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Granddad's health plan fails him when he needs it most

Mervyn Urquhart is helped to his feet by

Mervyn Urquhart is helped to his feet by his grandson John Arline and granddaughter Chivonne Williams at his home in Wheatley Heights. (Sept. 12, 2009)Mervyn Urquhart Photo Credit: Ed Betz

Mervyn Urquhart, 83

Retired

Insurers deciding treatment

Wheatley Heights

For at least six years, 83- year-old Mervyn Urquhart paid $200 to $250 a month for a Medicare Advantage plan.

His grandson John Arline of Wading River said the retired engineer believed the insurance - a privately run plan offered to seniors as an alternative to traditional, government-run Medicare - would take care of his health needs.

But Arline said that has not been the case: He and his sister ended up paying $15,000 for Urquhart's stay in a nursing home when his health plan denied coverage for physical therapy.

"The entire process is extremely broken," said Arline, who is associate director of emergency management for four city hospitals.

Others are also unhappy with Medicare Advantage plans, in which 10.2 million seniors are enrolled. President Barack Obama says the plans cost the government too much and that eliminating them would save $200 billion. Others say the plans confuse seniors and lack sufficient oversight.

Mark Wagar, chief executive of Empire BlueCross BlueShield - which administered Urquhart's plan - defends them. He said they typically offer more benefits than regular Medicare, with lower premiums and out-of-pocket costs.

On Jan. 3, Urquhart, who has had Alzheimer's disease since 2001, was admitted to Good Samaritan Hospital Medical Center in West Islip. He had a stomach virus and a deep vein thrombosis, a potentially lethal blood clot, in his right leg.

Until then, Urquhart had been fairly independent, despite his memory loss. For the past four years, he has lived in Wheatley Heights with Arline's sister, Chivonne Williams. He was able to dress and feed himself, and enjoyed going for walks in the park.

After the virus and blood clot had been treated, Urquhart's doctor recommended he be transferred to a rehabilitation facility to help him regain his strength. But on Jan. 12, Empire denied coverage, stating he was not a candidate for physical therapy because of his "cognitive status."

But Arline wanted his grandfather to receive the care his doctor had prescribed.

He appealed twice to Empire and was denied both times. He then appealed twice to Maximus Federal Services, a national board that reviews appeals for patients with Medicare Advantage plans, and was denied. He also appealed twice to IPRO, a not-for-profit health care consulting group. Again, he was turned down.

Worried that a month in the hospital was sapping Urquhart's strength, Arline and his sister decided to take him to a Huntington nursing home for a month. They paid the cost out of pocket.

"He's home; he's walking," Arline said. "I know that if he didn't have rehab, he wouldn't be walking. If he didn't have restorative care, he might not be here at all."

What's wrong

with the system

Arline is still angry. "These reviewers hired by the insurance company are getting paid not to give away money," he said. "I understand the business model perfectly."

Arline said he was infuriated that someone "a hundred miles away" who had never seen his grandfather overruled his doctor.

"It's about the patient; it's not about the cost, when [caring more] about the cost may be doing harm," he said.

What he'd like to change

Arline said doctors - not insurance companies - should decide who gets care. And he would like to see hospitals "get paid for the work they do." He also believes in somehow providing insurance for everyone, but doesn't pretend to have an easy solution for how to pay for it.

But on one thing he is clear: "I am for getting rid of Medicare Advantage plans. If everyone received regular Medicare, they would be so much better off."

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