Aug 122013

After years of dealing with Medicare, I have managed to distill their process into this simple card.

My latest healthcare adventures have involved Medicare. The Scripps Health system managed to get into the act again as well.

Case 1: Inclusion body myositis has left me completely immobile when I sleep at night. This makes me very susceptible to pressure sores. I had developed several and was being treated by a home health nurse who told me she did not think she could make them get better as long as I was sleeping on my old mattress. It was not a cheap mattress by any means, it was a special pressure reducing mattress that cost $500. However, she told me I needed a mattress that would alternate the pressure and thus relieve susceptible areas. It also has a feature called low air loss in which tiny holes let air leak from the mattress and provide a source of oxygen to the skin which is also good for healing. She ordered the mattress through a local supplier to deliver immediately and it worked great. Within a couple of months my pressure sores were nearly gone and the home health nurse said she did not need to come back anymore. Right after that I got a call from the mattress supplier telling me that they were coming to get the mattress because Medicare would not pay for it as long as my sores were better. I said, “But my wounds will come back right away without it.” They assured me they knew that, but that is the way Medicare wants it.

In this case, rather than trying to go through a dysfunctional medical system, I simply went to Amazon, found the same mattress and ordered it. I was expecting it to be many thousands of dollars, since Medicare was paying several hundred dollars a month to rent it. However it actually only costs a few hundred dollars. (And people wonder why the Medicare system is in trouble!) Think about it: during just the time that I was renting the mattress, Medicare paid far more than it would cost to buy a brand-new one. In addition, Medicare’s policy was designed to force me to develop pressure sores all over again at which time I would again have to rent the mattress, and hire home health care again. Medicare pays approximately $200 per visit for the 15 min. that a nurse spends changing a dressing.

Case 2: I have been on a BiPAP system every night for the past 15 years. Not only is my breathing weak because of inclusion body myositis, but I also have severe sleep apnea which was diagnosed by UCSD. Recently Medicare instituted a new “competitive bidding” system which opens up each type of durable medical equipment to bidding from any company anywhere in the United States. This has left out most of the smaller companies that had always given people excellent service. In my case, it meant my provider could no longer furnish me with BiPAP supplies since they did not win at competitive bidding. I either had to go to another local company which has a terrible reputation for bad service or go to one of the out-of-state companies that won the bidding. Neither was a good option. However, if my need could be escalated another level to a constant volume type of BiPAP instead of a constant pressure type, it would not be subject to competitive bidding and I could retain my good supplier. The supplier was certain that I would qualify due to my advanced disease. So I went to the doctor at Scripps who sent me to their pulmonologist who really did not know much about my history but was skeptical as to whether I needed that kind of help. So now before I can qualify, I have to do overnight oximetry which entails two trips to Scripps clinic, one to pick up the equipment and the other to return it. In addition I must have several pulmonary function tests and a blood arterial gas test. Then, depending on the results, he may prescribe the more advanced equipment. All because a bunch of clerks of Medicare think they know how to practice medicine.

Meanwhile, politicians in Washington are arguing about whether Medicare benefits should be cut back. They rarely argue about whether the Medicare system should operate more intelligently.

If you came here from the later article about low air loss mattresses, here is where you get back.

  6 Responses to “The Medicare Help Game”

  1. Mike, that is disheartening and also unbelievable. Have you considered an appeal? Perhaps the nurse should have mentioned strongly in her dismiss notes, that unless you keep using this mattress you will be in worse trouble than before and your situation will never improve due to the dx of IBM.

    Perhaps there is someone out there, family or friend who would bewilling to fight this battle with you? ADA compliance and Medicare rules will not change if we patients remain silent about these problems. In any case I feel for you.

    Would you please send me your phone # and current e-mail to Thanks, Dagmar

  2. […] Unfortunately, as I reported in a post two years ago, once I was getting better, Medicare took away the mattress. As we all know, Medicare takes little interest in preventing illness, preferring to spend much more money once we get sick enough.You can read the entire original story here. […]

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