Sylvia is one of many who benefit from the ADHC system funded by MediCal and she will suffer a significant loss in quality of life, and maybe lose her life if her center closes.To discuss Sylvia’s situation, we first need to explore the decision making process known as “medical necessity”.
The golden phrase of for-profit medicine is medical necessity. Medical necessity is the inverted pyramid on which reimbursement rests. Definitions are largely vague, tradition mediated standards of care. Here are some situations for the uninitiated.
A. You have an insurance plan; it says you are eligible for a procedure such as cardiac angioplasty. So you say to yourself “if I ever have heart problems, thank goodness I have that benefit”. If you were to develop heart problems the physician would write a statement demonstrating the procedure’s medical necessity. Plain and simple.
B. You have the same insurance plan and it says you can receive physical therapy services. So you say to yourself “I like physical therapy services, I should have some”. But you’d need to have a reason, a medical reason. Okay not so difficult to understand.
C. You are covered by MediCal (California’s Medicaid program) and, in the past, you did get dental services but due to past benefit reductions you can have dental services but only if you pay for them. We are all getting used to changing health plans.
D. You are a frail elder with hypertension, type II diabetes, depression w/ mild memory loss, osteoporosis of both the thoracic spine and right femur; you have mild loss of balance and need to get up at least once a night because of the diuretics you are taking for your high blood pressure. You are covered by MediCal and Medicare and you’ve been receiving nursing and therapy services at an Adult Day Health Service. But this has been a benefit of MediCal; Medicare does not pay for these services. By the summer of 2011 MediCal won’t either.
If you think you are getting the idea, hold that thought. In fact it’s worse than you think. I thought I might include one or more citations from Medicare - the arbiter of this type of definition - but chose not to. It is painful reading. To summarize simply, medical necessity is based on what those that pay believe providers of service should be doing. And because those that pay never see the patient they come to their conclusions based on reading some paper (the justification sent with the bill).
It was pointed out years ago that we cannot depend on what others do to ascertain standards of care. In 1992, Leape (2) chronicled how hysterectomies were being performed and paid for not because the procedure was indicated or that the patient wanted it but justified by an amorphous community standard of care. He went on and demonstrated how other surgeries such as tonsillectomies were routinely performed but not needed in his critical and critically acclaimed pamphlet “Unnecessary Surgery”. A significant percent of care delivered was considered unnecessary then and those figures remain today.
Many times we get what we need – physicians, nurses, technical specialists who are fantastic. I have received immediate and appropriate care; in fact I’ve received thoughtful and reflective care. But at times I had to demonstrate greater medical necessity than the physician concluded not for myself but for my patents. How do we know if we are doing too much, too little, or the right stuff at the right time?
Since the early 1990’s there has been a major uptick in quality review mechanisms in healthcare organizations. Not just coincidentally to the start of broad reductions in healthcare funding. At first it was a few committees, some memos with mandates and the problem of meeting medical necessity with quality services was going to be fixed. But with more cuts, there were more quality review projects creating more findings and more fixes. The community standard keeps evolving.
Once services stop getting paid for, they are no longer the target for a standard of care, are longer medically necessary. Cutting and reducing and then cutting some more alters what was at one time essential good healthcare practice, albeit that needed to be tweaked. However, as much as we need to cut the care that is unnecessary, not appropriate and not healthful, we must not throw out the baby with the bathwater.
Let’s get back to Sylvia. Sylvia, who prefers “Sylvie”, is a 92 year-old pistol. She relishes conversations, actively listens to others and transcends reverie when read to. She can speak one of several languages she learned to survive growing up in central Europe, and has gracefully aged to just under 5’ in height.
Sylvie loves coming to her center, her Adult Day Health Center. Every day she is welcomed by name with hugs and inquiring looks. It is probably true that when Sylvie first started at the center 10 years ago her necessity was personal, not medical. A holocaust survivor, she is an immigrant to the U.S. dependent on a family that does not entirely want her. She found respite to offset the weariness of long life.
Her situation now is quite different. She has both hearing and visual deficits requiring others to be by her side. That warm and large heart has worked over time and is weakened limiting her exertion. Those knees, oh vey, her knees regularly cause disabling pain which leads to less walking only to lead to more problems. Nursing staff monitor blood pressure and medication usage. During the week on any given day she is seen resting quietly with her head back on a soft pillow, with a cool compress letting the headache of her body and life ebb. She asks for little and gives back royally.
Sylvia personifies “medical necessity”. The medical diagnoses of:
chronic cardiac failure, hypertension, osteoarthritis of the knees with acute episodes, depression, dementia (mild) with acute episodes, loss of peripheral vision, hearing loss w/ inability to use hearing aid and inability to self-manage, and not having appropriate care or assistance at home collectively qualify as medical necessity.
But that is only if the ADHC program exists and someone will pay for it. Sylvie’s family, like many others, can’t afford the $1500/month for the program. Even if Sylvie received Social Security payments, that amount would not cover the care. Only if admitted to a nursing home would MediCal be willing to pay over $4100/month because, of course, there is medical necessity (3).
(1) Assemble Bill 97 (California) http://www.leginfo.ca.gov/pub/11-12/bill/asm/ab_0051-0100/ab_97_bill_20110324_chaptered.pdf page 59-61.
(2) Unnecessary Surgery, Annual Review of Public Health, Vol. 13: 363-383 (Volume publication date May 1992) , Lucian L. Leape.