings and investment strategies to make sure your money lasts through retirement. The implied assumption is that you will live your golden years in security until suddenly “the Big One” takes you out. Trouble with the assumption is that folks are living longer, and the longer they live the more expensive life gets. Consider how many people above age 90 live like 65 year olds? How many drive, maintain their own home without help, make their appointments and pay their bills by themselves? Perhaps most live in apartments that are “independent” or assisted living. The cost ranges from $2,500 to over $6,000 per month. Kind of ruins the financial plans.
Let’s consider the foregoing, just pointless quibbling about the computations. I agree that life does not go according to plan and yet it is better to have a plan that stretches one’s life savings to live in reasonable comfort and style. After all what if a person does travel, buy new cars and clothes and then runs out of money at age 85? It is better to prudently plan.
Let’s go to another part of my first point. Retirement is about aging and aging is about declining independence and health in many retirees. How much decline a person experiences is often directly related to the quality of healthcare the person actually receives. I did not say the quality that is available, but the quality received. From my experience an elder needs a healthcare advocate, a “patient advocate” to get the best outcome. Why? One reason is the complexity of healthcare and related to that is the incessant cost cutting the health insurers demand.
Yes, the quality of one’s life depends having adequate finances, but for many it depends more on the quality of the medical experience. And that requires a patient advocate who is acting under the authority of a healthcare power of attorney. But even more, the patient advocate must be informed about public and private benefits (Medicare and private health insurance for example). For many elders across the country it has been a patient advocate who saved their lives.
And so, that is why this entry is a short note. The subject of how to get quality outcome of your healthcare experience when your provider is trying to cut costs is not just a blog article. It is more than one big chapter in the book on retirement planning. I’m working on that one.
All the best,
Jim
Good news, but . . . Is this really news? Nursing homes have found a better way to reduce falls.
An AP article reports that nursing homes are moving away from physical items such as alarms, rails and mats to reduce falls and instead focusing on personal assistance. “What we really need to do is understand why that individual is wanting to get up in the first place,” said Joan Devine, director of education at the Pioneer Network, which is pushing for national changes.
This trend is good news, but I’m sorry everybody knows that when a sick elders gets out of bed they need to do something. Many of my clients in nursing homes have falls in the middle of the night. They are often trying to go to the bathroom rather than wait hours before an aide is scheduled to take the resident to the bathroom.
Knowing what the resident wants or needs is an oft repeated guide to good care for any condition. For example many difficult behaviors of advanced Alzheimer’s patients are attempts at communicating or doing some familiar activity. E.g. pacing is looking for something, acting out is a reaction to pain or a negative stimulus, and so on.
The immediate moral is for the patient advocate to be sure that the staff learns what a resident needs or is communicating and educate staff about those items, then be sure to monitor that care.
A broader lesson may be extended to home care. Falls happen for a reason. What is the person trying to do and how can we make that safer? Falls at night? Maybe wall rails in the bedroom and a clear path to the bathroom would make a big difference. Maybe having an aide in the evening adjust fluids, e.g. avoiding caffeine, or diet will make a big difference. Some elders drink juice late at night because they are hungry and that gives them temporary relief from hunger but will create the need to toilet later.
Learning a person’s needs and giving needed personal attention makes for a healthier elder. “Who’da thunk it?”
Read the article here: http://bigstory.ap.org/article/1b34373c50f74a2dba29ac17d5533c11/nursing-homes-phasing-out-alarms-reduce-falls
I would like to share a simply EXCELLENT guide for good care in a nursing home. It is “20 Common Nursing Home Problems – and How To Resolve Them” by one of the nations’s premiere legal advocates for nursing home residents, Eric Carlson. It is free and available through http://www.justiceinaging.org/.
Being a lawyer I cannot give a blanket recommendation but must, as does the 20 Common Guide, advise you to use your judgment and seek professional counsel if the Guide seems to steer you on a dangerous or futile path. The Guide is only a guide. You must use your judgment.
Here are my comment on some on some of the points.
Number 3 says the nursing home must accommodate a resident’s preferences and gives an example of everybody being awakened at 6 a.m. The explanation offered is inadequate staffing. So, If the resident does not want to be gotten out of bed at 6 a.m. the patient advocate may find the resident still in bed hours later because the aides are now taking care of other patients. The Guide suggests the patient advocate come up with an alternate plan for “sleeping in” and getting dressed and breakfast after other residents.
Number 4 points out that the law says each nursing home must provide care to enable the resident to reach “the highest practicable level of functioning.” Most patient advocates would find these words are other worldly goals that may not be met on this earth. Under-staffing is a chronic problem in nursing homes.
Number 5 deals with improper use of physical restraints and notes their use has decreased dramatically in the past decades. Everybody agrees that is good. And I have observed that it seems like all nursing home residents are put in wheel chairs. Could some walk with walkers? Are they in wheelchairs because they are easier to manage and there is less fall risk? The answers depend on the particular case. However, I must add falls are extremely dangerous for the sick elderly. They can lead to death through complications from surgery or hospital stays.
Number 5 gives bed rails as an example of a physical restraint. These rails prevent residents from falling out of bed. The Guide suggest that a bed can be lowered to the floor and a pad on the floor. This will take care of falls out of the bed. But they do not address the problem of the resident who gets out of bed and then falls when trying to walk.
Number 11 cites refusal to bill Medicare. Medicare has changed. Gone are the days when the patient’s doctor wrote a prescription and it was followed. Now Medicare controls the provider. The doctor does not. The provider must be able to put every service into a proper billing code while fearing charges of Medicare fraud if the billing is denied. Patients are offered a “rubber stamp” appeal system where KPRO, the Medicare “QIO,” denies almost all appeals. Billing Medicare does not produce the results it used to just 10 years ago.
Number 8 says a nursing home may not impose visiting hours. I have not heard from clients that nursing homes had visiting hours.
Number 17 says the nursing home may not charge residents extra for medical care. In today’s medical environment the issue of co-pays and deductibles, prescription formularies and limitations on coverage is well known. If an item is not paid it is usually a matter of insurance.
Number 18 says the nursing home must support resident and family councils. This may have been a big issue when nursing homes were homes for the frail elderly. Now these residents are in assisted lving apartments, not nursing homes. The nursing homes are taking care of a much sicker population now.
Number 14 offers very useful advice about dealing with the problem of the alleged “short term stay” facility explanation. That is, after post-hospital skilled care ends, e.g. rehab, the nursing home tells the resident they have to move because they are now “long term care.” That is untrue because all “nursing homes” are long term care facilities by virtue of their licensing.
However, the Guide sends a patient advocate into futile court battles when it advises that a nursing home can get a bed certified by Medicaid for the resident. Michigan restricts the number of Medicaid beds it approves. One local attorney took a well financed nursing home to court on the issue and lost.
Number 20 advises that a resident may refuse medical treatment. It is all to often true that the guide for medication in a nursing home is administrative convenience. However, the patient advocate may find it impossible to be consulted on each medication change before it happens. Some have waited all day to see a doctor to explain a change, only to have the nursing home doctor never show up.
Nevertheless, a patient advocate must advocate for good care and sometimes that means moving the resident out of a sub-standard nursing home.
Believe me, the above comments do not take away the immense value the Guide offers to Patient Advocates. If you have somebody in a nursing home, get it now. You will not regret it and you will find you will be sharing it as am I.