Benjamin C. Hamilton, an amputee, had hoped for faster progress on therapy, which was reduced. (Dudley M. Brooks — The Washington Post) Related Links Medicare Special Report Health Care Issues Section

By David S. Hilzenrath
Washington Post Staff Writer
Monday, May 10, 1999; Page A1

This year, an estimated 200,000 elderly or disabled patients will pay for a little-noticed cut in Medicare benefits that lawmakers tucked into the Balanced Budget Act of 1997.

At the time, politicians boasted of simultaneously saving Medicare from financial ruin and adding popular benefits such as mammograms and Pap smears. Yet generally not discussed was that they also placed a $1,500 annual cap on physical and speech therapy combined, and a second $1,500 limit on occupational therapy.

As many patients are discovering, the caps kicked in on Jan. 1, potentially impairing patients' rehabilitation from illness and injury. Patients recuperating from strokes, amputation and head trauma, as well as those grappling with degenerative diseases such as Parkinson's and multiple sclerosis, are exhausting their annual benefits and losing access to therapy.

Many patients can't afford the additional out-of-pocket expenses and are instead ending their therapy prematurely.

After Ruth M. Irwin, 67, of Pinellas Park, Fla., lost a leg to diabetes complications, physical therapy helped her walk again with the aid of an artificial limb and a pair of four-pronged canes. But Irwin stopped her three-times-a-week visits to a rehabilitation center in February after she hit the $1,500 annual limit. She had not achieved her goal of walking with only one cane and freeing the other hand.

Without regular therapy, Irwin said she lost much of her strength and balance; soon, she again needed a walker. In early April she tripped over a curb and broke three ribs. Now she is homebound and in a wheelchair.

"If I had been taking therapy, that wouldn't have happened to me," said Irwin, a retired office manager living on Social Security. "I'm mad that the country's doing this to me at this late stage in my life."

The limits on rehabilitation services were projected to save the federal health insurance program for the elderly and disabled $1.7 billion over five years, part of $115 billion over five years that lawmakers and the president wrung from Medicare to keep it solvent. Inserted by Rep. Bill Thomas (R-Calif.), chairman of the health subcommittee of the House Ways and Means Committee, the limits were intended to curb a rapidly growing expense. The Clinton administration and Democrats on the House subcommittee went along with them.

"Many of the decisions that we made were probably a bit more arbitrary than we would have liked," Thomas said in an interview, adding that Congress was handicapped by a lack of data from Medicare on the potential effects.

"I think the data is beginning to indicate that a thorough reexamination is appropriate, and we're in the process of doing that," Thomas said.

Some lawmakers predicted trouble for some elderly patients, but the imperative to balance the budget towered above other concerns.

"We were all in this together that costs were . . . totally running out of control and that there was significant abuse" of the therapy benefit, a Democratic House aide said. Yet, "everybody who looks at it knows it's bad health policy," the aide said.

An estimated 1 in 7 Medicare beneficiaries who seek rehabilitation therapy, or about 200,000 people, will reach one of the caps this year, said Stephanie Maxwell, a senior analyst at Congress's Medicare Payment Advisory Commission.

There are exceptions to the policy: It doesn't involve hospital patients, beneficiaries receiving home care, or nursing home patients in the first 100 days of a post-hospital stay covered by Medicare.

There also are ways of getting around the limits, at least in theory. Unless patients are in a nursing home, they can avoid the caps by seeking treatment at a hospital outpatient clinic. For at least the rest of the year, they also have the option of continuing therapy by moving from clinic to clinic, using $1,500 of treatment at each one. The federal Health Care Financing Administration is allowing that strategy temporarily because its computers are not yet equipped to enforce the law.

For some patients, though, neither of those options is practical. At best, shifting from one therapist to another sacrifices continuity of care, patients and therapists said.

Dorothy Delacroix of Bethesda, who has suffered a series of strokes and a recent bout of pneumonia, wanted to resume treatment at a National Rehabilitation Hospital satellite clinic in Bethesda, where she had been treated earlier this year. Delacroix, 73, said she hopes to regain the ability to walk to her mailbox and stand in her kitchen long enough to make lunch. But she has exhausted her $1,500 benefit at NRH, and recently shifted to Suburban Hospital for a six-week physical therapy regimen prescribed by her doctor.

The new therapist spent part of Delacroix's first appointment reviewing her medical history, something her former therapist already knew. Initially, the treatment "didn't work so hot because it was a new personality" and they had to learn how to work together, said Delacroix's husband, Gene.

Irwin, the Florida amputee, said it was too difficult for her to get to another physical therapy clinic or to manage the distance from the parking lot to the entrance of her local hospital.

Some therapists have begun rationing treatment to make the $1,500 last longer, but that approach entails another set of costs and issues.

Multiple sclerosis patient Avis C. Campbell of Alexandria, 44, said she hadn't been to therapy in about two weeks and that she has had difficulty keeping up with her exercises. "I don't do it on my own like I should . . . because you lose your balance and stuff," Campbell said. "At the therapist, they're there to catch you if you fall or to hold you up."

"Basically, we have been unable to give adequate therapy to neurologically impaired patients," said Linda Sigmund, a Fairfax neurologist. "They haven't been able to recover fully because of the caps."

Benjamin C. Hamilton, 79, of Derwood, Md., whose leg was amputated below the knee in September, believes he would have made faster progress if his therapist hadn't reduced the frequency of his visits from twice a week to once a week. Early in the new year, Hamilton recalled, his therapist told him, "‚'We're going to have to cut back, because we're limited to so many dollars.'‚" As a result, "some things we didn't get to at all," Hamilton said.

Patients say paying out of pocket for therapy can be prohibitive – or simply not worth the price.

Retired ophthalmologist Bernard Gerwin, 97, recently used up his $1,500 physical therapy allotment at the Marriott Brighton Gardens assisted living facility in Bethesda – and he was shocked to learn that it would cost him $45 for every 15 minutes of therapy, or $180 an hour, to continue.

Gerwin considered the charge "exorbitant" and stopped therapy. "I can do my own exercises," Gerwin said.

Some nursing homes are still providing therapy to patients who have exhausted their coverage, yet that About 200,000 Medicare patients who seek rehabilitation therapy will reach one of the limits this year on benefits.

takes money away from other nursing home residents and services.

The facilities may not have much of a choice. If they want to do business with Medicare, "nursing

homes are still required to provide their patients with all necessary care, including rehabilitation," said Robert Berenson, director of the Health Care Financing Administration's Center for Health Plans and Providers.

Businesses as well as patients have felt the squeeze. For companies that provide rehabilitation therapy under contract to nursing homes, the Balanced Budget Act delivered a double whammy. Even before the limits kicked in this year, the Balanced Budget Act began imposing a new payment system on skilled nursing facilities that has sharply reduced demand for therapy services.

Integrated Health Services, based in Owings Mills, eliminated 1,000 jobs in December, and its stock has lost 88.6 percent of its value in less than a year. NovaCare Inc., based in King of Prussia, Pa., has cut therapists' salaries by 25 percent and laid off more than 5,000 employees.

At a meeting convened April 23 by the agency, which runs Medicare, therapists and nursing home representatives denounced the caps as a meat-cleaver approach to budget cutting.

The Ways and Means Health subcommittee initially set the limits at $900, but they were raised to $1,500 in conference with the Senate.

Lawmakers settled on the dollar limits "not because it was sound health policy but because it was the number that was needed" to balance the budget, a Democratic congressional aide said.

Medicare spending on therapy had more than doubled from 1990 to 1993, and the General Accounting Office, a congressional watchdog agency, warned that providers were exploiting the program.

In retrospect, lawmakers might have achieved their budgetary goals without the therapy limits. Overall, Medicare spending has slowed much more than Congress anticipated when it adopted the Balanced Budget Act.

Even as the therapy provision was being written, members of Congress saw it as flawed. The law gives the secretary of health and human services until Jan. 1, 2001, to propose a revised approach that takes into account the needs of individual patients. Since the law was signed, some lawmakers have proposed repealing the caps.

Meanwhile, critics say the savings on therapy could be somewhat illusory if the caps cause patients to linger in nursing homes or contribute to more injuries.

The triple rib fracture that incapacitated Irwin is a case in point. Since the mishap, Irwin has been receiving regular visits by a registered nurse and a home health aide, all at Medicare's expense.

She's also receiving physical therapy three times a week, because now that she's homebound,she's exempt from the $1,500 cap.

"It's going to cost them a heck of a lot more if they got to keep me like this for years, until I die," Irwin said.