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| Alejandra Negron, 72, was helped by her daughter Carmen Hernandez at Ms. Negron’s apartment in Manhattan on Monday. Credit Hiroko Masuike/The New York Times |
Widowed
and disabled after a lifetime of New York factory work, including
decades making baby dolls with glue that proved to be toxic, Alejandra
Negron depends on a little help for nearly every step she takes. For
years, she has had just enough help to stay safely in her own tidy
one-bedroom apartment in Manhattan, despite pulmonary disease, asthma, diabetes, arthritis and a heart condition.
Medicaid,
the state and federal health care program for the poor, covers the cost
of a home-care aide during the day, and Ms. Negron’s two daughters and a
granddaughter take turns staying over at night and on weekends, despite
their own jobs and family obligations.
But
last winter, that carefully stitched web of caregiving was abruptly
torn apart by a call from Senior Health Partners of Healthfirst, a
managed care insurance company that has been one of the beneficiaries of
Medicaid’s overhaul of long-term care
for disabled and aged people in New York.
The company informed Ms.
Negron that her home care was immediately being cut to 25 hours a week
from 50, and her aide, the mother of a 7-year-old, was rescheduled to
work from Thursday through the weekend, not Monday to Friday.
“I
panicked,” Ms. Negron’s daughter Carmen Hernandez said, recalling the
scene she found at her mother’s apartment that day. The aide was in
tears, and Ms. Negron, 72, was petrified that she would have to go to a
nursing home. “My mother said, ‘If you put me in a home, I’m going to
commit suicide.’”
“I started to cry,” Ms. Hernandez added. “I didn’t know what to do.”
Now
a detailed report by a coalition of more than 100 nonprofit groups
shows that the crisis in Ms. Negron’s family has been repeated in
hundreds of households covered by Senior Health Partners. Since January
2015, that company and at least two others have been systematically
cutting the hours of home care for their disabled clients, typically
without proper notice or legal justification, the study found. By law,
only a change in a client’s medical condition or circumstance is
supposed to allow a reduction.
The
study was co-sponsored by Medicaid Matters, which is an advocate for
Medicaid beneficiaries, and by the New York chapter of the National
Academy of Elder Law Attorneys. It independently confirms similar
allegations made earlier this year in a federal class-action lawsuit
filed against Senior Health Partners and the New York State Health
Department on behalf of disabled and aged clients threatened with cuts
in home care. And it echoes the patterns explored in articles in The New York Times about the pitfalls of managed long-term care,
which beginning in 2012 replaced a fee-for-service system with a flat
rate for each patient enrolled, regardless of how much care was provided
to them.
The
flat rate “creates a perverse incentive” for Senior Health Partners,
the lawsuit says. “The less care they provide to each individual, the
more they earn.”
Between
June 2015 and December 2015, the study found a sixfold increase in
hearings that challenged home-care reductions. In more than 90 percent
of those 1,042 hearings, the companies lost or simply withdrew proposed
cuts when challenged. Though Senior Health Partners is only one of more
than 20 such plans in New York, serving about 12 percent of managed
long-term care clients, it accounted for 56 percent of those hearings.
Not
counting settlements, managed care companies prevailed only 1.2 percent
of the time. But the report said that many of the most vulnerable
clients had no way to fight cuts, unaware that they could appeal. And
even those who prevailed at hearings have often faced new cutbacks, said
Elizabeth Jois, a lawyer at the New York Legal Assistance Group.
That
was what happened to Ms. Negron, who is one of the named plaintiffs in
the lawsuit. Her daughter turned to Ms. Jois, who appealed. When Ms.
Hernandez, 54, showed up at the hearing to testify for her mother,
taking time off from her job as the newborn screening coordinator at
Mount Sinai Beth Israel, the company withdrew its proposed reduction.
But
in May, despite its own finding that her mother’s condition had
worsened, the company cut her mother’s hours of care to 40 from 50. At a
hearing last week, Ms. Hernandez was astonished when the company’s
lawyer argued that her mother could urinate or defecate in a “pull-up”
diaper and wait in a chair for two or three hours until a family member
could leave work and come to change her.
The decision is pending.
Senior
Health Partners, which calls itself “a not-for-profit managed care
organization sponsored by some of the most prestigious and nationally
recognized hospitals and medical centers in New York,” said it could not
discuss pending litigation.
“Senior
Health Partners’ primary concern at all times is the health and
well-being of all our members, who are among the most vulnerable
citizens of New York,” it added in an emailed statement.
The
State Health Department initially declined to respond to the report’s
findings, citing the litigation, but then issued a general defense of
managed long-term care. It pointed to a survey in which 87 percent of
all members said their plan was good or excellent, and it said that
members could change plans.
But advocates said most plans shun anyone with many needs
and are reluctant to increase hours for patients who need more. The
Legal Aid Society is preparing its own litigation against Senior Health
Partners on behalf of a woman who is in a wheelchair and whose request
for more hours of help was repeatedly denied, even after she was
seriously injured in a fall, said Patricia Bath, a spokeswoman for Legal
Aid.
That
client’s experience reflects Senior Health Partners’ pattern of denying
requests for more home care hours, Ms. Bath added, citing a Legal Aid
review of more than 135 state decisions issued in the past year for
people appealing such denials. Senior Health Partners’ denials have been
overturned 80 percent of the time, she said.
At Ms. Negron’s apartment, Ms. Hernandez fought back tears.
Full Article & Source:
Lives Upended by Disputed Cuts in Home-Health Care for Disabled Patients
This happens alot. Medicare and medicaid provider will rush right in with services, but quickly Medicare and Medicaid quit paying. And as soon as that happens, the provider is gone, leaving the family with nowhere to turn for help. It's very sad.
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