A 78-year-old Vermont mother of four who helped change Medicare coverage for millions of other seniors is still fighting to persuade the government to pay for her own care.

Glenda Jimmo, who is legally blind and has a partially amputated leg due to complications from diabetes, was the lead plaintiff in a 2011 class-action lawsuit seeking to broaden Medicare’s criteria for covering physical therapy and other care delivered by skilled professionals. In 2012, the government agreed to settle the case, saying that people cannot be denied coverage solely because they have reached a plateau and are not getting better.

The landmark settlement was a victory for Medicare beneficiaries with chronic conditions and disabilities who had been frequently denied coverage under what is known as “the improvement standard” —a judgment about whether they are likely to improve if they get additional treatment. It also gave seniors a second chance to appeal for coverage if their claims had been denied because they were not improving.

Jimmo was one of the first seniors to appeal her original claim for home health care under the settlement that bears her name. But in April, the Medicare Appeals Council, the highest appeals level, upheld the denial.  The judges said they agreed with the original ruling that her condition was not improving — criteria the settlement was supposed to eliminate.

After running out of options appealing to Medicare, her lawyers filed a second federal lawsuit in June to compel the government to keep its promise not to use the improvement standard as a criterion for coverage.  They are asking Medicare to pay for the home health care that Jimmo received for about a year beginning in January 2007.

“There was really no expectation that she would improve — she was getting skilled nursing and home health care to maintain her condition and reduce complications,” said Michael Benvenuto, director of Vermont Legal Aid’s Medicare Advocacy Project, who has filed review requests for 13 other seniors.  “It shows there may be real problems with implementing the settlement at the very highest level.”

In the settlement, Medicare officials had agreed to rewrite Medicare’s policy manuals to clarify that as long as patients otherwise qualify for coverage — for instance, they have a doctor’s order for skilled care to preserve their health or to prevent or slow deterioration —Medicare must pay for therapy and other care at home, in a nursing home or office.   Each of those settings has additional restrictions: for instance, nursing home coverage still requires a prior three-day hospital admission, and there are dollar limits (with exceptions) on physical, occupational and speech therapy.

They also agreed to educate providers, billing contractors and appeals judges about the change.

Medicare officials confirmed the settlement’s review process puts appeals into the regular appeals system,  but they would not say how many requests have been received or approved.

People shouldn’t have to decline in order to get the care they need.

Judith Stein, executive director of the Center for Medicare Advocacy

Nearly five million Medicare beneficiaries received physical, occupational or speech therapy in 2011, with an average of 16 visits, according to the Medicare Payment Advisory Commission, an independent group that advises Congress.

The council’s decision makes no sense to Judith Stein, executive director of the Center for Medicare Advocacy,  which filed the original class action lawsuit with Vermont Legal Aid  and helped negotiate the Jimmo settlement.

“People shouldn’t have to decline in order to get the care they need,” Stein said. “It is ironic and also not unusual for people to find themselves in that circumstance. We are unfortunately finding providers are still reluctant to provide care because they are so accustomed to Medicare denials based on a need for improvement.”

She recommended that seniors or their families get the center’s free “self-help” packet and contact her if they still have problems accessing care at improvement@medicareadvocacy.org.

The Parkinson’s Action Network, one of the seven advocacy groups that had joined the original Jimmo lawsuit, still receives several calls a week from patients who are told Medicare won’t cover their care because they are not improving.  But Parkinson’s disease is an incurable chronic degenerative neurological condition.

“Just maintaining function is a victory,” said Chief Executive Ted Thompson.

Joshua Cohen, a physical therapist with a small practice near Chapel Hill, N.C., is worried claims he submits to Medicare may still be questioned or denied. When patients are not progressing, he tells them they can continue therapy if they sign Medicare’s “advanced beneficiary notice of non-coverage” form, promising to pay the bill if Medicare doesn’t. “That in and of itself often prevents further therapy,” he said because patients are afraid they will end up with the bill.

Gabe Quintanilla, a lawyer for the city of San Antonio, refused to sign the non-coverage forms when he was told at least seven times this year that his 92-year-old mother’s physical and speech therapy would end because she was not improving following her hospitalization for a stroke.  One doctor predicted she would continue to decline and suggested hospice care.

“The only reason I was able to keep my mother’s therapy going is because I sent a copy of [the] Jimmo [settlement] to her doctor, her insurance company and the home care agency,” he said.   His mother has a Medicare Advantage plan, a private health insurance program that must also comply with the settlement.  He discovered it “by accident,” while researching legal options on the Internet.

His mother eventually left the hospital and received follow-up care at a nursing home before returning home. Despite the dire predictions, what began as maintenance therapy has led to unexpected, if slight, improvements.

In a video he posted on YouTube, he leans in close to share his prediction that the Spurs are going to beat Portland. And she smiles, pleased that her favorite basketball team won’t let her down.

“The Jimmo settlement saved my mother’s life,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Family medicine doctors are joining forces to win a bigger role in health care – and be paid for it.

Eight family-physician-related groups, including the American Academy of Family Physicians, have formed Family Medicine for America’s Health, a coalition to sweeten the public perception of what they do and advance their interests through state and federal policies.

The launch of their five-year, $20 million campaign Thursday comes at a critical time for primary-care doctors. Thanks to the health law, millions more people can seek care with newly gained insurance.  But there’s growing debate about whether nurse practitioners and physician assistants should provide a lot more basic care, either on their own or as part of clinics sponsored by pharmacies or other businesses. Some major doctor groups have challenged the ability of lesser-trained medical professionals to independently treat patients.

Glen Stream, chairman of the new coalition, said that it plans to focus on:

– Paying primary-care doctors for more than just office visits, including the time they spend making referrals to specialists, checking in with patients about treatment regimens, being available 24/7 and calling and emailing patients. Specialty doctors generally are paid more for their time and for procedures they do.

– Creating additional incentives for medical school students to go into primary care and tying medical schools’ federal funding to the primary care training they provide.

– Making electronic health records less burdensome, freeing more time for conversation with patients.

– Getting doctors to switch to a team-based, patient-centered “medical home” format, with a payment structure that reflects the work that goes into coordinating care for a patient.

– Persuading private and public employers with health plans to lean on insurers to increase compensation for primary care services.

“If we don’t spend enough on primary care, outcomes in the future will suffer because much of the chronic diseases that drive spending are preventable,” said Stream, a family physician and former president of the American Academy of Family Physicians. He added that larger employers could negotiate higher payment rates for primary care when picking an insurance company.

While the campaign is touted as helping patients, it’s also about asserting that family doctors are important.

“It’s always a question of what motivates groups to do these kind of campaigns — is it looking out for patients or your own interests, and generally it’s a combination of both,” said Atul Grover, chief public policy officer at the Association of American Medical Colleges.

In September, the American Academy of Family Physicians announced recommendations on medical school funding, saying teaching hospitals should provide more primary care training as a condition of continuing federal funding at the same level. But Grover said the kind of training medical students receive doesn’t drive what type of doctor they become. The reimbursement system – which typically pays specialists at higher rates – is more important.

Grover also said that while primary care is important, taking funding away from specialty training isn’t necessarily a solution because an aging population will need more specialty care.

Other groups in the coalition are the American Academy of Family Physicians Foundation, American Board of Family Medicine, American College of Osteopathic Family Physicians, Association of Departments of Family Medicine, Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Take a break from worrying about Ebola and get a flu shot this fall. While the Ebola virus has so far affected just four people in the United States, tens of millions are expected to get influenza this season. More than 200,000 of them will be hospitalized and up to 49,000 will likely die from it, according to figures from the Centers for Disease Control and Prevention.

A new HuffPost/YouGov poll of 1,000 adults found that the flu is perceived as only slightly more threatening than the Ebola virus, however. Forty-five percent of people polled said that the flu posed a bigger threat to Americans than Ebola, but a substantial 40 percent said it was the other way around. Fifteen percent said they weren’t sure.

“Ebola is new, mysterious, exotic, highly fatal and strange, and people don’t have a sense of control over it,” says William Schaffner, a professor of preventive medicine and infectious disease at Vanderbilt University.

Influenza, on the other hand, is a familiar illness that people often think they can easily control, Schaffner says. “They think, ‘I could get vaccinated, I could wash my hands’ and prevent it.”

Yet that familiarity may lead to complacency. Flu shots are recommended for just about everyone over six months of age, but less than half of people get vaccinated each year.

Now there’s even more reason to get a shot. The health law requires most health plans to cover a range of preventive benefits at no cost to consumers, including recommended vaccines. The flu shot is one of them. (The only exception is for plans that have been grandfathered under the law.)

The provision making the vaccine available with no out-of-pocket expense is limited to services delivered by a health care provider that is part of the insurer’s network.

Depending on the plan, that could include doctors’ offices, pharmacies or other outlets.

Medicare also covers flu shots without patient cost sharing.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.