Inequalities in stroke treatment: health insurance coverage does matter

March 18, 2009 by  

All people are created equal. So why don’t people get equal treatment when it comes to stroke? Does it have something to do with health insurance coverage?healthcare-cost

Ischemic stroke occurs when a blood clot blocks a blood vessel supplying blood to the train. The cutting off of the blood supply (and therefore oxygen) of the brain can lead to death of brain cells which can in turn cause permanent damage. Ischemic stroke is the most common type of stroke and is a major cause of disability.

The state of the art in the treatment of ischemic stroke is the tissue plasminogen activator (tPA). tPA is a thrombolytic or clot-busting agent and is the only drug of its kind which has been approved by the US FDA for the emergency treatment of acute ischemic stroke. It is also a time-critical type of treatment and should be given within 3 hours after the onset of stroke symptoms to be effective. Recent studies even suggest that tPA can still reverse the neurological effects of stroke and prevent death and disability when given up to 4.5 hours after the onset of stroke.

However, a recent study funded by the U.S. Centers for Disease Control and Prevention (CDC) showed that “between July 1, 2005 and June 30, 2007, the tPA treatment national average was 2.4 percent of all ischemic stroke patients in the Medicare database.” Reports of rates of tPA administration in hospitals all over the US range from 0 to 24%. The rate of 2.4% among Medicare patients is seemingly low. In addition, 64% of all hospitals in the US did not administer clot busters to Medicare stroke patients during this time period.

According to a Dr. Lee Schwamm, an associated professor of Neurology at Harvard University

This study sheds important light on a major disparity in acute stroke care delivery…Individuals and agencies responsible for the equitable distribution of healthcare resources need to examine these and other data to identify strategies that will provide adequate acute stroke care to all their citizens.”

There are of course other factors to consider, including the size of the hospitals in question, as well as their geographical location. A previous study on emergency care of stroke victims also found that the following factors can make a difference in the kind of treatment received:

  • the type of hospital (does it have a Primary Stroke Center?)
  • the manner of patient arrival/delivery (walk in vs. ambulance delivery)
  • gender (men get treated faster!)

The issue of health insurance coverage is a major issue in the US.  Read more about the “crisis of the uninsured” in a previous post.

A Rant About Home Health Care Workers

September 29, 2008 by  
Filed under ALZHEIMER'S

Okay, you will forgive me for the rant, but I ran into an old friend this past weekend and she is struggling as she cares for her mom who has Alzheimer’s disease. We shared and compared war stories. It was therapeutic for both of us.

She had some of the same issues that I did. Why is it so hard to find good help? From a Medicare perspective, you must always have a backup plan. Well, I’m thinking, if I had a backup plan, I wouldn’t need a home healthcare worker to come. I’d use my backup.

Then there is the issue of the dependability (or lack thereof) of the home health workers. I mean, once I was heading out of town for a speaking engagement. The aide was to show up at 6:30. 6:30 came and went as did 6:40 and 6:50. Finally, at about 6:55, I called the agency only to find out that the aide was not coming. How nice it would have been to have gotten a phone call. I was so angry that I told the person who answered the phone that SHE needed to come and stay with my mother. Of course, she told me that I was to have a backup, which sent my blood pressure THROUGH the roof. Like I said before, if I had a backup, I wouldn’t have needed their services.

Unfortunately, this happened a lot. Over the course of the time that I cared for my mom, I used four different agencies. All made great promises during the sales and intake period, but in the end, they didn’t differ that much.

Now, we did have a few good Aides. Ms. Florence was one of my favorites. She was always on time, she never, that I can recall, just didn’t show up and if she was going to be a few minutes late, she always called.

I don’t mean to badmouth ALL home health care workers. There are probably some good ones out there. So, let’s do this. Please tell me your GOOD stories. Show me that mine was an isolated experience. Tell me about the angels that are helping you to care for your loved one. I know they are out there and I think it would do us all good to hear something positive as we battle this monster called Alzheimer’s disease and all that it brings with it.

The Legal Rights of Diabetics in the Workplace

July 7, 2008 by  
Filed under DIABETES

Your rights as a diabetic are covered by the laws listed below. Be a smart consumer and review them.

There won’t be a quiz later–but please consider this a jumping off point to advocacy.

If you are unable to self-advocate then it is important that you utilize your diabetes managment team, personal advocate as discussed in the Battling Diabetes archives.

The Americans with Disabilities Act of 1990: Basic guidelines of the ADA include:

· Employers may not discriminate against a person with diabetes

· Employers must provide “reasonable accommodations” in the workplace for qualified employees with a disability.

· An individual with a disability must be able to perform the “essential functions” of the job with or without reasonable accommodation.

· Employers may ask only job-related medical questions.

· Employers will treat all employees the same.

What is reasonable accommodation? It requires employers to modify an employee job responsibilities and or hours for example so they may check their blood sugar or eat at reasonable intervals. This may include modification of work equipment (for visual retinopathies for example) or allowing an employee to come in late and make up the hours during medical treatments. Employers are not required to make changes that would require an undue hardship on the business.

For Questions and Answers about Diabetes in the Workplace and the Americans With Disabilities Act please see this excellent fact sheet provided by the Equal Opportunites Commission.

Report violations of the ADA to the Equal Employment Opportunities Commission, (EEOC), within 180 days of the incident.

Statistics from the EEOC, “In Fiscal Year 2006 EEOC resolved 15,708 disability discrimination charges and recovered $54.4 million in monetary benefits for charging parties and other aggrieved individuals (not including monetary benefits obtained through litigation).”

The Rehabilitation Act of 1973 prohibits employers from discriminating against employees because they have cancer. This act only applies to employees of the executive branch of the federal government, as well as private and public employers who receive public funds. The Congressional Accountability Act prohibits the same discrimination practices in the legislative branch of government. Acts of discrimination in the executive branch of the federal government must be reported to the EEOC within 45 days of the incident.

The Family Medical Leave Act of 1993: The FMLA allows an employee to take unpaid leave due to a serious health condition that makes the employee unable to perform his job or to care for a sick family member or to care for a new son or daughter (including by birth, adoption or foster care). For cancer patients, this can mean up to twelve weeks of unpaid protected leave.

Guidelines to be covered under FMLA:

You must be employed for 12 months or 1,250 hours prior to requesting leave and your work site employer must have at least 50 employees.

Advances have been made against discrimination against diabetics thanks to the American Diabetes Association.

For example the ADA overturned bans that prevented diabetics on insulin from flying private plans or from driving commercial vehicles on interstate highways. The systems now in place evaluates each person on a case-by-case basis. While diabetics are still unable to join the military or fly commercial planes the National Fire Association now allows evaluation of potential fire fighters on an indiviual basis.


The New York Times, December 26, 2006. Diabetics Confront a Tangle of Workplace Laws.

“Doctors, …say that with improved medications and methods of self testing blood sugar, most diabetics can do almost any job if they properly manage their illness. Yet myths about the disease persist, advocates say, leading many companies to shun diabetic employees.”

Patient Advocate Foundation: a non-profit national organization that seeks to safeguarding patients through effective mediation assuring access to care, maintenance of employment and preservation of financial stability relative to their diagnosis. Besides providing information on legal issues they also provide personal assistance.

“Patient Advocate Foundation offers assistance to patients with specific issues they are facing with their insurer, employer and/or creditor regarding insurance, job retention and/or debt crisis matters relative to their diagnosis of life threatening or debilitating diseases.”

Reconstruction After Breast Cancer – No Good Choices

May 19, 2008 by  
Filed under HEALTHCARE

An article in my local newspaper makes me wake up and take notice of a real problem for women who, after breast cancer surgeries, wish to have their breast(s) reconstructed.

Mind you — we aren’t talking about breast enhancement surgery. No discussion of “boob jobs” here.

We’re talking about women who have had their breasts removed to remove cancerous cells, and who simply want to have additional surgery to reclaim as much of their femininity as they think they need to feel “whole.”

(Men — if you have trouble with this — picture losing your most manly appendage to cancer. Would you want a reasonable facsimile to replace it?)

In the United States, by federal law, a woman has a right to ask for reconstruction, and, by law, her insurance must pay for it. Sort of. Even Medicare or Medicaid must pay for it. Sort of.

The problem is, like with any medical service or procedure, these companies tell the physicians and surgeons what they will pay them, without regard to what those physicians and surgeons charge.

Think of that this way: it would be like you telling your auto mechanic what you will pay for repairs on your car, without regard to what your auto mechanic charges. Sounds like a great idea, right?

But — the problem is that at a certain price, your auto mechanic would just refuse. If you didn’t offer enough money, and if someone else offered more, then your mechanic would do the work for the person who was going to pay him more. That’s his choice.

And that’s how plastic surgeons, the ones who do breast reconstruction, look at it, too. Depending on how much cancerous breast tissue needs to be removed, the reconstruction surgery can take 5 to 11 hours. On average across the US, plastic surgeons charge $9300 per breast. Medicare and Medicaid reimburse at only $600. Is it any wonder that plastic surgeons won’t take breast reconstruction cases?

Even private insurance only reimburses a maximum of 80 percent — meaning — if both a woman’s breasts need reconstruction, then it will cost her more $5000 or more (don’t forget — the surgeon’s fee is only part of the cost. She must still pay for the hospital stay, meds, and all the other aspects.)

And some plastic surgeons will not work with private insurers either. If a woman wants the additional surgery, she needs to pay out of her pocket first ($18,600!) — and hope to get reimbursed by her own insurance later.

Of course, this becomes a very easy way to divide the haves from the have-nots…. and it made me wonder what would happen if we had a national health plan. Would it solve the problem?

Yes and no.

I looked to Canada’s national health coverage to see what the situation is there for women who want reconstruction surgery. From what I can learn, all Canadian women who choose reconstruction post breast cancer surgery can have it. It costs them nothing beyond what they are already paying into the system through their taxes — BUT — they have to wait up to two years before they get their “turn.”

And I believe the Canadian “haves” — the women who prefer to have the surgery immediately — are coming to the US to pay to have it done. Which, of course, means that those American plastic surgeons don’t have time to reconstruct the breasts of the have-nots in the US. They are busy being paid in cash by our Canadian counterparts.

The answers? No easy ones. No good choices. We Americans need to ask ourselves… is it better to pay cash and have the surgery immediately? Or is it better to wait for awhile and have it taken care of for us?

Or do we even have choices at all? I know I couldn’t afford it. Can you?

Medicare Made Simple

April 23, 2008 by  
Filed under ALZHEIMER'S

In battling healthcare issues in general and Alzheimer’s disease specifically, it’s important to know and understand Medicare and/or your private insurance coverage. 

What is Medicare?  Medicare is a government program that provides healthcare insurance coverage for Americans who are 65 years of age and older.

Medicare, like most insurance, does not pay 100% of medical costs. 

Medicare pays about 50% of medical costs for seniors.

In general, Medicare pays for: 

  • Hospitalization, doctors, some nursing care, some prescription drugs, and medical equipment and supplies.

Medicare has four main parts: A, B, C & D

  • Part A includes coverage for hospitalization, some skilled nursing facility/home health care, and hospice (someone has called hospice, the best kept secret in Medicare.  I am planning a series of posts on this important coverage)
  • Part B includes coverage for doctor’s services and outpatient care including: X-rays, lab work, physical and occupational therapy, some home health care and some preventive screenings.
  • Part C (sometimes called Medicare Advantage) is Medicare received via an HMO (Health Maintenance Organization), which is a privately managed care system.  Coverage can also be received through a PPO (Preferred Provider Organization). 
    • The important aspect of this plan is that it includes all of the benefits of Parts A and B as well as some additional coverage from the private plan.
    • The caveat of this plan is that it limits WHERE and HOW members receive care
  • Part D consists of private insurance plans that partially cover prescription drug costs.

Who is Eligible

In short, citizens or permanent residents of the United States who are 65 years of age or older qualify for basic Medicare benefits.

Eligibility for Part B coverage-All United States citizens and legal residents over 65 years old are eligible.  If, however, a person has been receiving Social Security disability for two years OR has a chronic kidney disease, they may also be eligible. 

How Do You Enroll for Medicare?

Parts A and B

If a person is receiving Social Security benefits of any kind, they will be automatically enrolled in Parts A and B. They should receive Medicare enrollment cards and information in the mail three or so months prior to their 65th birthday.

If it doesn’t happen automatically, then you can go to the local Social Security office and sign up.

You can also go to the Medicare site and complete the online enrollment form.

Parts C and D

These are optional coverages and enrollment is handled via the specific HMO or PPO that they want to be enrolled in.

Here are a few resources to help you along the way as you deal with Medicare information gathering and enrollment. (click on medicare)

Information for this post was gathered from the above links and my personal experiences.

Do You Need an Elder Law Attorney?

April 22, 2008 by  
Filed under ALZHEIMER'S

 Caregivers in general and caregivers of Alzheimer’s patients specifically need to evaluate their legal needs. This is best done earlier versus later in terms of the progression of Alzheimer’s disease.  Yesterday, I talked about Power of Attorney (POA).  There really isn’t a question here as to if you, as a caregiver should get power of attorney, the question is when; and the answer (again) is sooner rather than later.

It’s not quite as simple when it comes to using the services of an Elder law attorney.  So, I’ll spend a little time talking about:

  1. What an Elder Law attorney is
  2. What an Elder Law attorney does
  3. And when an Elder Law attorney is necessary

What an Elder Law Attorney Is:  An Elder Law attorney is an attorney that specializes in issues that are germane to senior citizens.

What an Elder Law Attorney Does:   Elder law attorneys, as they practice areas of law that impact the aging, basically handle three major categories. These are the basic categories included in the practice of elder law:

  1. Estate planning and administration (taxes included)
  2. Medicaid, disability, long term care issues
  3. Guardianship, conservatorship and fiduciary administration

The name hints at what they are and what they do. So, let’s explore whether or not you need an Elder law attorney.

  1. Will  your loved one become disabled over the next few years?
  2. Does your loved one have an estate?  Not in the sense of a sprawling multi-million dollar mansion, but property, a savings account, maybe an IRA or CD’s.
  3. Does your loved one have grandchildren that he or she would like to help financially?
  4. Will your loved one need long term care insurance?
  5. Does your loved qualify for Medicare or Medicaid?

If you answered “yes” to any of the above questions, then you should seriously consider talking with an Elder law attorney.

Some additional considerations:

  • Social Security Benefits
  • Other benefits
  • Veteran’s issues

Many Elder law attorneys give free first time consultation services. To locate one in your area, contact your local senior center or check out Elder Law Answers on the web.

Elder Law Answers is an informative site, with a wealth of valuable information.  The site also has an active forum with many of the major categories and several specific issues/questions covered.

If there is any question about your loved ones assets, benefits or or future planning, see an Elder law attorney. A small investment today will save you time, money and frustration later.

Hospital Patients Get Their Say – On a Scale of 0 to 10…

April 17, 2008 by  
Filed under HEALTHCARE

The US Department of Health and Human Services / Department of Medicare and Medicaid (CMS) provides a website called Hospital Compare that allows potential patients to size up a hospital before they are admitted. Need to know how many heart surgeries are successful at your local hospital? Need to know its mortality rate? The information can be found at

And now, a new addition to the website will make this website even more valuable to those of us who do our due diligence. I love this!

Patients are asked a series of survey questions as they are discharged. CMS will give the survey to 300 patients per hospital, per calendar quarter. Only short-term, acute care, non-specialty hospitals participate (not specialty or one-day outpatient type hospitals.)

Those questions are these:

  1. How often did nurses treat you with courtesy and respect?
  2. How often did nurses listen carefully to you?
  3. How often did nurses explain things in a way you could understand?
  4. How often did doctors treat you with courtesy and respect?
  5. How often did doctors listen carefully to you?
  6. How often did doctors explain things in a way you could understand?
  7. After you pressed the call button, how often did you get help as soon as you wanted it?
  8. How often did you get help in getting to the bathroom or in using a bedpan as soon as you wanted?
  9. How often was your pain well controlled?
  10. How often did the hospital staff do everything they could to help you with your pain?
  11. Before giving you any new medicine, how often did the hospital staff tell you what the medicine was for?
  12. Before giving you any new medicine, how often did the hospital staff describe possible side effects in a way you could understand?
  13. How often were your room and bathroom kept clean?
  14. How often was the area around your room quiet at night?
  15. Did hospital staff talk with you about whether you would have the help you needed when you left the hospital?
  16. Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
  17. Using any number from 0 to 10 (0 is the worst hospital possible and 10 is the best hospital possible) what number would you use to rate this hospital during your stay?
  18. Would you recommend this hospital to your family and friends?

CMS then uses the results as a part of its hospital compare program, allowing patients to make determinations about which hospital will tend not just to their surgery and care needs, but how well they are treated by the staff at the hospital.

Why do I love this? Let me count the ways!

There is not a hospital in this country that doesn’t take care of Medicare and Medicaid patients. That means all hospitals in the US will be listed, and the experience patients have had with them will be recorded.

The information will be objective. Since patients are being surveyed randomly at the hospital, as they are being discharged, the rankings won’t be skewed like the rankings and input we typically find online. The online ranking systems haven’t found a good way to be objective yet. Disgruntled patients and doctor’s staffs can skew those results in one direction or another.

And yes — I do see some shortcomings. Two things: First, I think they would do well to survey patients’ loved ones, their caregivers, in addition to the patients themselves. Often its the caregiver who knows far more about how that patient was treated.

And second — there is one very important population not being surveyed at all. That’s the person who doesn’t get discharged. We have to imagine that many patients who acquire MRSA or other infections, for example, aren’t making it out alive. Their opinions are important, too. Perhaps the idea of surveying caregivers would make sure the deceased patient’s opinions are represented to.

Are you facing a hospital stay? Check out the CMS Hospital Compare website. And if your doctor is affiliated with the wrong hospital? Then ask him or her what your options are. You need the complete package, and this is one more tool to help you get it.

Future Planning for a Loved One With Alzheimer’s Disease

October 22, 2007 by  
Filed under ALZHEIMER'S

By J. Trevey

If you have a loved one who has recently been diagnosed with Alzheimer’s disease, you may initially be filled with questions about what the diagnosis means for your family. If you have spoken with the doctor and performed your own research about Alzheimer’s disease, you have likely realized that the diagnosis will undoubtedly bring about some changes in the lifestyle of your loved one. Your loved one will need more care and support as time goes on, not to mention the financial implications of medical visits and eventual fulltime care. Though you may be faced with a barrage of emotions at first, it is important to remember that you are in the company of millions of other people in the same situation, as made evident by the plethora of organizations, support groups and associations that exist to help people like you understand and respond to the symptoms of Alzheimer’s disease.

Besides educating yourself about Alzheimer’s disease, it may also be beneficial to begin planning for the future now, while your loved one is the most independent and able to provide input about decisions affecting his or her future. Creating a plan for your loved one’s medical and other care expenses and establishing how decisions will be made on his or her behalf in the future can help ensure that your loved one has access to proper care and prevent you from encountering a gray area that leaves your hands tied in the future.

Arranging for healthcare is an important stage of planning for your loved one’s future. Establishing a situation in which long term medical care is available and affordable can benefit anyone, but is especially important for people with a long term illness such as Alzheimer’s disease. If your loved one currently has a long term care insurance policy, carefully read over the policy as it relates to progressive or long term illnesses. Clarify with the provider any portion of the policy about which you or your loved one have questions. If your loved one is uninsured, you may consider the possibility of obtaining the best policy that is affordable, paying particular attention to the coverage of medical care for long term illness outlined by the policy.

If your loved one is over the age of 65, he or she should qualify for Medicare, a federal health insurance program that covers some hospital, medical and prescription expenses. You may want to investigate your loved one’s eligibility for Social Security and Medicaid benefits as well to ensure that he or she receives the maximum assistance for which he or she qualifies.

The progressive nature of Alzheimer’s disease results in a decreasing decision-making ability over time. For this reason, it is important to discuss financial planning with your loved one as early as possible, and establish how and by whom he or she would like financial decisions to be handled. The procedure through which future financial, medical and other decisions will be made on behalf of the patient can be officially established by a document called a power of attorney. A power of attorney, often a component of a person’s estate plan, gives an appointed person or organization the authority to make decisions on behalf of your loved one when he or she is no longer able to do so. Talk to a trusted lawyer about the type of power of attorney that is appropriate for your individual situation.

Planning for the future is an important step in caring for your loved one with Alzheimer’s disease. Taking the initiative now to plan for future financial, medical and decision making needs will provide numerous benefits to yourself and your loved one moving forward.

About the Author: John Trevey is the manager of The Breckinridge, a Kentucky assisted living home specializing in Alzheimer’s care. For more information, please visit

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NOTE: The contents in this blog are for informational purposes only, and should not be construed as medical advice, diagnosis, treatment or a substitute for professional care. Always seek the advice of your physician or other qualified health professional before making changes to any existing treatment or program. Some of the information presented in this blog may already be out of date.