No point in keeping to myself all that I had to figure out these past five months.
By: Dov Fischer
This is the penultimate of a quadrilogy, I guess, for readers who have become my family over the years. In the aftermath of my losing my precious wife of 20 years, Ellen the love of my life, I share observations that, although sometimes personal and in some discrete instances unique to my Orthodox Jewish religious faith and practices, I think also are universal and will help many readers navigate your own future experiences. Even though, besides being an attorney of 26 years and a law professor of 16 years, I also am a rabbi of 40 years, it turns out that there was a great deal of significant information I simply did not know.
I just spent the past five months learning so much so rapidly, leveraging the lessons and precautions learned during decades of my legal experience to avoid major pitfalls along the way, that it seems a shame for me not to share guidance with my loyal family of readers. Even the two trolls who invariably comment on my writings will benefit here. Ellen was laid to rest in the Holy Land of Israel on 15 Tamuz, July 7, in a service that was live-streamed by two separate companies so that it could be viewed by more than 600 long-time friends, fellow synagogue congregants, coworkers, and family members in America who could not be there.
- Usernames and Passwords
Before my beloved Ellen, of blessed memory, went into the hospital for her third glioblastoma resection, she prepared a comprehensive list for me of all her computer-account usernames and passwords. She did not mention it to me, nor did I realize that she perceived the peril she was facing for the third resection, because the prior two resections of September 2017 and December 2018 saw her rebound famously. But she intuited that this time would be different. After she returned home, I happened to be looking for something, and I found the list. That enabled me to get into her credit card accounts and pay all bills timely, set them up thenceforth for auto-pay, and attend to a bunch of stuff she otherwise would have handled, respond to emails that had been sent to her, get back to callers who had left her voicemails on her smartphone, and such. She also gathered all her important documents in one place. As it happened, I later needed to find her passport because she was being laid to rest in the Holy Land of Israel, and she had made my finding it instantly facile.
- Medicare and Hospital Stays
Ellen was on Medicare, not because of her age but because of disability. For people under 65, Medicare health coverage begins after 24 consecutive months on Social Security Disability. People diagnosed with glioblastoma and certain other particularly perilous or disabling illnesses are accepted for Social Security disability benefits very rapidly without the hassle that many others encounter. Even so, the Medicare system wants to be certain that a disability will extend a long enough term to justify the administrative process of moving an under-65 disabled person onto Medicare.
When someone is admitted into a hospital and has Medicare coverage, the financial end works like this: The hospital certifies the illness or reason for hospitalization by assigning the matter a certain numerical code or codes that Medicare associates with that medical condition. Medicare then pays the hospital a flat lump sum for that patient’s hospitalization, based on Medicare’s institutional assessments of what such a code number typically should entail for hospitalization and treatment for that condition. The thinking is that Medicare does not want hospitals using Medicare patients to run up profits at government expense (because Medicare so carefully avoids waste and fraud … ). Therefore, if the hospital wants to maximize profitability, it will treat efficiently. If the patient is cured and discharged more effectively, efficiently, and rapidly than Medicare’s average anticipates, the hospital thereby earns the right to pocket the leftover lump sum payment. By contrast, if the patient lingers longer than the Medicare average, needs extra doctors’ care, and requires extra diagnostic procedures, that overage comes at the hospital’s own expense. Therefore, the hospital has an enormous incentive to move Medicare patients out the door. Again: Be aware that hospitals have a steep financial interest in speeding Medicare patients out the door and back home.
Honorable, top-quality hospitals will absorb the financial losses when Medicare patients run into complications that extend their stay and increase their needed treatment. First, because the hospital cares about its reputation. Second, because the longer stays ultimately get balanced out by the shorter stays. Less honorable or less competent hospitals are kept somewhat honest, too, because they know they will be sued for malpractice if they mess around. Nevertheless, all hospitals will try to get Medicare patients out the door and discharged as fast as possible, even when a dithering idiot can see that the patient needs more hospital time. The villain whose job it is to dump the patient back on the family is called the “Case Manager.” The Discharge Case Manager or Discharge Nurse or Discharge Doctor calls and is very nice, makes sugary-sweet small talk, and assumes you do not know that he or she is a mercenary. She or he presents that the patient really wants to be home now and hardly can wait. Be aware. You are dealing with a blood-sucker who would put Dracula to shame.
Therefore, ideally, every person should have a “Dov” in their back pocket, who is ready (i) to argue the ethics and morality of premature hospital discharge with the spiritual passion of a rabbi, (ii) to fight with verbal hammer and nails as a trained high-stakes litigator who never lost a case in 10 years, and — if necessary — (iii) is ready just to kill the damned Discharge Case Manager with such readiness that the Discharge Case Manager knows it. By your having a close relative or reliable life-long friend who really loves you, is not a sucker, and will not be cowed (whether Holstein or otherwise), you can extend a loved one’s hospital stay for longer until the loved one truly has been cared for as completely as is appropriate, Medicare or no Medicare.
Beyond your having a passionate and capable advocate, Medicare likewise has a backup system for those who do not have a “Dov.” In each state there is a Medicare-certified QIO (Quality Improvement Organization). You look online to find the one in your state. By law the hospital must give you a written notice two days before they intend to throw you out. You then can appeal by contacting the QIO by no later than noon of the day immediately after the hospital gives you the notice. Thus, if they give you the note on Tuesday, you have to appeal to the QIO by Wednesday 12 noon. If you have not read this article, how in the world would you know before your appeal deadline has passed that you are on such a deadline? (Yes, it is in the small type on the two-day discharge notice. But you will read that like you read the terms of the agreement you check off when you set up an online account or like when you check off some agreement to terms before downloading a computer program, and it gives you 10 pages of legalese to agree to. Or like when they give you 600 “disclosures” to sign when you get a home mortgage.)
(To be continued next week)
