MONTPELIER, Vt. — Five New England residents and five national health care advocacy groups filed a lawsuit Tuesday against the federal agency that administers Medicare, saying it had illegally reduced or denied benefits to thousands of patients with chronic health problems.
The lawsuit, filed in U.S. District Court in Burlington, named Health and Human Services Secretary Kathleen Sebelius as its sole defendant and took aim at an arm of Sebelius' agency, the Centers for Medicare and Medicaid Services. It charged that when clients were deemed to be making no improvements after receiving nursing, physical, occupational or speech therapy, those services often were cut off.
The standard has never been subjected to the review and public comment that federal regulations normally undergo, the lawsuit said, but was "a covert rule of thumb that operates as an additional and illegal condition of coverage" resulting in the termination, reduction or denial of benefits for thousands of Medicare beneficiaries annually.
The plaintiffs asked that the lawsuit be certified as a class action, a request the court has 60 days to grant or deny.
A spokeswoman for the Medicare program, Ellen Griffith, said the government had not had a chance to review the complaint and would withhold comment.
The suit did not say the alleged practice affected the patients' hospital, prescription drug and other types of care. But the Washington-based Center for Medicare Advocacy, which announced the lawsuit Tuesday in a media conference call, argued that denying chronically ill patients home-health visits or physical therapy would force many of them to seek more expensive hospital care due to earlier neglect.
One of the named plaintiffs, 79-year-old Edith Masterman of Wilton, Maine, has used a wheelchair since a farming accident when she was a teenager. During the past 10 years, she developed pressure sores, and her doctor ordered that she get home health care. Then her Medicare funding for her home nursing services was cut off because her condition was not improving.
She went to live in a succession of nursing homes for the 100 days that Medicare would fund.
"I found that my stay in five nursing facilities was pretty much a waste of time as I did not get the help I needed," she said. As the nursing home funding was about to run out, two physical therapists accompanied her to her home to see how she would cope, Masterman said, and "they said I would do much better in my own home where I have the necessary equipment."
She's still without Medicare-funded care for her pressure sores, but the state of Maine provides some Medicaid funding. Instead of home care, she has to head out in her wheelchair to the wound clinic at a nearby hospital, something the lawsuit said involved "taxing effort and discomfort."
Other named plaintiffs were Glenda Jimmo of Bristol, Vt.; K.R. of Bennington, Vt.; Miriam Katz, widow of David Katz of Bloomfield, Conn.; Mary Patricia Boitano of Narragansett, R.I.; the National Committee to Preserve Social Security and Medicare; the National Multiple Sclerosis Society; the Parkinson's Action Network; the Paralyzed Veterans of America; and the American Academy of Physical Medicine and Rehabilitation.