When Medicare refused to authorize home health care services for Edith Masterman, saying that her pressure wound would never heal, it appeared that the 79-year-old Wilton, Maine, woman could end up in a nursing home. That was in January 2010 following skin graft surgery and three months of rehab.
But Masterman, who has diabetes and is paralyzed from the waist down from a farming accident, doggedly made calls and cobbled together some services through the state's Medicaid program and the assistance of neighbors. "That wound did heal in September," she says. However, for the last year she hasn't had much-needed physical therapy that Medicare used to cover.
Denying Masterman services because of a Medicare policy that requires patients to demonstrate improvements in conditions in order to qualify for services is illegal, according to a lawsuit filed on behalf of Masterman and others by the Center for Medicare Advocacy (CMA). "Because they have long-term conditions like multiple sclerosis or paralysis, people all over the country are denied Medicare coverage for which they qualify and access to care they need," says CMA executive director Judith Stein. CMA is trying to get class-action status for the suit on the basis of allegations that tens of thousands of Medicare beneficiaries are wrongfully denied care.
Meanwhile, Masterman does her best to enjoy a rich and productive life, which includes writing a weekly column for a local paper, cooking in a specially adapted kitchen, and gardening.
"It just doesn't make sense [to deny services] if you take into consideration the cost to the government," Masterman says. "It costs a lot more in a nursing home than to stay at home."
Laurie Udesky is a writer in San Francisco.