Gilroy, CA : Medicare and Medi-Cal Patients Mired In Red Tape : View From A Private Duty Caregiver Serving, Carmel, Carmel-by-the-Sea, Gilroy, Hollister, King City, Marina, Monterey, Pacific Grove, Pebble Beach, Salinas & Seaside, California
A story in the Wall Street Journal said that one of the problems hindering our ability to get a balanced budget is the high cost of caring for people who are eligible for both Medicare and Medicaid (Medi-Cal in California). These dual enrollees now total 9.7 million. Although they account for 16% of Medicare enrollees, they account for 27% of spending. For Medicaid, they total 39% of Medicaid spending, according to the Centers for Medicare and Medicaid services. Combined, they take up $300 billion of the $900 billion spend annually on Medicare and Medicaid. The article says that chronic diseases and heavy use of nursing homes account for the high cost, but that federal officials and health-care professionals say that since people are getting aid from both their State and the Federal Government, it results in mismanaged care and inefficient treatment. It cited the the sad story of Victor Maceyra, a quadriplegic who lived on his own until he toppled out of his wheelchair and was moved into a rehab center. His wound healed and he wanted to go home. However, since Medicare and Medicaid couldn't agree on whether a caregiver coming to his home was a covered benefit or which one would pay for an aide to bathe him and help him use the toilet, he was left in the rehabilitation center for six months. Rather than coordinating benefits, the two programs often end up trying to dump the costs on one another, which results in unfortunate situations like the one Mr. Maceyra faced. Another problem is that reimbursement rates for most services are much lower when Medi-Cal pays than they are for Medicare. When a Medicare patient goes from a hospital to a nursing home, the government pays at an average rate of $422 a day for 100 days, after which Medicaid starts paying at $172 per day, on average. Because of this, nursing homes have a financial incentive to send the patient back to the hospital after 100 days so they can be readmitted and they get reimbursed by Medicare at a rate that is more than double what Medicaid/Medi-Cal pays. This sounds completely unethical, but I'm sure it happens all of the time. The Centers for Medicare and Medicaid Services say that 40% of the hospital visits for these patients are avoidable. What a shame that this situation is so well known and costs taxpayers so much money, and yet little attention has been paid to it. Hopefully legislators fighting over balancing the budget read the Wall Street Journal article and will pay attention to the problem. Money isn't the only issue. Imagine being in Mr. Maceyra's position, wanting to go home for six months and yet being trapped in a nursing home.
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