As those of you who are regular readers know, I am NOT a fan of Medicare Advantage plans. One of the top five promoters of these plans is Humana. While I am going to single them out in this blog, rest assured, the other four (Aetna, Cigna, United Healthcare, and Anthem) all are looking at how this rolls out and planning on implementing similar cost-cutting measures. But I am getting ahead of myself.
Where Would You Like to Spend Time Recovering If You Were Ill?
I had hip replacement surgery almost three years ago. A typical recovery plan after surgery like this includes several days of post-surgical care to insure there are no complications, followed by some physical therapy to make sure all the pieces parts are back up and running, and, if there is a need for additional services, referrals to the appropriate providers. All of this is covered by my insurance plan: Original Medicare.
I was able to be discharged directly to my home, where I received follow-up services that are called, by those in the know, Home Healthcare. Some of you may be familiar with this, but you may not be aware of its unique composition and function in the Medicare system.
Home Healthcare Services
If you Google “home healthcare” you will find a list of companies that offer these services. You need to scroll down quite a ways to find the Medicare page that describes these covered services, but I encourage you to click on the link and read about this wonderful benefit!
Basically, you get a care team consisting of a nurse, a social worker, a physical therapist, and sometimes even a psychologist!
While each of the team members has a specialty, all operate together to see that you are returned to functional status, healthy, in working order, and ready to resume your life.
You may see one or more of the team members more frequently, but all are collaborating in seeing you recover. And when you have recovered, they are gone!
How Is This Paid For?
What you may not understand, however, is how these services are actually paid for. This is considered a “bundled service” under Medicare insurance coverage. Medicare pays a single reimbursement rate for the whole team (as opposed to each provider separately) based on whether you are improving (getting better) or are unable to benefit from the services (not getting better).
What this means is while you get a team of providers to care for you, that team has certain limitations around how long they will see you and just which members of the team show up. If you have original Medicare, you won’t see a bill. If you have a Medicare Advantage plan, however, you might find yourself left high and dry.
Which brings me back to Humana. According to Becker’s Payer Issues, Humana, who ran a huge home healthcare service (SeniorBridge) decided this program is no longer financially feasible and is laying off lots of people and “shuttering all SeniorBridge locations”. No warning. Just shutting things down.
Why Should You Be Paying Attention to This?
SeniorBridge was originally touted as a state-of-the-art home healthcare delivery system that would provide beneficiaries with skilled nursing, physical therapy, and a bunch more services. And for many beneficiaries, for a number of years, that is exactly what they did!
But then they stopped. Just up and decided it wasn’t financially in Humana’s interest to continue to provide these services, leaving employees and patients without back-up. You can’t even scroll through the website!
Costs of Services vs. Needs for Services
As more and more of us age, there is a greater likelihood that at some time we will need assistance in getting back to our functionally active selves. That need should be what drives the service. Instead, these services are being shut-down, sold, and/or merged with other kinds of profit-driven companies.
Once privatized, all too frequently the quality of care provided by well-intentioned but poorly managed home healthcare companies declines. The result? You scramble to find your own caregivers and pay more money out of pocket, but don’t receive the care you are eligible to receive.
Truth is, home healthcare is a costly benefit. But it is one that is amazingly successful. People receiving care at home are less likely to need to be readmitted to the hospital. And, with exceptions, most people I know would prefer to be in familiar surroundings when recovering from surgery or illness.
You Don’t Know You Need This Until You Do
Of course, this is a problem that happens to other people until it is you that needs the care! Even though more and more of my peers are having hip and knee surgery and are being discharged home, very few are aware of the home healthcare benefit. And why would you know about it?
Even though I was a Medicare provider, for many years I had no idea that this service was provided and covered under my Medicare plan! But let me tell you, I have become a HUGE ADVOCATE for using these services and making sure they are available.
What Needs to Be Done?
Back in 2018, the Center for Medicare Advocacy pointed out that a fundamental change in approaching reimbursement and service delivery needed to be made. They noted, “While the Centers for Medicare & Medicaid Services (CMS) online and print materials now more accurately reflect Medicare home health coverage law, CMS continues to administer the benefit as if it is for patients with acute care needs. Further, although some beneficiary protections have been expanded, CMS payment policies, quality measures, and fraud investigations create disincentives for home health agencies to provide care to all who qualify; patients with longer-term needs are particularly disfavored.”
The Way Forward Is Not at All Clear
Here we are in 2023 and frankly, the need for home healthcare services has only increased with the pandemic. Many Medicare-eligible beneficiaries are needing support around health issues that were once managed through a short-term stay in a nursing home. These beds are hard to come by or non-existent. This means that people are suffering and not receiving the care they are due.
We seem to be starting the year in political turmoil that will take more time and energy away from the very real work that Congress needs to be doing. And sadly, the needs of America’s aging adults have rarely been at the top of that agenda. Still, there are more and more of us who are recognizing and claiming what is already law: respect, quality care at reasonable prices, and elder justice.
It’s Not Sexy, but It Just Might Help You Live a Little Longer
I realize I am a policy nerd. Not everybody gets excited reading about eligibility and insurance coverage. But I invite you to do a little exercise that might motivate you to at least become familiar with the basics. If you are interested in learning more, check out my website.
Functional Present/Function Future Exercise
Your functional capacities will change as you age. How you adapt and accommodate to these changes depends on many different factors. Having a realistic assessment of your current functioning can help predict future challenges and needs. Think about the items below and take time out to chart your future.
Use this exercise to help you identify where your strengths and vulnerabilities lie in terms of your capacity to care for yourself and get your needs met. Keep in mind that all of us tend to over-estimate our capacity. The goal here is to get an accurate picture of where you are now, so that you can make a solid plan for dealing with the inevitable changes that will come.
What is your “Functional Present”?
Identify what your strengths are and who you have on your “support team” right now.
What is your “Functional Future”?
Imagine possibilities/probabilities based on information you gather from informed resources. These resources may include family, friends, professionals, or other sources that will help you.
Example
| Healthcare | Present Functioning | Future Functioning (short/long-term) |
|---|---|---|
| What I’m doing now | What will probably change | |
| Description | See PCP for annual check-up On 3 medications Wear glasses Could lose some weight Generally healthy | May need specialists May need nutritionist May need cataract surgery May need PT |
| Next Steps | Research providers Estimate how far I need to travel for hospital/specialty care Check insurance coverage for home healthcare | |
Now it’s your turn. Use the form below to help you identify where you are at now and identify those areas where you might be wanting to do some research!
One response to “First Rant of the New Year”
Mary, as those of us who have WORKED WITHIN the USA’s healthcare “system” all too well know, our country’s unwitting (witless???) and brainwashed “decision” to view healthcare AS A BUSINESS — has been a train wreck, from the beginning. Unless, of course you happen to be an insanely high-paid “private” insurance executive, a major stockholder of all such “private” businesses or a Wall Street “gambler” – literally with other people’s health and LIVES. For all the rest of us? Construing an utter (and often life-or-death) service like health care as “a business” has been one of the most lemming-like and DUMB “decisions” our country has ever made.
And of course, a sizeable fraction of the obscene PROFITS from this gory “business” (literally trading off the illness of others) continuously IS invested in massive advertising (propaganda for the “religion” of private health care) and also in literally acquiring for itself “the best government (their) money can buy.” Those two “clever” investments thus perpetuate the ginormous LIE about how “wonderful” American health care is. All this is cynically self-serving to the max, and in fact, is deliberately evil.
And of course anyone who dares question these FACTS: that health care in the USA costs an average of THREE TIMES more than in any other major industrial country, while now being rated in 26th (near bottom) place for quality of outcome . . . is instantly labeled a “socialist’ or even (shudder, shudder) a “commie.” In particular, the American private health care “industry” (and how “industrious” it is!), has spent a fortune labeling (for example) Bernie Sanders as a “commie,” as “un-American” and as “a crazy OLD nutcase.” (Obviously to them, being OLD is as much a sin as not being a True Believer – in unadulterated greed).
So there’s MY “first rant of the new year!” Whee! (And, for the countless Americans lacking care or being bankrupted by this “system”) – BOO!