While most hospital discharges are agreed upon by doctors and their patients, there are some circumstances when there is disagreement about whether it’s time for the patient to leave. Most of those disagreements are with the insurance company or another payer who deems that patient’s time is up (and they will no longer pay.) But sometimes the situation is just the opposite. The patient feels as if he or she is ready to leave, but the doctors say no – they don’t believe that the patient is ready to go. If the patient does, indeed, walk out the door, it will be labeled, “Discharge Against Medical Advice (DAMA).”
The first reason is obvious. The longer you stay, the more money they make, as long as they can be reimbursed by your insurance, another payer, or from your own pocket. That time may be limited by your insurer, but the hospital will always do its best to maximize its reimbursement and income from every patient’s stay.
The second reason is less obvious. That is, the longer you stay in the hospital, the more things they can do to you – extra procedures, extra tests and so forth. Of course, the more they do, the more they can bill for. The third reason is relatively new. That is, through the Affordable Care Act, hospitals are penalized if Medicare patients are readmitted within 30 days of their discharge.
So, while their interest may not necessarily be in your improved health for your own sake, it’s definitely important to them that you be healthy enough when you leave so that you won’t have to come back (until day 31 anyway.)
A New York Times article published in early July details the story of Barbara Barg, a Chicago poet, who collapsed at a bus stop this spring. She suffered a heart attack in 2014 and had been feeling vaguely nauseated for several months. She was enroute to see her primary care doctor about nausea when a bystander who saw her falter called 9-1-1. Ms. Barg, 70, didn’t want to go to an emergency room but that was the only place paramedics would take her. “I was freaking out,” she acknowledges.
“I’d just gotten out of the hospital, and I didn’t want to go back in.” She’d had two recent hospital stays, one to replace a pacemaker lead, another to look for a blocked artery (none was found).
Now, “I just wanted to see my doctor.” Affiliated with the hospital, he had an office directly across the street. Refusing emergency care, Ms. Barg asked to be taken to his office. No. She asked the staff to call him. No. Twice, she walked out of the emergency department, “and they came after me and said, ‘We can’t let you leave.’”
Finally, after she agreed to sign a DAMA form, an aide wheeled her across the street; her doctor prescribed an anti-nausea drug that quickly resolved the problem.
People discharged against medical advice may be reluctant if problems develop or persist. A study at Highland Hospital in Oakland, California (where most patients were younger) has shown that when they leave against medical advice, they often do not get the appropriate follow-up appointments or medications needed.
“Reasonable people can disagree about whether a patient needs to stay one more day for an additional scan,” said Dr. Cordelia Stearns, a hospitalist, and the lead author. Fuller conversations about why patients want to leave might yield less contentious solutions, including outpatient treatment, home visits or drugs taken orally at home instead of being administered intravenously.
Alzheimer’s disease is one of the biggest concerns many of us have as we get older. While you may have been told that all you can do is hope for the best and wait for a pharmaceutical cure, the truth is much more encouraging. Promising research shows that you can reduce your risk of Alzheimer’s and other dementias through a combination of simple but effective lifestyle changes. By leading a brain-healthy lifestyle, you may be able to prevent the symptoms of Alzheimer’s disease and slow down, or even reverse, the process of deterioration. Experts agree that in the vast majority of cases, Alzheimer's, like other common chronic conditions, probably develops as a result of complex interactions among multiple factors, including age, genetics, environment, lifestyle, and coexisting medical conditions. Although some risk factors—such as age or genes cannot be changed, other risk factors—such as high blood pressure and lack of exercise — usually can be changed to help reduce risk. Research in these areas may lead to new ways to detect those at highest risk.
By identifying and controlling your personal risk factors, you can maximize your chances of lifelong brain health and take effective steps to preserve your cognitive abilities. There are six routines for a brain-healthy lifestyle that are within your control.
If you were injured or became seriously ill while serving in the military, you may be eligible for VA disability compensation. In 2017, eligible veterans can receive up to $3,458 per month tax-free, depending on the level of disability and number of dependents.
According to the VA’s website, disability compensation is paid to veterans who are at least 10% disabled because of injuries or diseases that were incurred in or aggravated during active duty, active duty for training, or inactive duty training. A disability can apply to physical conditions, such as a chronic knee condition, as well as mental health conditions, such as post-traumatic stress disorder (PTSD). You must also have been discharged under other than dishonorable conditions.
Medical evidence of a current physical or mental disability and its relationship to an injury, disease or event in military service is required. However, under some circumstances, the VA may conclude that certain current disabilities were caused by service, even if there is no specific evidence for your claim. For example, the cause of a disability is presumed for veterans who:
* are former POWs;
* have chronic/tropical diseases that become evident within a specific period of time after discharge;
* were exposed to ionizing radiation, mustard gas or Lewisite while in service;
* were exposed to certain herbicides, such as by serving in Vietnam; and
* served in Southwest Asia during the Gulf War.
The benefit amount is determined on a case-by-case basis and is graduated, on a scale of 10% to 100%, according to the degree of the veteran’s disability. Compensation may also be paid for disabilities that are considered related or secondary to disabilities occurring in service and for disabilities presumed to be related to circumstances of military service, even though they may arise after service. The degrees of disability are also designed to compensate for considerable loss of working time.
If you have dependents, an additional allowance may be added if your combined disability is rated 30% or greater. Your compensation may be offset if you receive military retirement pay, disability severance pay, or separation incentive payments. More information about disability compensation benefit amounts can be found on the VA’s Compensation Rates page.
Claims can be submitted online, in person at a regional VA office, or through an accredited agent or representative. All supporting documentation should be submitted with your claim, including medical evidence and how the disability has affected your life; separation documents; and dependent records (such as marriage and children’s birth certificates). A change in family status can affect your benefits. Be sure to notify the VA immediately of a marriage, birth, divorce, death, parent moving in with you, or child aging out of dependent status.
Medicaid, the single largest source of health coverage in the United States, provides health coverage to almost 75 million Americans, including children, pregnant women, parents, seniors and individuals with disabilities.
Medicaid is a federal program, but it is administered by the states. To participate in Medicaid, federal law requires states to cover certain groups of individuals, such as low income families and individuals receiving Supplemental Security Income (SSI). States may choose to cover other groups, such as individuals receiving home- and community-based services.
Funding for the Medicaid program comes from both the federal government and the individual state governments. Currently, the federal government gives each state a specified percentage of its program expenditures. This Federal Medical Assistance Percentage (FMAP) is based primarily on the per capita income of the state receiving assistance, so it can vary widely from state to state. For example, a rich state like New Jersey might receive $1 from the federal government for every dollar it spends on Medicaid while a poor state like Mississippi would receive $3 for every dollar it spends. The FMAP is adjusted every three years to account for changes in the economy.
Conservatives have long argued that Medicaid would be more efficient if states received a lump sum—a block grant—from the federal government and could then manage the programs as they saw fit. President Ronald Reagan proposed block grants in 1981, Speaker Newt Gingrich in 1995, and President George W. Bush in 2003. President Clinton agreed to block grants with the Temporary Assistance for Needy Families (TANF) program. Now that Donald Trump is President, and Republicans have control of both the House and the Senate, block grants are back on the table.
Proponents claim this could save the government billions of dollars and give the states more opportunity to be creative with their programs. Critics are afraid that people will not have access to the care they need. They are concerned that the states would cut benefits or force beneficiaries to take on more cost-sharing. Most of the Medicaid spending is on the elderly and disabled, with Medicaid paying for the care of almost two-thirds of the people in nursing homes, and critics are afraid they will suffer the most. In addition, they claim hospitals and clinics that treat large numbers of Medicaid beneficiaries will likely have to adjust their services and staff.
Of course, this is all speculation right now as no details on a block grant plan are available. But they may be coming soon. Republicans have placed a high priority on repealing and replacing Obamacare. That, and portions of a block grant proposal, could be accomplished through a process called budget reconciliation. Because it would only require 51 votes in the Senate, a Republican plan could pass without Democrat support. If a block grant plan for Medicaid is included, look for details on the implementation and see how the critics’ concerns are addressed.
Last month, the U.S. Supreme Court unanimously sided with a 13-year-old Michigan girl with cerebral palsy who had been fighting with school officials for years over whether she could bring her service dog to school with her.
At issue are two federal disability laws. The school district claimed it could ban the dog under the Individuals with Disabilities Education Act, which allows a teacher’s aide to assist students instead. The law also requires families that contest school decisions to first go through administrative proceedings. But the family said it could sue for damages under a different law, the Americans with Disabilities Act, because the district refused to allow the dog for more than two years.
Ehlena Fry’s family asked to use her specially trained dog, Wonder, when she started kindergarten. At the time, Ehlena suffered from severe mobility problems. Wonder was trained to help open doors, pick up items and give Ehlena some independence. Initially, the school said the dog could not accompany her and insisted that adult aides could help her. Eventually the school relented, but placed so many restrictions on the dog that Ehlena’s parents decided to home-school her. They later transferred her to a different school that welcomed Wonder. (Ehlena’s mobility and independence have since improved and she now attends school without her dog.)
Writing for the court, Justice Kagan cited two scenarios. In one, a child who uses a wheelchair sues a school for discrimination because the building lacks access ramps. That case hinges on equality of access to public facilities, not whether a school’s special education program is adequate. In the other, Kagan described a student with a learning disability who sues the school for failing to provide remedial tutoring. In that case, the issue is whether the school offers an adequate education. Kagan said nothing in the Frys’ lawsuit suggests a conflict on the adequacy of her education. Rather, the family is asserting Ehlena’s right to bring a service dog to school regardless of alternatives the school district provided.
Lower courts had ruled against Ehlena, saying she first had to try to resolve her dispute with the school district. The Supreme Court ruled that federal disability laws might allow her to pursue her case in court without first having to go through an administrative process, and that the lower court must look more closely at the facts before deciding.
The National School Boards Association, which backed the Michigan school district, is concerned the court’s ruling may cause more confusion than help for lower courts trying to apply the law. But the ACLU, which represented the Frys, applauds the Court for “breaking down unfair barriers faced by students who seek to vindicate their rights under the Americans with Disabilities Act.”
Jason A. Waddell is a Board Certified Florida Elder Law Attorney who practices on the Panhandle of Florida.