The Health Care Spectator

Obamacare Takes a Life

Daughter, doctor blame President for father's death.

By 4.1.14

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Yesterday the Obama Administration boasted that six million people had signed up for Obamacare.

There was not a word about Frank Alfisi.

Frank Alfisi was killed by Obamacare.

His daughter, Amy DiFrancesca, is furious. And yes, she quite specifically blames the President of the United States for her father’s death. As did the doctor who told Amy: “You can thank Mr. Obama for this.”

Before we get to the specifics of how Frank Alfisi died, let’s begin with the who of this story. Mr. Alfisi was not a statistic. He wasn’t a guinea pig or a lab rat. Frank Alfisi was a real person. A son, a brother, a husband, a father, a grandfather. So let’s start here by getting to know something about Amy’s Dad Frank.

Frank, 73 when he died on January 12, 2014, grew up “very poor” in New York City. His own father — Amy’s grandfather — died when Frank was young. So Frank quit school to work in the produce business alongside his brothers. Among other things, Frank Alfisi sold bananas, a mundane fact of the produce business life that decades later would win him an affectionate nickname from his friends.

Frank earned a “decent living” in the produce business. He married, and with wife Phyllis (whom he called “Philly”) had four kids, raising his family in Seaford, Long Island. In the 1990s Frank gave up his produce buying business and his home to devote himself to taking care of Philly — who was suffering from lung cancer. Frank and Philly lived across the street from Amy and her family, a situation Amy recalls fondly as “very Everybody Loves Raymond,” a reference to the old sitcom that had parents living next door to their married son. “Poppy” (as he was known to his grandchildren) was a neighborhood favorite. “All of the neighbors liked my father” she says. He was a “kind, friendly, gentle man who always had a corny joke to tell you when he saw you” and loved taking his dogs to a nearby park where he would meet a group of friends.

When Phyllis was stricken with lung cancer. Frank was so devoted to Philly, says Amy, that a few months before she passed Frank sold both their home and his business so he could be devoted to nothing but caring for Philly. Frank and Philly moved across the street to live with daughter Amy and her family. Amy recalls: “When my mom was sick, expenses were increasing so my parents sold their house which was across the street from mine, and moved in with my family. My husband and I turned the back of my house into a one bedroom apartment for them.”

Frank used his money to pay for an aide to be with Philly during the night. Frank ate dinner with Amy’s family every night, proudly watching his grandson grow up and showering him with a grandfather’s love and pride.

Philly died in 2000. Frank, who had been by Philly’s side every step of the way through her ordeal, was devastated. Frank stayed on with Amy, but lived in the apartment set up in Amy’s house. The arrangement enabled Frank to be close to his family yet still maintain his independence. He had his own living space. He drove and came and went as he chose, joining his family for dinner most nights. 

Until 2012 and Hurricane Sandy. Frank and Amy’s family, like a lot Long Islanders, could only watch helplessly as Sandy barreled through and flooded both Amy’s home and Frank’s apartment. Frank lost everything. Everything. Clothes, furniture, household items, papers — all were ruined. Once again Amy made it a point to help Frank, and soon, with the help of local officials, Frank was back on his own in a seniors apartment in nearby Wantagh, a town away from Amy. It wasn’t an “assisted living” facility — there was no care provided. Frank had his independence — and he loved it. “It was wonderful” Amy says, because her Dad visited the senior center in the complex almost daily. He made friends, a lot of them. Frank loved going out to eat, playing cards and pool, his new pals calling him “Frankie Bananas” in deference to Frank’s old job in the produce business. Frank even found a new girlfriend. He played shuffleboard and bocci, taking trips and making all the holiday parties. He “had a lot of friends at the senior center” his daughter reports, laughing that her Dad “was very popular, despite his corny jokes!” 

But over the years of that hard work Frank had gotten sick. He had multiple myeloma for eight of those years, requiring chemotherapy. Yet he got his strength back. Then there was the heart problem. Atrial fibrillation — “afib” as it is shorthanded. Still, Frank was able to live on his own. In spite of one other problem.

The chemo had induced kidney failure — and Frank needed dialysis. Three times a week he would make the journey to the DaVita City Dialysis Center in nearby Garden City, Long Island. DaVita is in the business of providing dialysis for those who suffer from kidney failure.

The dialysis treatment that removed toxins from his body was a routine in Frank’s life three times a week, every week. Dialysis flushes a build-up of toxins from the body and cannot be missed. Frank, as with all dialysis patients, needed dialysis to survive — and he was getting it. Like clockwork Frank received his dialysis as an out-patient at DaVita on Tuesdays, Thursdays, and Saturdays, with Sundays, Mondays, Wednesdays, and Fridays off. If you aren’t healthy enough to get to DaVita on your own as an outpatient, then the patient is directed to go to the hospital. Often, Amy tells me, by Tuesday morning the “toxins and/or fluids had two days to build up” in Frank’s body and he “wouldn’t be feeling so well.” Making it all the more important that Frank get his dialysis in a timely fashion — which he was. Routinely getting to DaVita on his own steam.

Until, that is, the Tuesday Frank was suddenly “nauseous and vomiting.” “Thinking he had a 24-hour stomach virus that was going around,” Amy says, Frank stayed home. And missed his Tuesday dialysis session.

Setting Frank Alfisi on a direct course — a fatal course — to meet Obamacare.

Now into Wednesday and having missed his regularly scheduled Tuesday dialysis session because of his 24-hour stomach bug, Frank called Amy saying he felt very sick and didn’t know what to do. Amy instructed her Dad to quickly push his life alert button. Knowing the soon-to-arrive ambulance would take him to St. Joseph’s Hospital in Bethpage, Long Island, Amy called ahead. “I called ahead to the ER and told them the last time he was dialyzed was 3 ½ days ago. I also gave them all the pertinent info; meds he’s taking, his medical conditions, Doctor info, etc.”

Let’s let Amy tell the story: 

My father went to the hospital emergency room at St. Joseph's Hospital in Bethpage, NY, about 10am. My brother met him there and informed the doctors that he needed dialysis. He also spoke to them about my father’s blood pressure being too high. This has happened before because when he retains fluid combined with his heart condition (atrial fibrillation), fluid builds and causes him to have high blood pressure. Other than due to fluid build-up, my father had no history of high blood pressure and his heart condition was easily managed with medication. I informed the doctors again over the phone that my father required dialysis because he hadn’t had it for 3 1/2 days.

After several hours, my brother had to leave. He told me my father’s blood pressure was still high and he hadn’t yet been dialyzed.

I called the ER doctor who said he knew my father needed dialysis but could not give it to him because it’s only covered for inpatients and they could not admit my father as an inpatient because his condition did not meet the new Medicare insurance standards for admission. (These new standards include a rule which says a patient should require a two night stay to be admitted.)

The doctor agreed that my father should not be discharged and did need dialysis but insurance wouldn’t pay for it so he ordered a CT Scan of the abdomen hoping to find something, anything, that would allow him to admit my father. He also said that my father’s blood pressure was high, but not high enough to admit him. I continued to call the ER and was told by a male nurse that they were still doing different tests to try to find something that would allow them to admit my father. 

About 10 hours later from the time my father went into the ER, some time after 8:30pm, I received a phone call from the ER doctor that my father’s blood pressure got so high he had a seizure.

When I got to the hospital about half an hour later, I was told my father had just had a 2nd seizure. He was unconscious.

My father was unconscious for 2 days. On Thursday, 11/14/13, the first day he was unconscious, he would grimace and moan as if in great pain. The neurologist said his present condition was a direct result of not being dialyzed. He said the toxins that build up don't just affect the kidneys, but they affect every part of the body and caused his blood pressure to go so high that his brain couldn't handle it so he had seizures. We spoke about putting my father on hospice care and giving him morphine. Because my father appeared to be in pain in his unconscious state, and I didn't want him to suffer while I waited to meet with the hospice people, I contacted his oncologist, who has privileges at the hospital. (FYI his regular oncologist left the group and my dad hadn’t ever met the new one yet). I wanted the doctor to prescribe something to ease his pain. A different doctor from the group was at the hospital that day and came to see my father. When I told him about my father not being dialyzed because he couldn’t be admitted due to the new Medicare regulations, the doctor said to me, “You can thank Mr. Obama for this.”

Stop right here and take in what Amy was told. Frank has now had not one but two seizures and as a direct result is now unconscious — needlessly — because of Medicare’s new “two midnight rule.” Frank’s dialysis doesn’t take one overnight in the hospital, much less “two midnights.” Remember that he was an outpatient, going three days a week for his dialysis treatment and returning afterwards to his apartment at the senior center. But because the new Medicare regulations — which had to be written to comply with Obamacare — wouldn’t allow Frank to be admitted and thus dialyzed, Frank was now in very serious, life-threatening trouble. The attending doctor, an oncologist, understood exactly what had happened to Frank, and he was, says Amy, “very angry.” Said the doctor: “You can thank Mr. Obama for this.” Note: This doctor, whom Amy identifies to me but who is not identified here because he has not yet responded to a call for comment, is in fact one of several doctors and medical personnel involved in Frank’s case for whom I have Amy’s contact information. 

Amy goes on:

My father awoke on Friday, 11/15. When he awoke, the toxins that built up in his system and the seizures did so much damage that my father was permanently on oxygen at the highest level, had trouble breathing, could no longer walk and was wheelchair bound, had constant hallucinations, had great vision loss and could barely eat. He had retained so much fluid and now continued to retain fluid that they put him on a very restricted fluid intake. He was so dry every day that his lips bled and his tongue would stick to the roof of his mouth and make it difficult for him to speak. This was a man who used to meet his friends daily at the senior center to play cards and billiards and who would go out to lunch and dinner with his girlfriend.

On Sat. 11/16, terrible hallucinations began. My father felt as if the bed was tipping over and shaking him out of it. He saw strange faces all of the time. He told me he knew they weren't real, but it was still terrifying because they looked real. At one point, he crawled out of the bed and onto the floor because he couldn't stop the feeling that he was going to fall out of the bed. I was told by a nurse that if my father did that again, they would have to strap him to the bed. I hired aids to be with him all night and whenever I couldn't be there so they wouldn't strap him down. The hallucinations continued for a couple of weeks and were so bad that my father said he wished he would just die.

I asked the nurse on three separate occasions to have a hospital administrator contact me about why my father wasn’t dialyzed. I wanted to know what dialysis patients should do if they're too sick for outpatient dialysis. No one ever got back to me.

On Monday, 11/18, even with the oxygen, my father’s breathing was so bad in the night that he requested to meet with hospice. He didn’t want to spend another night like that and just wanted to be drugged so he didn’t have to suffer anymore. His cardiologist told him he was acting prematurely and he might still get better, so my father put it off.

My father never went home again. Once he had the seizures, my father lost everything, all of his independence and even the sense of being a person. Obamacare treats you like a statistic. If you recall from the notes in my previous e-mail, my father was told he could no longer stay at the rehab in Commack (Gurwin Jewish) because Medicare and Medicaid would not cover it. On Christmas Eve, I was told by the social worker at Gurwin that my father would have to leave or I would have to pay them about $800/night. They said he would be discharged and sent home the day after Christmas! My father was terrified because he was in such bad health that he couldn’t go home alone. Because he had a studio apartment, he couldn't get a 24 hour aide either. I couldn't take my dad in because we were and still are to this day making repairs from Sandy. I also live in a split-level home which made it impossible for him to get around with the wheelchair. I filed an appeal with IPRO (founded in 1984 and formerly known as the Island Peer Review Organization, IPRO has contracts with the federal, state and local governments. IPRO is an independent national organization providing “a full spectrum of healthcare assessment and improvement services that foster more efficient use of resources and enhance healthcare quality to achieve better patient outcomes”) and won but no one could tell me for how long. A week later, on New Years Eve, I was told the very same thing. My father was again in a panic. This time I lost the appeal and will never forget the shock that we had only 2 days to figure out what to do with a man who required so much (24 hour oxygen, dialysis, etc.). The social worker insisted that they were going to put him in an ambulette and transfer him to his front door if I couldn't afford to pay them $5,000/week. My brother told the social worker he would find a way to pay until we figured out what to do. It’s amazing how dehumanizing the medical industry has become. My father died less than two weeks from the time he left Gurwin yet they were ready to throw him out. Fortunately, I found help from a kind woman who knew how the system worked and she directed me to Parker Jewish where my dad was transferred. 

My father was wheelchair bound and was so breathless and weak he couldn't push the wheels himself, he lost so much vision he couldn’t view the TV or a newspaper (which he used to love to read.) He still couldn't drink and was always thirsty. He barely ate because he had no appetite and when he did, he couldn’t get the food down because of how dry he was. He couldn’t get himself from the bed to the wheelchair independently because of the oxygen he required. He couldn’t even use the bathroom without help getting there. He had no quality of life whatsoever. 

On Sunday, January 12th, 2014, my father told me he could not live like that anymore and knew he was ready for hospice. We prepped to speak with hospice on Monday, but that night, my father went to sleep and never woke up. He died on January 14th at Long Island Jewish Hospital.

As close as I was to my father, I had no idea just how much he meant to so many people until his funeral. Friends from the senior center who he saw daily came in droves and all of them shared stories with me about him. And, the one thing that kept making me smile, despite being in such a solemn place, was that each and every one of them commented on his “corny jokes.”

Amy, understandably furious at what happened to her Dad, ends by saying this:

In short, my father was sick, but that’s not what killed him. The way he suffered and cutting his life short happened because of a Medicare regulation that makes no sense. But, I guess we had to “pass the bill to see what’s in it.”

When my sister-in-law, an ER nurse in Upstate NY, found out about this, she said similar situations have happened where she works. Patients who should be admitted for a day are discharged because they don’t fit the criteria to be admitted for two or more days. She said it’s not a secret and while we, the public, may be unaware of this, it’s well known by doctors and nurses.

Amy has reached out to New York’s U.S. Senators Charles Schumer and Kirsten Gillibrand, both supporters of Obamacare. She has heard nothing back. Likewise she contacted her congressman, Peter King — who voted against Obamacare — and he too did not get back to her. Now, let’s get to the policy specifics. What caused this massive disruption to the age old idea of the doctor-patient relationship? What caused Frank Alfisi to die?

Specifically, what killed Frank Alfisi was, in the impersonal language of bureaucracy, “CMS 1599-F.” A new rule courtesy of the Affordable Care Act — aka Obamacare. A rule which CMS — the Centers for Medicare and Medicaid Services — describes this way:

Section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program, which requires CMS to reduce payments to IPPS hospitals with excess readmissions, effective for discharges beginning on October 1, 2012. The regulations that implement this provision are in subpart I of 42 CFR part 412 (§412.150 through §412.154).

Further detail can be found here at Health Reform GPS, a project sponsored George Washington University's Hirsh Health Law and Policy Program and the Robert Wood Johnson Foundation. Which reads in part:

Changes Made by the Affordable Care Act (P.L. 111- 148, § 3025 as amended by § 10309)

Hospital Readmissions Reductions Program, § 3025

• Overview. HRRP will reduce the Medicare payment to hospitals with a high number of readmissions for “applicable conditions” over a specified time period.[8]

English translation? CMS was now required by Obamacare to come up with a new rule which cut Medicare costs. Which CMS did by coming up with CMS 1599-F. This new, Obamacare-forced rule specified that a hospital stay can only be paid for by Medicare insurance if that stay “(1) expects the beneficiary to require a stay that crosses at least two midnights and (2) admits the beneficiary to the hospital based upon that expectation.”

This has become known in the world of doctors and hospitals as the “two midnight rule.”

Recall that as Amy tells Frank’s story, she says this:

I called the ER doctor who said he knew my father needed dialysis but could not give it to him because it’s only covered for inpatients and they could not admit my father as an inpatient because his condition did not meet the new Medicare insurance standards for admission. (These new standards include a rule which says a patient should require a two night stay to be admitted.)

What does the CMS think about their two midnight rule? CMS Administrator Marilyn Tavenner says:

“This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers.”

The “two midnight rule” became a death sentence for Frank Alfisi. An Obamacare Catch-22. 

Simply put: Frank Alfisi could not be admitted to the hospital because he needed dialysis. Dialysis does not require a “two midnight” stay in the hospital. So, therefore, Frank would not be admitted as an in-patient and given dialysis. And since the lack of dialysis — which was deliberate per the Obamacare directive to the CMS — had now made Frank so sick that it resulted in two seizures and unconsciousness, a need for oxygen and a wheelchair, Frank certainly was no longer qualified to be an outpatient at DaVita. 

For Frank the centuries old idea of medicine — that a patient’s treatment is a decision between the patient and his or her doctor and that the first responsibility of a doctor is the famous dictum “First, do no harm” — was overridden. Overridden by the demands of Obamacare, the Affordable Care Act. The demands not of medicine but of politics. Bureaucracy.

On the eve that the two-midnight rule was to take effect, alarm began to spread in the medical community. As here in this 2013 article in Forbes that specifically cited the Obama administration’s role in creating this 1,500-page regulation and reads in part:

A fundamental principle of the American health care system has always been that your medical care is driven by two things: your own choices and your doctor’s judgment. It’s what’s right, and it’s what works.

But if a new rule proposed by the Centers for Medicare and Medicaid Services is finalized August 1, that principle will be undermined by removing provider judgment from the decision to admit a patient to the hospital. It’s a dangerous precedent that’s bad for the health care system, bad for providers, and bad for patients — and would cost hundreds of millions of dollars to implement.

And so?

And so Frank Alfisi — Amy’s beloved Dad, “Poppy” to his grandchildren and “Frankie Bananas” to his friends, the man who only mere days earlier was going out to dinner, playing cards, pool, shuffleboard and bocci, driving a car, enjoying a girlfriend — that Frank Alfisi disappeared into the cold, impersonal “care” of Obamacare.

It killed him.

Incredibly, this past Sunday Obama adviser David Plouffe went on ABC’s This Week to proclaim “the law is working.”

On March 27 — last week — the U.S. House of Representatives passed a bill popularly known as the “doctor fix.” Included in that bill, according to news reports, is language that “postpones hospital compliance with the controversial ‘two-midnight rule’ and recovery audits of medically unnecessary claims until March 2015.” CMS has jumped into the breach as well, issuing not one but two delays.

But the fix — and it would be a temporary fix along the lines of the “mend it, don’t end” approach so many Democrats are being urged to adopt about Obamacare — begs the question.

What business did the government have in getting between Frank Alfisi and his doctors in the first place? In fact, as long as Obamacare is not repealed what happened to Frank is inevitable. This is what occurs when the cold rules of a centralized impersonal Washington bureaucracy that views Americans not as individuals but statistics are substituted for the judgment of a doctor.

And recall Amy’s mention of that chilling statement of her sister-in-law the ER nurse? The statement saying “similar situations have happened where she works. Patients who should be admitted for a day are discharged because they don't fit the criteria to be admitted for two or more days. She said it’s not a secret and while we, the public, may be unaware of this, it’s well known by doctors and nurses.”

This time, the victim was Frank Alfisi. The next time? It could be your “Poppy,” your Mom, your child. It could be you.

And one more thing. The detail of Frank Alfisi’s previous illnesses? Why did Amy feel it necessary to list them in telling her father’s story? Because, in Amy’s words, “I’m sure Harry Reid’s people will point these things out if it ever gets that much attention.”

Think of that. An American citizen feels the need to get out the details of her father’s private life in illness as she recounts his death struggle with Obamacare because she thinks it possible the Majority Leader of the United States Senate will call her a liar. As Reid has previously stood on the floor of the Senate and said that the Obamacare horror stories coming from other Americans are “untrue… tales, stories made up from whole cloth.”

Raising another question.

What kind of country has America become?

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About the Author
Jeffrey Lord is a former Reagan White House political director and author. He writes from Pennsylvania at jlpa1@aol.com.