Keeping funding for Medicaid services is always a struggle, but over the last year or so, Medicaid has become a favorite target for both politicians and hard-working homeowners who chafe at ever-increasing property taxes imposed by counties struggling to keep pace with ballooning Medicaid costs. As a homeowner and taxpayer, I agree that something has to be done to cut the fat out of Medicaid spending. As a person who has relied on Medicaid when I had no other health insurance, I strongly disagree with anyone who proposes reducing or eliminating much-needed services. What most homeowners, taxpayers and politicians fail to understand is that the fat that needs to be excised from Medicaid lies in the excessive bureaucracy and short-sighted policies made by firmly entrenched bureaucrats. If you need a real-life example, here it is.

Faith, a young woman with multiple sclerosis, had been in a nursing home for over a year when she was referred to STIC's Community Integration Advocates. Prior to institutionalization, she had her own apartment, which was inaccessible, and as her physical condition deteriorated, Faith began to have difficulty there. She fell often and had to call 911 for assistance. As a result, Faith was deemed unsafe in her environment and placed in the nursing home as a long-term resident. Despite her very young age, Medicaid picked up the tab for nursing home care, no questions asked.

As part of the transition planning process, STIC helped Faith apply for wheelchair accessible housing at all of the HUD-subsidized apartment complexes in Broome County. Six months later, she was approved for an accessible apartment and, with much excitement, went to take a look. The apartment, in a freshly renovated building, was brand-spankin' new! It had larger rooms than most subsidized units, with big windows that let in lots of light. It also featured a large, fully accessible kitchen with roll-under sink, stove and counter space. The bathroom was large enough to accommodate a Hoyer lift and for Faith to turn around in her power chair. In short, the lovely little apartment had most everything Faith needed.except a roll-in shower. Of course, she needed a roll-in shower or some type of equipment that would allow her to use the bathtub. A traditional tub transfer bench wasn't going to cut it. Although the Hoyer lift could maneuver around the large bathroom, it could not get close enough to the tub to place Faith on a tub bench and she no longer had the upper body strength to pull herself across the bench into the tub. This left Faith with a dilemma. She could turn down the apartment and stay in the nursing home until another became available, which could take a year, or she could accept the apartment and find a piece of equipment that would make the tub accessible to her. She chose the latter option.

With all of the innovations in assistive technology, it wasn't difficult to find a combination shower chair/tub bench that would work. The DuraGlide is a two-piece system that allows a person to be transferred into a shower chair on wheels that rolls into the bathroom and is positioned alongside the tub. It is then fastened into two rails mounted on the tub and the wall. Once the chair is locked into the rails, an aide can slide the seat from the shower chair across the rails to transfer the person into the bathtub. When the person has finished showering, the process is reversed. Not only does this simple but remarkable device give a person with a disability the freedom to live in a home or apartment without a roll-in shower, it is also relatively inexpensive, compared to modifying a bathroom. At about $3,000, the cost is comparable to the Medicaid reimbursement rate for one month in a skilled nursing facility.

Preparations to obtain the DuraGlide began before Faith was discharged from the nursing home. An occupational therapist evaluated her and wrote a letter stating that the DuraGlide was medically necessary. This letter, and a prescription for the DuraGlide from her doctor, were submitted to Medicaid for pre-authorization. Now, in a perfect world, the Medicaid examiner would have authorized payment, the vendor would have immediately ordered the equipment and Faith would have enjoyed her first hot shower in her own home within three months after moving in. Of course, we are living in a world that is very far from perfect.

The Medicaid examiner denied Faith's request. When I called the examiner to ask her reasons for the denial, she became incensed, exclaiming that she was not about to approve a $2,900 shower chair when a $600 inflatable bed tub that resembled a rubber dingy more than a bathing system would, in her opinion, do the job. Of course, I could not end the conversation without at least trying to make this person understand why her recommendation wouldn't work for Faith. So I explained that the individual in question was prone to chronic urinary tract infections and needed to ensure that her perineal area could be cleansed thoroughly. This didn't go over well at all. The examiner practically spat into the phone that she had been a public health nurse for twenty-some-odd years and she had never in that time seen or heard of chronic UTIs caused by the inflatable dingy. It didn't take me long to figure out that changing this bureaucrat's mind would be about as easy as slapping a fresh diaper on King Kong as he made his way up the Empire State Building. I sighed loudly into the phone and told the crotchety nurse that we would take the matter to fair hearing, to which she replied, "Okey-dokey" and hung up.

Some three months after that conversation I went before the Medicaid Fair Hearing judge with documentation from Faith's doctor citing the frequency of UTIs that she'd had since leaving the nursing home and justifying the need for a traditional shower where she would not be lying in the dirty water that collected in the bed tub. I was also armed with hand-written notes from the OT, which explained that Faith's spasticity would be more of a danger if she was flat on her back in the bed tub instead of sitting up in the shower chair. I was accompanied by one of Faith's PCAs who helped with bathing and personal care in the morning. Unfortunately, Faith could not attend due to a conflict between the hearing time, which could not be changed, and her attendant's schedule.

After another three months of waiting for news of the decision, Faith called to tell me that she had won the fair hearing! Great! She was on the home stretch! I fully expected that she would be taking her first shower at home within the next month or two, giving the bureaucrats enough time to stamp whatever they needed to stamp with approval and send it on the back of a backward-crawling snail to the vendor who would then order the DuraGlide. I'm a hopeless optimist!

Two months went by, then three. Faith called to ask if I had heard anything and I had not, so I called the vendor to see what was happening. He explained that he was still waiting for the approval from Medicaid to be sent. When I sighed in exasperation, and asked if Medicaid had sent him the notice of decision from the fair hearing, he said, "Oh yeah, they did that, but I had to submit all of the documentation that I sent the first time to them again before they would approve the payment. I can't order the chair until I get a notice of prior authorization."

"HUH???" I said. Were they kidding? The fair hearing decision notice stated that the request had been approved and that Broome County DSS was ordered to comply immediately. So how could the folks in Albany drag their feet by making the vendor re-submit all the forms? Good question. I still don't have an answer.

It took one year for Faith to get her shower chair, almost to the day, and another two weeks of adjustments to the equipment before she could finally enjoy her first hot shower in her own home. What enrages me about this story is that Medicaid balked at buying a piece of necessary equipment that costs slightly less than one month of care at the nursing home that Faith had left. Of course, Faith suffered the consequences of Medicaid's stubborn, hidebound, short-sighted policies by way of chronic UTIs, bladder infections and other health complications. Of course, had her health deteriorated a bit more dramatically, Medicaid officials would not have batted an eye at the cost of sending her back to the nursing home. Her return to the community would have been a short one simply because she could not adequately bathe her body. Isn't irony wonderful?

The other rage factor here is that my tax dollars, and those of all the folks screaming about the high cost of Medicaid, were wasted on paying some bureaucrat to re-process information that was already lying dormant in a file cabinet, probably within easy reach of his/her desk! The same money that was spent on that person's salary and nifty benefits package could have been used for the shower chair that Faith needed in the first place. Now, I'm not saying that there shouldn't be oversight of equipment requests. There are a few folks who ask for everything under the sun and feel that Medicaid is Santa Claus, the bringer of gifts, whether they are needed or not. Those people, however, are in the minority by a wide margin. Most of the people who are on Medicaid use it because they have no alternative to pay for homecare and equipment that lets them live in the community and stay as healthy as possible. I can only conclude that the excesses of Medicaid spending lie not in equipment and services, but in the madness of a system that feeds on itself.