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so many doctors, so little care
In 1971, US President Richard Nixon and his friend Edgar Kaiser invented the HMO. Nixon’s Counsel John Ehrlichman explained the President’s support for the HMO:
All the incentives are toward less medical care, because the less care they give them, the more money they make.
When Gwendy, Mom & I met with Mom’s Park Regency case manager Kat on Feb 12, she gave us the vague impression that mom might be able to stay at Park Regency until her next appointment with her surgeon Dr. Shamlou on March 10. She definitely didn’t promise that. And I had the distinct sense that if we could move the appointment up a week and get a less restrictive physical therapy prescription, like Weight Bearing as Tolerated, that mom’s odds would be a lot better. Still, from this meeting I thought we had a little time.
So I was shocked on Wednesday February 17th when mom’s CareMore case manager Nicki Lomeda(sp?) ordered mom’s therapy stopped immediately and ordered her out of Park Regency in 48 hours. As I posted later on Wednesday Ryan filed an appeal with a 3rd party arbitrator, and the appeal was granted a few hours later. Since then I’ve been on the phone for hours each day. Here’s the summary:
Although this order to end mom’s treatment and put her out came much sooner than I thought I’d been led to expect, when I spoke with Kat she wasn’t surprised at all.
While the only thing that Kat had expressed to us last week was mom’s progress in walking, this week the criteria by which mom had been judged “plateaued” and deserving of no further care has apparently been changed to “Bed Mobility.” Kat said that mom’s bed mobility was progressing too slowly and that was why CareMore was ordering an end to all treatment.
By the time I spoke with Kat, Ryan’s appeal had already been approved, but Kat warned me that CareMore could, and would, try to throw mom out every 48 hours. Even if you win an appeal, you only have to face another one.
Kat also offered that it was a good idea for the family to contact mom’s CareMore case manager. She said that HMO’s are not really impressed when a Care Center Case Manager pleads a patient’s case, but sometimes they get scared when families call.
I don’t want to paint Dr. Keisner as the “bad guy” here. She spoke with me for a long time and was sympathetic to mom’s situation. She was kind enough to call from the dog park where her dog did a vastly-better-than-Tiki-ever-would-have-done job of staying out of trouble.
Even so, as best as I understand it, mom’s “care” is not Dr. Keisner’s job. As I understand it, Dr. Keisner is hired by CareMore to do one thing only: write a dismissal order for mom. As best as I understand it, Nicki Lomeda(sp?) mom’s CareMore case manager calls Dr. Keisner every day and asks,
Why is Cecilia Zucman still receiving treatment?
Dr. Keisner explained that Park Regency is a “fringe facility”. By “fringe” I think she meant not a typical part of the CareMore umbrella. Therefore CareMore contracts her medical group to oversee patients there. Dr. Keisner is not mom’s normal CareMore doctor. Dr. Keisner explained that normal doctors have no standing in facilities like Park Regency. She explained that the idea of having a personal physician is long gone. Like financial derivatives, health care in America today is delivered by many fractionated doctors, none of whom are directly tasked with patient “care.”
Dr. Keisner did offer of mom that “she’s in a hard place”. And she repeated what Kat had offered last week, that it’d be a lot better to only break 1 thing at a time.
Dr. Keisner emphasized the distinction between therapeutic needs and custodial needs.
CareMore covers Therapeutic Needs. CareMore does not cover Custodial Needs.
While Dr. Keisner was sympathetic to mom’s situation, she also said that she was “not impressed” with mom’s progress. Mom has now walked down the hallway of Park Regency a couple of times. By “walked” I mean her left hand on a walker-like device, and her right side being held by two therapists. I thought mom actually out of bed and vertical was fantastic news! Dr. Keisner said that walking with 2 people having to hold you is “not impressive.”
As with Kat, Dr. Keisner seemed less focused on walking than on “bed mobility” which she described as “not impressive.” Dr. Keisner wanted to see mom swivel in bed and transfer weight.
Apparently the reason Ryan’s appeal was granted was that mom’s bed mobility had improved in the last couple of days.
Dr. Keisner emphasized that doing the 45 minutes / day of PT that CareMore pays for is insufficient. That mom needs to be working all the other hours of the day too. That even without weight bearing she should still be doing leg lifts and arm lifts and as much as possible. Even though mom can’t put weight on her shoulder, she can still move it and should be doing windmilling or other motion of the shoulder. Any range-of-motion activity is good.
Dr. Keisner said (on Thursday) that she wouldn’t be going to Park Regency on Friday. That she wouldn’t be back (to issue another end-of-coverage) until Monday or Tuesday, and that when she issues the next one mom will have 48 hours to get out.
Dr. Keisner thought that us privately paying to stay at Park Regency, or hiring a private nurse for home, were both expensive options. She thought that once CareMore is able to dump mom, our best option for the remainder of mom’s recovery is a Board & Care Facility.
I asked Dr. Keisner why her orders were so completely opposite from Dr. Shamlou’s orders? She explained that,
Orthopedic surgeons don’t have a clue how HMO’s work.
I spoke with Dr. Shamlou’s Physician’s Assistant Grace. She said that she would order the nerve conduction test re the drop foot on Monday.
I told her that Dr. Shamlou had told Alicia on Feb 11 that he wouldn’t allow mom to be released from Park Regency until she could get in and out of bed by herself, and now Dr. Keisner was ordering mom sent home. Grace did not have a lot to offer on this question.
I asked if mom’s next appointment could be sooner than March 10th in hopes of getting a less restrictive prescription so mom could show more progress to CareMore. Grace said there would be no point in coming in sooner.
I asked if the appointment could be on the 9th or 11th as I teach on the 10th? Grace said Dr. Shamlou was very busy and that wasn’t likely.
Nicki explained that she works with Dr. Keisner (both paid by CareMore) to determine when CareMore can issue a last cover date.
Nicki’s comments were consistent with those from Park Regency’s Kat and Dr. Keisner (all paid by CareMore) that Physical Therapy and Occupational Therapy justify Medicare coverage. Custodial Needs do not.
Nicki said that she issued the Wednesday last cover date because in her judgement mom had already made Maximum Progress and had Plateaued and was incapable of making any further progress at this time.
It turns out that the reason that Ryan’s appeal was approved so fast was that it didn’t actually go through the appeals process. After Ryan filed the appeal Nicki looked at a more recent record record of mom’s bed mobility that stated she had progressed from maximum assistance to moderate assistance and that based on that she had decided to allow mom to stay for another 48 hours.
CareMore is an HMO with annual revenues of US$1.2 billion. They operate in 8 states and have 150,000 patients. That might be revenues of US$8,000/patient/year. CareMore was acquired by Anthem in 2011 with 2 main goals in mind: give Anthem more power in Southern California, and help pave the way for the transition from fee-for-service care to value-based care. I was unfamiliar with the term value-based care. In very brief research, it appears that the current/old model is for physicians to order a lot of tests and procedures which HMO’s then pay them for. Under value-based care physicians will be encouraged not to order tests or perform procedures and then the money saved by not caring for patients will be split between the HMO and the doctors.
Kat and Dr. Keisner both emphasized that I shouldn’t consider CareMore the “bad guy” here. That CareMore only wants to throw mom out the same way that any other HMO would. Although when I shared that with my also elderly next-door-neighbor Laura, she offered that when she had her shoulder surgery she was in a rehab facility for over a month and Kaiser never pushed to evict her.
Bob said that I should request all of mom’s records: medical records, progress notes, therapy records. I asked Nicki from CareMore for records and she was unwilling to give me anything, not even the letters she wrote dismissing mom from Park Regency (which I have never seen). She said that if I wanted documentation I would have to speak to Park Regency. Mom’s Park Regency case manager Kat is already gone for the day (Friday), so that will have to wait till Monday.