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The Medical Advancement of Personal Needs 

By Vincent M. Riccardi, MD
(Page 2 of 2)

With the widespread adoption of the managed care mentality, putting a premium on minimizing expenditures, one option for doing so became paramount: declaring that a particular need or consequent service no longer is considered to be “medical.” For example, mental health disorders were declared totally separate in terms of medical decision-making and financial responsibilities of healthplans. If your heart is sick, they’ll spend thousands and thousands of dollars. If your brain is sick, maybe you only receive a few hundred dollars. Why? Who made these decisions, and under what authority?

In the meantime, my focus here is on the increasing exclusion of needs and services that could be attended to or provided by caregivers. One of the most important areas of medical consumer contention that I deal with daily is the denial of payment for services because the services can be provided by a caregiver, even though just a few years ago they were almost automatic healthplan benefits. And the pattern will continue with increasing intensity. Healthplans and professional medical groups (who do almost all of the utilization review and denials of healthcare benefits) are becoming looser and looser in their determination that a patient with a stroke has “plateaued” or merely requires “custodial” care. This simply translates into caregivers (if the patient has them) assuming the responsibilities for maintaining the health and well being of the patient.

This trend will continue. Caregivers will assume financial and hands-on responsibility for what in the 60’s, 70’s and early 80’s was provided by healthplans. Be ready. One of the ways to be ready is to be willing to use organizations with names giving the sense of “Caregivers ‘r’ Us,” allowing for hiring of people to provide the various services that traditional caregivers provide. Such expenses will be outside the realm of medical necessity and benefits. Over the long run, there will be a need for caregivers to choose whether relegation of such expenses to non-reimbursable costs is appropriate or that the medical advancement of such services is most appropriate. Please choose deliberately and choose wisely.

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