Medicare does not require that older adults demonstrate improvement in order to receive ongoing therapy.

This article first appeared March 29, 2018 on Kaiser Health News.

By Judith Graham

For years, confusion has surrounded the conditions under which older adults can receive physical, occupational and speech therapy covered by Medicare.

Services have been terminated for some seniors, such as those with severe cases of multiple sclerosis or Parkinson’s disease, because therapists said they weren’t making sufficient progress. Others, including individuals recovering from strokes or traumatic brain injuries, have been told that they reached an annual limit on services and didn’t qualify for further care.

Neither explanation stands up to scrutiny. Medicare does not require that older adults demonstrate improvement in order to receive ongoing therapy. Nor does it limit the amount of medically necessary therapy, for the most part.

The February congressional budget deal eases long-standing concerns by lifting a threat that some types of therapy might be restricted. But potential barriers to accessing this type of care remain. Here’s a look at how Medicare now covers such services.

Medical necessity. All therapy covered by Medicare must be deemed “reasonable and necessary to treat the individual’s illness or injury,” require the services of skilled professionals and be subject to medical oversight.

What isn’t a precondition for receiving services is ongoing improvement — getting measurably better. While this can be a goal for therapy, other goals can include maintaining a person’s current abilities or preventing deterioration, according to a groundbreaking legal settlement in 2013.

The implication for older adults: If your therapist claims that she can’t help you any longer because you aren’t making substantial progress, you may well have grounds for an appeal. At the very least, a discussion with your physician about reasonable goals for therapy is advisable.

Part A therapy services. Often, older adults require therapy after an untoward event brings them to the hospital — for instance, a stroke or a bad fall. If a senior has an inpatient stay in the hospital of at least three days, he or she becomes eligible for up to 100 days of rehabilitation, including therapy, in a skilled nursing facility under Medicare Part A.

Therapy services covered by Medicare Part A also can be obtained in an inpatient, hospital-based rehabilitation facility. In this setting, requirements call for therapy to be “intensive” — at least three hours a day, five days a week. Stays are covered by Medicare up to a maximum 90 days.

If a senior returns home after being in the hospital, he or she may receive therapy from a home health agency under Medicare Part A. To qualify for home health care, an older adult must need intermittent skilled services, such as those provided by a registered nurse or physical therapist, and be substantially homebound. Each episode of home health care can last up to 60 days and be renewed with a physician’s authorization.

“A lot of home health agencies believe, wrongly, that the home health benefit, including therapy services, is limited in duration to a couple of 60-day episodes,” said David Lipschutz, senior policy attorney at the Center for Medicare Advocacy. The bottom line for beneficiaries: You may have to advocate aggressively for the care you think you need and enlist your physician to intervene on your behalf.

Part B services. Physical, speech and occupational therapy are also covered by Medicare Part B in private practices, hospital outpatient clinics, skilled nursing facilities (when a patient’s Part A benefits have run out) and, less frequently, in people’s homes (when individuals no longer qualify for Part A home health services but still need assistance).

More than 5 million older adults and people with disabilities covered by Medicare receive “outpatient” therapy services of this kind each year. Care can last up to 90 days, with the potential for renewal if a physician certifies that ongoing services are necessary.

Questions about coverage for Part B therapy services have surfaced repeatedly since Congress authorized annual limits on the care that Medicare would cover in 1997 — a cost-saving move.

Faced with criticism, Congress delayed implementation of these “caps” for several years. Then, in 2006, it created an “exceptions” process that allowed caps to be exceeded, so long as therapy was judged to be medically necessary.

The exceptions process had two steps. First, a therapist had to request that services be extended when a patient reached an initial “cap” — set this year at $2,010. Then, another request had to be made when a patient reached another, higher threshold — initially set at $3,700 this year, but reduced to $3,000 in the budget legislation.

Both steps called for therapists to justify additional services by providing extra documentation. At the second, higher threshold, therapists also faced the prospect of intensive medical review of their practices and, potentially, audits.

At that point, therapists were often hesitant to pursue exceptions, which has made it difficult for patients with complex medical conditions to access care. Also, sometimes requests for exceptions have been denied, posing another barrier.

“We use the exceptions process, but we’ve tried to be very vigilant in who we used it for,” said Sarah Gallagher, a physical therapist at South Valley Physical Therapy in Denver, which specializes in treating people with complicated neurological conditions. “The risk is putting your clinic at risk for an audit if you ask for exceptions too often.”

With February’s budget deal, Medicare has gotten rid of the “caps” but retained the notion of “thresholds.” After billing for $2,010 in services (about 20 therapy sessions at $100 per visit) this year, a provider has to add an extra code to a bill. After billing $3,000, targeted medical reviews and the potential for audits can again be prompted.

Eliminating the caps should make things easier for older adults who need a time-limited course of therapy. But whether therapists will be wary about approaching the $3,000 threshold, with its extra administrative burdens and potential risks, remains to be seen. If so, patients recovering from strokes or brain injuries and those with complicated chronic conditions, who need intensive therapy for an extended period, could be affected.

“We fear that there still might be barriers to accessing care,” said Lifschutz, of the Center for Medicare Advocacy. “We suspect some providers will say I don’t want to deal with this process, and if I’m getting anywhere near that $3,000 threshold, I’m just going to give it up.”

“Theoretically, all the uncertainty we’ve been living with, related to the therapy caps and acceptable goals of therapy, has been resolved,” said Kimberly Calder, senior director of health policy at the National Multiple Sclerosis Society. “But only time will tell.”

Hospitals and medical practices are urging patients to sign up for portals, which allow them rapid, round-the-clock access to their records.

This article first appeared March 27, 2018 on Kaiser Health News.

By Sandra G. Boodman

As she herded her two young sons into bed one evening late last December, Laura Devitt flipped through her phone to check on the routine blood tests that had been performed as part of her annual physical. She logged onto the patient portal link on her electronic medical record, scanned the results and felt her stomach clench with fear.

Devitt's white blood cell count and several other tests were flagged as abnormal. Beyond the raw numbers, there was no explanation.

"I got really tense and concerned," said Devitt, 39, a manager of data analysis who lives in New Orleans. She immediately began searching online and discovered that possible causes ranged from a trivial infection to cancer.

"I was able to calm myself down," said Devitt, who waited anxiously for her doctor to call. Two days later, after hearing nothing, she called the office. Her doctor telephoned the next day. She reassured Devitt that the probable cause was her 5-year-old's recent case of pinkeye and advised her to get tested again. She did, and the results were normal.

"I think getting [test results] online is great," said Devitt, who says she wishes she had been spared days of needless worry waiting for her doctor's explanation. "But if it's concerning, there should be some sort of note from a doctor."

Devitt's experience illustrates both the promise and the perils of a largely unexamined transformation in the way growing numbers of Americans receive sensitive — sometimes life-changing — medical information. A decade ago, most patients were informed over the phone or in person by the doctor who had ordered testing and could explain the results.

But in the past few years, hospitals and medical practices have urged patients to sign up for portals, which allow them rapid, round-the-clock access to their records. Lab tests (with few exceptions) are now released directly to patients. Studies estimate that between 15 and 30 percent of patients use portals.

The push for portals has been fueled by several factors: the widespread embrace of technology, incentive payments to medical practices and hospitals that were part of 2009 federal legislation to encourage "meaningful use" of electronic records, and a 2014 federal rule giving patients direct access to their results. Policymakers have long regarded electronic medical records as a way to foster patient engagement and improve patient safety. Studies have found that between 8 and 26 percent of abnormal lab results were not communicated to patients promptly.

Are portals delivering on their promise to engage patients? Or are these results too often a source of confusion and alarm for patients and the cause of more work for doctors because information is provided without adequate — or sometimes any — guidance?

Releasing results on portals remains "an answer with many questions," said Hardeep Singh, a patient safety researcher at the Michael E. DeBakey VA Medical Center in Houston. "There is just not enough information about how it should be done right," said Singh, who is also an associate professor at Baylor College of Medicine and one of the few researchers to study patients' experiences obtaining test results from portals. "There are unintended consequences for not thinking it through."

Although what patients see online and how quickly they see it differs — sometimes even within the same hospital system — most portals contain lab tests, imaging studies, pathology reports and less frequently, doctors' notes. It is not uncommon for a test result to be posted before the doctor has seen it.

That means that a patient may be the first to learn of a suspicious breast mass, a recurrence of cancer or possible kidney failure. At Johns Hopkins medical system in Baltimore, for example, results of a PSA test to screen for prostate cancer come with this disclaimer: "While Johns Hopkins providers check results frequently, you may see results before your provider has seen them."

Breast cancer specialist Lidia Schapira is an associate professor at the Stanford University Medical Center and editor-in-chief of Cancer.net, the patient information website of the American Society of Clinical Oncology. While she regards online access as beneficial, "the danger is that the patient may learn information they're unprepared to receive and may feel abandoned if they can't reach their doctor."

"Those are the Friday afternoon phone calls," she said, when "at 4:59 [p.m.] a patient has accessed the results of a scan and the doctor signs out at 5." The recipient of the anguished inquiry that follows is typically a covering doctor who doesn't know the patient or details of the case.

When Is Use Meaningful?

A recent study by Singh and his colleagues found that, like Devitt, nearly two-thirds of 95 patients who obtained test results via a portal received no explanatory information about the findings. As a result, nearly half conducted online searches. Many with abnormal results called their doctors.

That echoes a 2016 study led by researchers from the University of Pittsburgh. These scientists found that in addition to engaging patients, portal use may increase anxiety and lead to more doctor visits.

Among patients with low health literacy and numerical skills, confusion about the meaning of results is common. Many tests are reported in the same form that the doctor sees them, which even savvy patients may find "literally meaningless," observed Brian Zikmund-Fisher, an associate professor in the school of public health at the University of Michigan.

"In some situations we run the risk of patients misinterpreting that there is no problem when there is one, or assuming there's a problem when there isn't," said Zikmund-Fisher, lead author of a study that advocates the use of explanatory graphics to convey results. "What we need to be focusing on is giving patients context."

A year or so ago, Geisinger Health System in Pennsylvania began making most test results — but not biopsies or HIV screening — available to patients within four hours of being finalized.

"We essentially release results twice a day seven days a week with a four-hour lag," said Ben Hohmuth, Geisinger's associate chief medical informatics officer. The delay, he said, gives doctors time to review results. Patients who log on over a weekend can contact an on-call physician if they can't reach their own doctor. The goal of rapid release, Hohmuth said, is to "be patient-centered and transparent."

"The majority [of patients] want early access to their results, and they don't want it to be impeded" while waiting for doctors to contact them, Hohmuth said, even if the news is bad.

Patient reaction, he adds, has been "overwhelmingly positive"; the few complaints have come from physicians.

Health lawyer Kathleen Kenyon said she would have appreciated faster access to blood test results for her elderly mother, who had multiple medical problems including Alzheimer's disease. Kenyon, who managed and closely monitored her mother's condition, said she believes speedier access could have helped stave off a four-day hospitalization in the intensive care unit of a Washington hospital caused by her mother's plummeting sodium level.

"It is safer for patients to have more information," said Kenyon, formerly a senior policy analyst at the Department of Health and Human Services. "I was begging them to get my mother's lab information in earlier."

What Does This Mean?

At 46, writer Rebecca Esparza has survived Stage 4 ovarian cancer as well as thyroid cancer. She normally loves having round-the-clock access to her records and the ability to email her doctors.

But in 2016, immediately after extensive abdominal surgery at a hospital several hours from her home in Corpus Christi, Texas, doctors told her they suspected she had developed colon cancer. Confirmation would require further evaluation by a pathologist.

Esparza went home and waited, checking her portal repeatedly. A week later, she logged on to find a highly technical biopsy report she could not understand. A friend who is a nurse read it and told Esparza there was no mention of a malignancy. Two weeks after Esparaza left the hospital and a week after the report appeared on her portal, one of her doctors confirmed that she didn't have cancer after all.

"It was really traumatic and the one time I wish I hadn't had access," said Esparza, an advocate for the National Coalition for Cancer Survivorship.

Although Esparza considers her experience to be "a fluke," she notes similar confusion among other cancer patients in the online support groups she runs.

"People post their blood test and other results all the time and ask what it means," she said. Esparza said she intercedes by reminding participants "we're not doctors."

One way for a physician to provide guidance, said Stanford's Schapira, is for doctors to negotiate with patients in advance, particularly if they are concerned the news might be bad.

It is a strategy she employed at her previous job at Massachusetts General Hospital in Boston. "I would say, 'Let's do a scan and then schedule a visit two days later, and we can discuss the results,'" she said.

One Doctor's Experience

Mass General internist Katharine Treadway knows what it's like to obtain shocking news from an electronic medical record. The experience, she said, has influenced the way she practices.

More than a decade ago — long before most patients had portals — Treadway, with her husband's permission, pulled up the results of his MRI scan on a hospital computer while waiting to see the specialist treating his sudden, searing arm pain.

"It showed a massive tumor" and widespread metastatic disease, Treadway recalled. She never suspected that her 59-year-old husband had cancer, let alone a highly aggressive and usually fatal form of advanced lymphoma.

Treadway said she remembers intently checking the name and date of birth, certain she had the wrong patient, then rebooting the computer several times "like I was going to get a different answer."

"The difference is that I knew exactly who to call and what to do," said Treadway, whose husband has been cancer-free for more than a decade. "In the event of bad news, a doctor has to surround the patient with 'I am here for you and here's the plan.'"

Schapira agrees. "Clinicians have to start tackling the issues that have arisen as a result of instant access," she said.

The stakes over DACA are particularly high for those who have bet everything on professions that require high-cost educations and several years of training.

This article first appeared March 23, 2018 on Kaiser Health News.

By Ana B. Ibarra

Among the young people known as "Dreamers," Ever Arias belongs to a select group.

Of the roughly 700,000 unauthorized immigrants who have temporary but tenuous protection from deportation, only 99 are in medical school. Fewer still have made it to their final year.

Arias is one of them and, come June, will start his medical residency — the on-the-job training he needs to become a doctor.

What's not clear is whether he'll be allowed to finish and, ultimately, practice in the United States.

"We're at the mercy of the government at this time," said Arias, 27, who will graduate this May from Loyola University Chicago's Stritch School of Medicine.

Last Friday, Arias got great news. On Match Day, when 31,000 medical students nationwide found out where they will be trained as residents, he learned he would be heading to Southern California, where he was raised. His three-year residency will be in internal medicine, and his goal is to practice in underserved communities that need bilingual doctors, he said.

But at this pivotal moment in his medical career, Arias must focus both on his academic future and his legal one. In September, the Trump administration announced it would end the Deferred Action for Childhood Arrivals (DACA) program, setting off an ongoing political and legal battle that could overshadow the careers of immigrant doctors in training.

The tug-of-war has left Dreamers — the name given to people brought illegally into the U.S. as young children — wrestling with apprehension and uncertainty. The stakes are particularly high for those like Arias, who have bet everything on professions that require high-cost educations and several years of training. The end of the DACA program could mean the end of their careers in the United States.

"The biggest fear I have is that one day everything I've worked for will be taken away," Arias said.

President Barack Obama created DACA in 2012. The program allows qualified young people to obtain temporary work permits, which Arias and other Dreamers need to complete their training and advance in their careers.

The future of DACA is tied up in courts. Earlier this year, federal judges in California and New York temporarily blocked Trump's move to terminate the program, and his administration is appealing.

For now, Dreamers can reapply for the status every two years, but there's no guarantee how long that will last.

"Without DACA, there is very little possibility that medical students will be able to fulfill their profession," said Betzabel Estudillo, of the California Immigrant Policy Center. This is of particular concern in the medical field where there is an urgent need for a "robust and diverse workforce," she said.

Ignacia Rodriguez, immigration policy advocate at the National Immigration Law Center, called Arias and other Dreamers "pioneers."

"They've had this ambition before DACA was around and they'll continue to work towards it even if DACA were to be taken away," she said. "But they deserve stability."

After months of applications and interviews, Arias was excited that he "matched" with his first choice, a residency program in Southern California. He declined to name the institution, citing the uncertain political situation.

Arias, who was born in Mexico and brought to the U.S. at age 6, grew up in Costa Mesa, Calif. He graduated from the University of California-Riverside in 2012 and, after a two-year break, started medical school.

When the Trump administration announced its plan to rescind DACA last year, Arias was in the middle of applying to residency programs. He worried that they might reconsider whether to continue accepting DACA recipients because they could run the risk of losing their trainees midstream if DACA were eliminated.

But some residency programs aren't letting the uncertainty cloud their decisions.

"We want programs to be able to choose from the best and brightest and to be able to select applicants who would be best suited for their institutions and communities, regardless of status," said Atul Grover, the executive vice president at the Association of American Medical Colleges, which represents medical schools and teaching hospitals.

Residency programs take a risk with every student they admit, not just Dreamers, added Sunny Nakae, the assistant dean for admissions at Loyola's medical school. "The threat that looms over DACA obviously adds a more foreseeable risk," she said. But "there's no guarantee that anybody … is going to finish."

Arias toyed with the idea of waiting a year before applying; he thought maybe the political climate would cool by then.

"But we decided it was now or never," Arias said of himself and the other Dreamers in his graduating class.

He recently applied to renew his DACA status, he said, and is trying to simply focus on "the craft of learning medicine," not the turmoil surrounding the immigration debate. If DACA were eliminated, he and other recipients would lose their status at different times, whenever their two-year terms ended.

Before DACA, people without permission to live and work in the U.S. couldn't get medical residencies because they didn't have work authorization, Nakae explained.

Raquel Rodriguez, 30, was one of the few undocumented students who started medical school before DACA was created.

Rodriguez, who was born in Mexico City and raised in San Diego, is a second-year family medicine resident in Southern California. She also declined to disclose the name of her residency program.

Rodriguez received her undergraduate degree from Harvard University in 2009. But because she had neither immigration papers nor DACA, her academic counselor discouraged her from applying to medical school, explaining that she wouldn't be able to secure a residency spot, she said.

She applied anyway, and in 2011 she started medical school at UCLA.

"I applied, but didn't think I'd get in, and then I did and I had no idea how I was going to pay for it," she recalled.

Medical school is expensive — the median in-state tuition at a public medical school was about $37,000 for the 2017-18 academic year, according to the Association of American Medical Colleges.

Rodriguez's friends from Harvard helped her pay for her first year. Then in June 2012, DACA paved the way for other financial opportunities. By patching together scholarships and loans, Rodriguez got herself through her remaining years of medical school.

She will finish her medical residency training next year. She also has a master's degree in public policy and hopes to find a job that combines both disciplines. She's still not sure what that will look like, but she knows she wants to give back to low-income communities.

So does Arias. Members of his family didn't have health insurance because of their legal status, so he'd like to serve populations who also struggle with limited access to coverage and care, he said.

"I see the role I can play in my community," he said. "I don't want that to be stripped away from me."

The federal government has historically declined to provide Medicaid dollars to states that don't allow patients to choose between 'any willing provider.' Texas is asking for a change in that position.

This article first appeared March 22, 2018 on Kaiser Health News.

By Phil Galewitz and Anna Gorman

The Trump administration is weighing whether to allow Texas to receive millions of federal Medicaid dollars for its family planning program, which bars abortion providers.

The Lone Star State eliminated its Medicaid-funded family planning program five years ago when state officials said they wanted to specifically exclude Planned Parenthood because the group provides abortions. Dozens of women’s health clinics closed as Texas established a wholly state-funded program that officials say today serves 220,000 women.

Medicaid’s family planning program is optional for states and used by half of them to provide contraception services for low-income women who earn too much to qualify for traditional Medicaid.

Texas, Iowa and Missouri gave up that federal money to avoid supporting groups that offer abortion. Planned Parenthood says it does not use any government money for abortions.

Texas is the first state to appeal to a more conservative White House to restore the funds. The federal government has historically declined to provide Medicaid dollars to states that don’t allow patients to choose between “any willing provider.” Texas is asking for a change in that position.

As part of its “Medicaid Nation” series, Kaiser Health News is examining the far-reaching impact of Medicaid — which has expanded its services in the past decade — and how millions of American households routinely access health care through its programs.

The provision that covers only family planning is a tiny part of Medicaid, which now serves about 74 million Americans. But it is seen by advocates as a vital way to avoid unwanted pregnancies and for states to save money by reducing Medicaid-covered births and coverage for infants and children.

Nationally, about 2.8 million people were enrolled in the coverage last year, according to a Kaiser Health News survey of state Medicaid officials. California alone had 1.8 million people in the program.

“This is expanding Medicaid to cut Medicaid,” said Elizabeth Momany, associate research scientist at the University of Iowa. “If you avert one childbirth, you save quite a bit,” she said, noting that children on full Medicaid remain in the program for at least five years after birth, on average.

Medicaid began in 1965 as a way to provide for poor children, their mothers and people with disabilities. Maternal benefits are a key part of traditional Medicaid. It pays for half of all U.S. births and covers 45 percent of children under the age of 6.

The federal government encourages the benefit limited to family planning— which does not include physician visits or hospital care — by covering 90 percent of the cost. In contrast, Medicaid covers births and related costs at 50 to 74 percent, with states picking up the rest of the tab.

The cost savings help explain why the family planning program is popular among states. Even some of those most opposed to the expansion of Medicaid under the Affordable Care Act — including the entire Southeast — largely take part in the Medicaid family planning program. North Carolina, South Carolina, Alabama and Florida rank in the top five by enrollment, behind California, the Kaiser survey found.

“For two decades, states across the country, red, blue and purple, have expanded Medicaid eligibility for family planning services because doing so helps people to avoid unintended pregnancies and to plan and space wanted pregnancies,” said Adam Sonfield, senior policy manager at the Guttmacher Institute, a reproductive health research organization that supports abortion rights. “In the process, that has also been proven to save the state and federal governments many millions of dollars.”

While eligibility and benefits vary by state, the family planning programs generally provide free coverage for a wide array of contraceptives, including birth control pills and long-acting implants. Some also provide checkups, assistance in kicking tobacco, cancer screenings and testing for sexually transmitted infections.

In family planning programs around the country, services are generally provided by Planned Parenthood clinics, county health departments, federally funded community health centers and private physician offices. Critics say prohibiting Planned Parenthood from family planning programs would hurt patients’ access to services.

Eligibility in some states starts as early as age 12, while others automatically enroll women in the programs after their maternity benefit expires, typically 60 days after giving birth.

In California and some other states, both men and women are eligible, but women make up the vast majority of the enrollees.

North Carolina Medicaid officials estimate the program saves the state about $15 million a year, according to spokesman Cobey Culton. 

Alabama has also seen savings. Kari White, a health policy professor at the University of Alabama at Birmingham, said the program covers about 120,000 women in the state with income levels below 141 percent of the federal poverty level, or about $17,000 for an individual.

An evaluation she conducted for the state last year found the birth rate for women enrolled in the program was one-third of what would have been estimated without the coverage.

“It helps to save Medicaid dollars overall to have these programs,” White said. 

Even the Trump administration, which is seeking to reduce the number of adults on Medicaid rolls, signaled its support of the family planning program in late December when it approved a 10-year extension of Mississippi’s program.

California’s program — called Family Pact (Planning, Access, Care and Treatment) — covers people with incomes up to 200 percent of the federal poverty level (about $24,000) who don’t have other sources of family planning coverage.

“It provides a very essential public health benefit to all Californians who otherwise wouldn’t get these services,” said Claire Brindis, director of the Philip R. Lee Institute for Health Policy Studies at the University of California-San Francisco, who evaluated California’s program.

A big reason California’s enrollment is so much higher than other states, in addition to its much larger population, is that undocumented immigrants can also receive the services, although their care is paid for only with state funds. 

Marta Mateo of Los Angeles is using the family planning program for a tubal ligation to prevent another pregnancy.

“I’m ready to have my tubes tied,” she said in the lobby at Eisner Pediatric & Family Medical Center as the youngest of her four children slept in her arms. “I don’t want any more babies.”

Mateo said she’s grateful for the coverage because her factory job doesn’t offer it, and she can’t afford to buy it on her own.

“I just don’t have the money for that,” she said. “This is a good opportunity for us to get care.”

Nationwide, the number of women covered by the Medicaid family planning program dropped from 3.8 million in 2013 to last year’s 2.8 million, as many people gained other coverage through the Affordable Care Act, according to the KHN survey and interviews with state officials. The enrollment decline was also due to several states discontinuing the program.

Three states that expanded Medicaid under the ACA dropped the program — Michigan, Illinois and Ohio. But the Medicaid expansion covers women up to 138 percent of the federal poverty level, which is an annual income of about $16,700 for an individual, while the family planning programs had an average eligibility level of 185 percent of federal poverty level, or $22,400.