Opinion ID: 214263
Heading Depth: 2
Heading Rank: 4

Heading: GMCF Reduces Moore's Nursing Hours in 2006

Text: In November 2006, GMCF notified the Moores that, effective December 2006, Callie's nursing care would be reduced from 94 to 84 hours per week. The GMCF Medical Review Team determined that now 84 hours, not 94 hours, were medically necessary to correct or ameliorate Moore's medical condition. In its Letter of Notification of Approved Skilled Nursing Hours, GMCF cited four policies in the GAPP Manual to support its revised 84 hours allotment: Chapter 701: The cost analysis should be made to determine that the cost of caring for the member in the home & community is below cost of providing the same care in an institution. Chapter 702.2 part b. The Primary caregiver must assist with the member's care in the home. Chapter 702.2 C. The availability and ability of caregiver(s) or significant other to actively participate in the care of the member. Chapter 702.2 E. The expectation that the primary caregiver(s) will become competent to assume some responsibility to care for the child. GAPP Medical Director Dr. Joseph M. Rosenfeld [12] served on the GMCF Medical Review Team that assesses GAPP members' medical necessities. Dr. Rosenfeld made the final decision to reduce Moore's nursing care from 94 to 84 hours per week. In a 2007 deposition, Dr. Rosenfeld testified about his definition of medical necessity, explaining that it is based upon the general accepted medical practices in the community and can vary by regional expectations. Dr. Rosenfeld derived this standard from the GAPP Manual and from the factors typically considered by the GMCF Medical Review Team. Dr. Rosenfeld's concept of medical necessity hinges on the medical well-being of the GAPP member, not the convenience of the GAPP member or health care provider. Lastly, Dr. Rosenfeld's understanding of medical necessity is informed by his belief that it should be the most effective or conservative way and cost less than hospitalizing the child. This is consistent with the GAPP policies referenced in GMCF's letter above: (1) [t]he Primary caregiver must assist with the member's care in the home and (2) a cost analysis should be made to determine that the cost of caring for the member in the home & community is below cost of providing the same care in an institution. Dr. Rosenfeld discussed the factors he considers when determining what nursing hours are medically necessary. Dr. Rosenfeld does not apply a strict formula but considers various elements, including (1) the severity of a child's condition, (2) how unstable they are, (3) what needs can be provided by family members, and (4) hospitalizations. [13] Dr. Rosenfeld's understanding is that GAPP was designed as a weaning program based on the parents' ability to care for the child. Under GAPP's model, primary and secondary caregivers are trained to care for the GAPP member and, over time, nursing hours are reduced based upon the competency, [and] knowledge of the parents. Dr. Rosenfeld justified his ten-hour reduction94 to 84 hoursin weekly nursing hours based on several considerations. First, Moore had not been hospitalized in the recent past, a factor he frequently takes into account when reducing nursing hours. [14] Second, Dr. Rosenfeld concluded that many of the conditions that Dr. Braucher highlighted in his Letter of Medical Necessity would not be affected by a reduction in nursing hours. Specifically, Dr. Rosenfeld concluded that neither Moore's gastroenteritis complications nor her acute urinary retention would be adversely impacted by the nursing reduction. Moore's malabsorption difficulties posed a potential problem, but not an actual problem. Furthermore, Moore's need to be repositioned while she slept was a home healthcare issue and did not require skilled nursing. [15] Lastly, Dr. Rosenfeld's decision to reduce Moore's nursing hours was due to her being relatively stable and the fact that her parents ... could be able to assume one hour and a couple of minutes of extra care per day since she had been on this many hours for a very long time. Given the competency of Moore's parents in her care, Dr. Rosenfeld determined the hours reduction would not endanger Moore's welfare and she would continue to basically receive the same type of care that she has received prior to that. Dr. Rosenfeld characterized Moore's conditions as chronically stable, a term he used to describe children who are going to never get better who are ... very ill, but who are stable in the sense that ... the disease process is not getting worse, not getting better, and they're not requiring hospitalizations, and they're going to stay at this steady state for a long time. When asked if he considered Moore's mother's needs when calculating medically necessary nursing hours, Dr. Rosenfeld commented that his GMCF Medical Review Team generally did not factor in a caregiver's convenience: We're looking at strictly what is medically necessary for the care of the child. The only time we really take into consideration the caregivers is when it's in a foster situation and the foster parent is really helping the state out. When calculating medically necessary nursing hours, Dr. Rosenfeld takes into account a caregiver's work schedule and sleeping needs, but not such activities as going to the grocery store or attending social functions.