"Take
care of your health; you have no right to neglect it, and thus become a burden
to yourself and perhaps to others."
~ William
Hall
Here follows another episode in my continuing adventure as
unpaid fiduciary agent for a dementia patient dependent upon Medicare and
Medical for her custodial care in a residential skilled nursing facility. When
we last left our patient, her annual re-evaluation for eligibility for Medical
was approved 3 months into the current year. The story of establishing her
financial need would be a hilarious saga of plot twists and missed chances if
wasn’t such a sad and pathetic tale of bureaucratic bungling and ineptitude.
But that was then. In this latest episode, we have at
least two problems. If you count not knowing whether the first two problems are
related, we have three problems.
The first issue is what I’ll call a question of
“coverage”. Such problems are always heralded by an ominously unexplained
“Notice of Action” in which some (usually bad) decision has been made but which is less enlightening about why. In May, we received a NOA instructing us that
because the patient had informed them she was moving to Riverside, her case was
being transferred there. Ok, they explained why, but they were wildly wrong. The
effect would have been to terminate her coverage at her local facility in
September. We called, we wrote, and we
called some more to assure them nobody had ever told them she was moving, that
she could not move from bed to toilet, and accordingly that moving from San Diego to Riverside
was out of the question. We assumed that the matter would be resolved. Foolishly
as it turns out.
When the skilled nursing facility notified us in July the
service was still going to terminate in September we called, and after about 20
minutes on hold we explained to James what had happened. He found the file. He
found the notice and no information about the patient saying she was moving. He also found our written explanation that no move was contemplated. We
believed James when he explained that while he couldn’t personal and directly
fix this matter of the move to Riverside, he would e-mail the authority that
would. He couldn’t copy us on the e-mail for reasons I can only conclude to be
that then I’d have a genuine contact to a real person with real authority and
well, we can’t have that can we? But James assured us we would receive a call
in a few days assuring us that the case would remain in San Diego. All this
was, of course, complete rubbish.
Fool me twice etc. I blame my own naïve faith, coupled
with my exhaustion from trying to deal with these people for my failure to
follow up when the call never came. That, plus a slight degree of bitterness that this shouldn't be my problem to begin with, but I'm the only adult in the room.
So, on September 11 we received a Notice of Medicare
Non-Coverage (NOMNC) from the facility saying the 95-year-old patient’s
coverage would end on September 12. Coincidently, this was the same day the
patient had returned to the facility from the hospital for her latest bout with
COPD, Congestive Heart Failure and an unidentified infection which later proved
to be UTI. No reason was given for this action. I have however, formed two
theories. One is that the case has been moved to Riverside. The
other is that Medical is trying to loosen my already tenuous grasp on sanity in
the hopes that I’ll drink myself to death, not appeal their non-coverage
decision, and the facility can move the patient’s hospital bed out into the
back alley and forget about her. I believe that’s what Medicare would call a win-win since they'd be down two Social Security checks.
This “timely” 24-hour notice included information that if
we wanted to appeal we should do so “promptly” by calling our “Quality
Improvement Organization (also known as a QIO)”. Needless to say, I quickly made
a shaker of vodka martinis with rosewater and lemon syrup before promptly
calling the QIO about appealing the NOMNC. Was told by Maria that we’d be
contacted by a case manager “in a few days”.
It’s too soon to say whether the QIO measures a few days by Medical time
or by actual calendar time.
The next issue is one of “eligibility” i.e. of proving poverty.
Related? Perhaps. Perhaps not. Although
the patient’s financial eligibility for Medical coverage was approved on 2/23/13
for the calendar year 2013, it turns out there is no reason why this issue
shouldn't be raised, say every 15 minutes. Here’s how that went down.
We received not one, but two separately mailed notices
both dated 9/5/13, both from the same local office of the county Health and
Human Services Agency that administers Medical. One was a health insurance
questionnaire I’ve seen, completed and returned not less than three times,
detailing the patient’s Medicare and Medi-gap insurance coverage. (This matter was fake-resolved last February but because since then Medicare first deducts the monthly premium from her Social Security check then promptly refunds it to her, it clearly wasn't real-resolved.) The other was
the equally familiar Verification Checklist
saying we need to “establish/re-establish” eligibility for Medical.
Apparently there is no form letter to re-re-re-establish such coverage. We
dutifully completed the forms, attached the required bank statements
documenting the patient’s poverty. We returned each form in each separate
postage-prepaid envelope to the same place.
Let me conclude by saying that I know the social services
safety net is pretty tattered. Workers are underfunded and agencies are understaffed.
Times are tough and the bureaucrats are more likely to be too busy to read
correspondence and forms than they are to be illiterate morons: although the
results are the same. I expect that the rate of staff turnover exceeds that of
the staff turnover beneath that shade tree outside the Home Depot parking lot.
I expect that idealistic workers with a Bachelor’s Degree in some social
services major and a desire to do some good for their fellow men experience
burnout at rates exceeding that of a cheap cigar. That said, I spent my entire
career as a professional bureaucrat and saw some seriously bad shit. But never,
not even when contracting with CalTrans, have I experienced such a deficiency of coherent consistent practices combined with such pervasive
incompetence.
"Flora,
always tall, had grown to be very broad too, and short of breath; but that was
not much. Flora, whom he had left a lily, had become a peony; but that was not
much. Flora, who had seemed enchanting in all she said and thought, was diffuse
and silly. That was much. Flora, who had been spoiled and artless long ago, was
determined to be spoiled and artless now. That was a fatal blow."
I partly concur with Mr. Dickens that the fatal blow, the perfectly
avoidable change that age brings which is beyond the pale, is to remain as
spoiled as we presumably were when we were young and more like lilies than
peonies; when we were more condensed than diffuse. Age can’t afford to remain
spoiled. You have to come to terms with the fact that the process of aging is
the process of letting go of whatever indulgences you were allowed as a youth.
