Senior With Fractured Back Battles Insurance Company

Seventy-seven-year-old Angela Dispenza considers herself fiercely independent. She lives in a modest home with her 83-year-old sister in Queens, N.Y., where she tends her garden and walks to mass each Sunday. She says she loves to spend time in her neighborhood.

The one place she does not like being is in the hospital.

But this summer, the usually active senior citizen found herself on a stretcher in the emergency room at nearby Jamaica Hospital after falling at home.

"I don't want to be here," Dispenza said of her hospital stay. "I've got a house to take care of [and] bills."

Dispenza's family says after the fall, she could not care for herself, much less her home.

After her pain became too much to handle, she was brought to the hospital, where doctors diagnosed Dispenza with a fractured spine.

Multiple physicians confirmed the finding and recommended that Dispenza be admitted to the hospital for pain management and further treatment. But when hospital staff asked Dispenza's insurance company, Oxford, to authorize her admission to the hospital, the company refused.

Hospital workers say they tried repeatedly to explain to representatives from Oxford why Dispenza needed to be admitted.

Lisa Schneider, the director of social work at Jamaica Hospital, said the insurance company told staff members that "she's not for admission," and "that she did not need to be in the hospital."

Medicare Advantage

Schneider says she was surprised by the difficulty staff members had getting Dispenza's care approved, because she is a senior citizen.

That's because most seniors in the United States are enrolled in the government-run health care system called Medicare. As part of the program, seniors are typically treated immediately by hospitals and doctors when they need care.

Medicare does not require patients to receive "pre-authorization" before being treated. The government negotiates the rates at which it will reimburse medical providers for the medical care in advance, and pays providers once the care is provided.

While Dispenza had the option to enroll in the government-run Medicare system when she reached retirement age, several years ago she and her sister opted to enroll in a new version of the program called Medicare Advantage, which is run by private insurance companies.

Originally called Medicare Choice, the program was conceived during the Clinton administration as a way to reduce the escalating cost of Medicare. Supporters argued private insurers could provide medical services to seniors more efficiently than Washington, and could reduce the amount of money the government spent on the program. The program remained small through most of the 1990s.

During the Bush administration's push to add prescription drug coverage to Medicare during 2002 and 2003, the program — renamed Medicare Advantage — was overhauled. To entice insurers to create Medicare Advantage plans and enroll seniors, the annual government payments to participating insurers were increased. Almost immediately, analysts say, insurance companies saw a potential financial windfall and began creating new plans and signing up seniors.

As of November 2007, nearly 9 million seniors — or 1 in 5 of those enrolled in Medicare — have opted for a Medicare Advantage plan.

But as enrollment has swelled and new plans created, critics have become more vocal in their complaints about how Medicare Advantage works.

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