Medicare Benefits Exhausted : Stroke Patient Stuck in Bureaucratic Tangle

Marguerite Cronin has spent the last 6 months in a hospital room.

Attached to a machine that monitors her heartbeat and oxygen intake, she breathes through a tube in her throat and rests on a special bed that automatically shifts every 15 minutes to prevent her lungs from congesting. Because of a stroke, complicated by bronchitis and frequent bouts with pneumonia, her life depends on the constant care of health professionals.

For the first 5 months, the 82-year-old woman’s stay at Memorial Medical Center of Long Beach was relatively uneventful.

Then came a twist. Her Medicare benefits ran out. The federal health-care program for senior citizens had been paying Cronin’s medical bills, which averaged about $1,500 a day.

Since then, Cronin has been at the center of a controversy involving her family, the hospital, state health officials and private health-care providers.

The issue: What kind of permanent care does she need and who is willing to pay for it?

On one side is her family, which wants the hospital to keep Cronin until arrangements for suitable home care can be made. On the other is the hospital, which at one point was prevented by a court order from releasing her against the family’s will to a nursing home.

Somewhere in the middle are the state Department of Health Services and private health-care firms. The state department administers a home-care program designed to care for patients such as Cronin at a fraction of the cost of hospital treatment. Private firms provide the home-care services, and the state reimburses the companies. But many private providers apparently are reluctant to participate because they believe the state does not pay enough to make it economically feasible.

The controversy, besides triggering the temporary court order, is also likely to result in a lawsuit by a health advocacy group.

To make matters even more confusing, Cronin’s condition has recently deteriorated to the point where her treatment is on hold, hospital officials acknowledge.

“She’s a fighter,” says her son, John P. Cronin, 38, a bank vice president. “But lately she’s been getting very depressed.”

The woman’s medical problems began in May when she experienced breathing difficulties. John Cronin said he feared for his mother’s life and took her to Memorial where she was put in an intensive care unit and eventually was treated for pulmonary stress. A resident of Los Alamitos, she lived with her husband, Thomas, an 83-year-old retired accountant, on a fixed income.

Sometime during her first weeks in the hospital, doctors believe, she experienced a stroke that permanently impaired her ability to breathe and perform other bodily functions. Doctors performed a permanent tracheostomy--an incision in the throat to aid breathing--and put her part time on a respirator.

State Denies Application

After her Medicare benefits were exhausted about a month ago, John Cronin said, the hospital applied to the state to have the Medi-Cal program pay the costs of providing acute medical care--defined as treatment that can only be provided in a hospital. The application was turned down.

At that point, John Cronin later said in a deposition, he received a telephone call from a hospital employee, Dorothy Jackson, who told him that his mother was a “trespasser” on hospital premises and would be physically removed by security personnel unless he paid $2,000 the next day. Jackson, who works in the admitting section, declined to comment.

Ron Yukelson, a hospital spokesman, said he was unable to substantiate that such a call was made and would “dispute that somebody from Memorial Medical Center would say that to a patient’s family.”

But Cronin was alarmed enough to go to Los Angeles County Superior Court and obtain a temporary restraining order preventing the hospital from discharging her until an appeal can be heard in January regarding her Medi-Cal eligibility.

And Jane Perkins, an attorney for the National Health Law Program, a health advocacy firm based in Los Angeles, said her group plans to file a lawsuit on behalf of Marguerite Cronin and at least one other patient to permanently prevent the California Department of Health Services from withholding Medi-Cal payments without due process from patients undergoing acute life-giving care.

Condition Is Low Again

In the meantime, according to Yukelson, the elderly woman’s condition has again deteriorated to the point where the hospital now acknowledges that she needs to stay there. As a result, Medi-Cal is paying her medical costs for now. But hospital officials fear that they will never be paid for 3 weeks in which no coverage was approved.

“In early November, when doctors determined that Mrs. Cronin was not acutely ill and therefore did not require further hospitalization at Memorial, the medical center made every effort to place her in a nursing facility where she could receive the appropriate level of care,” he said, reading from a prepared statement during an interview. “Since that time, however, Mrs. Cronin’s medical condition has changed to the extent that she again requires acute-level hospital care, which she is currently receiving and will continue to receive until her personal physician sees fit to discharge her and make continuing-care arrangements.”

John Cronin interprets that to mean that the moment his mother’s condition stabilizes, the institution will again attempt to remove her despite the fact that she can’t survive without specialized around-the-clock medical services. And he believes that the hospital may try to pressure her personal physician, Dr. George Huthsteiner, into concurring on an early release.

Huthsteiner denies that any undue pressure has been, or is likely to be, exerted on him. In an Oct. 11 affidavit, in fact, he described his patient as “completely helpless.”

“As of this date,” he wrote, “the only convalescent hospitals that have been located to take this patient are in San Diego and Hollywood. . . . I agree with the patient’s son that the patient’s morale would suffer severely if she were sent to a skilled nursing facility that far from her family. . . . However, at this time the patient appears stable enough to be cared for at home with in-home nursing care.”

Psychiatrist’s Opinion

Jay B. Cohn, a psychiatrist specializing in neurological disorders at the UCLA School of Medicine, went a step further. He described Marguerite Cronin’s condition, even before the recent deterioration, as “acute and critical.” He predicted in an affidavit that the patient, if placed in a skilled nursing facility rather than a hospital or at home with specialized one-on-one care, would “quickly contract bacterial pneumonia and probably die within 3 days.”

The state-sponsored In Home Medical Care Services program offers home care designed to avoid just such drastic outcomes. Provided by private companies, the service is later paid for by Medi-Cal. But finding a willing provider has proven to be a major stumbling block. In the past few weeks, John Cronin said, he has approached several would-be providers without success.

One company, he related, said it was not accepting any more Medi-Cal patients because of difficulties in getting reimbursed by the state. Another said it could not find enough trained nurses to provide the service. And a third, Cronin said, offered to provide the service only if he would pay an additional $3,000 a month beyond what the state was willing to pay.

Lesley Nichols, an assistant vice president at Personal Care Health Services in Santa Ana, with which John Cronin is negotiating, said her company has restricted the number of Medi-Cal patients it will accept because it loses money on them.

“Financially it’s wiping us out,” she said. While the provision of acute in-home care costs an average of $20.75 an hour, she said, the state is willing to reimburse the company at only $17.45 an hour in Southern California and $19.50 an hour in the San Francisco Bay area. So although her company can take care of patients such as Marguerite Cronin for about $396 per day--less than a third of the cost at Memorial--few patients have been able to avail themselves of the service in recent years.

Higher Rate Proposed

In Marguerite Cronin’s case, Nichols said, the company has agreed to provide care at home if the state agrees to reimburse the company at Bay Area rates rather than Southern California rates, a proposal the state is unlikely to accept.

“We don’t do that,” said Rich Wilcoxon, chief of field service operations for the state Department of Health Services, which administers Medi-Cal. With reimbursement rates based on average pay rates in a given area, he said, the federal government--which foots half the bill--is generally unwilling to be flexible.

“It isn’t impossible, but it’s never easy,” Wilcoxon said of finding companies able to provide the service at state-approved rates. Although the state earmarked enough money to provide in-home care for 175 people statewide, he said, only 132 patients have found providers willing to meet the state’s financial guidelines. “I think that what’s happening to some extent is that the overall shortage of nurses in California has affected in-home care as well as hospitals,” he said.

All of which leaves Mrs. Cronin with no place to go. So she lies in bed, sleeping most of the time, or staring at the walls. Her husband of 61 years sits home alone in front of his television set and cries frequently, according to their son.

“This is the first time they’ve been separated,” the son explains. “When you’ve been together that long you’re almost like one person. He just doesn’t understand why it’s taking so long.”