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Medicare Settlement and At-Home Care

Jimmo vs. Sebelius, takes away the “improvement standard” that left out chronically ill and elderly patients because they hoped to maintain their condition, rather than get better with care.

This Medicare settlement may save people from needing more expensive care, such as in hospitals or nursing homes, and makes it easier for people to qualify for at-home skilled nursing.

For example, a nurse who monitors someone with diabetes or a heart condition to make sure he takes his medications and has good vital signs may keep him from needing emergency care.

Allowing more patients to receive home health care services could cost the government more initially, but several experts say it could save money in the long term. 

In her article posted on USAtoday.com, Medicare Settlement Would Expand At-Home Carewriter Kelly Kennedy explains that under the settlement, the Department of Health and Human Services agreed to change guidelines to allow skilled nursing and therapy services for people who cannot prove that their medical conditions can improve.  This does not include basic care such as cooking or bathing.  More than 10,000 who were denied skilled care before the settlement will also be allowed to try again.

Kenneth Thorpe, chairman in the department of Health Policy and Management at Emory University states, “Ninety-five percent of health care costs come from those with multiple chronic health issues, and monitoring those could substantially lower costs.”

Health and Human Services spokeswoman Erin Shields Britt explains that under this proposed settlement, Medicare policy would be clarified so that claims from providers will be reimbursed consistently and appropriately.

And, Joanne Lynn, director of the Center for Elder Care and Advanced Illness at the Altarum Institute, commented, “The decision makes it clear that Medicare has to cover skilled services when the aim is to maintain function or to slow the rate of decline and that is huge.”

Medicare patients often leave the hospital with no follow-up care, and one in five head back to the hospital within one month of admission, often because they don’t understand doctors’ instructions, they take medications that don’t interact well with each other or they simply don’t have what they need at home. That costs Medicare billions of dollars every year. Calculating savings, however, isn’t a simple matter.

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