Robert Lewinger is tired of being berated by his gastroenterologist because he’s overdue for a colonoscopy. He’s perfectly willing to have one. And he’s more than ready for cataract surgery on his second eye.
The problem: Mr. Lewinger, 72, a retired lawyer who lives in Manhattan, can’t schedule either of these procedures, which involve anesthesia or sedation, unless he supplies the name and phone number of the person taking him home afterward. Otherwise, clinics and outpatient surgical centers refuse to make appointments.
Mr. Lewinger is also willing to undergo Mohs surgery, as his dermatologist has recommended, for two small skin cancers on his face. But the surgeons associated with her practice also insist on medical escorts, even though most Mohs surgery is performed under local anesthesia and doesn’t require them.
Transportation itself isn’t the difficulty; Mr. Lewinger could summon an Uber or a Lyft, call a car service or hail a cab. What he needs is “someone to escort me out of the building, take me back to my apartment and see me into it,” he explained. “It shouldn’t be so hard.”
It is, though. Mr. Lewinger is divorced and lives alone, like a growing number of older Americans. His daughter lives in Boston; the cousin who brought him home after cataract surgery a few years ago has moved away. He doesn’t have friends to help. Phone calls to Aetna, his Medicare Advantage insurer, revealed that Medicare doesn’t cover a medical escort. He struck out with home-care agencies, too.
He even offered maintenance workers in his apartment building $100 to pick him up after their shifts. “They lost interest when I couldn’t be specific about what time they’d have to be there,” Mr. Lewinger said.
Older people across the country describe similarly maddening efforts to find “door-through-door” escorts for outpatient surgery and screenings that involve anesthesia — especially if facilities require those escorts to remain on the premises until the patient’s discharge.
Health Care in the United States
The problem is “rampant,” said Janet Seckel-Cerrotti, executive director of FriendshipWorks, a nonprofit whose trained volunteers serve as free medical escorts in and around Boston. “We see it every day. It’s hard on your dignity.”
Doctors explain that door-through-door requirements are a safety measure. With a colonoscopy, for instance, patients often receive an anesthetic, like propofol, or a narcotic such as Demerol or fentanyl, combined with anti-anxiety medication like Versed or Valium.
“They affect the brain, and they can stay in the system for four to six hours,” said Carol Burke, a gastroenterologist at the Cleveland Clinic and a past president of the American College of Gastroenterology. “You’re not in full control of your faculties.”
On a bus or in an Uber, she said, “what if you fall asleep or you start to vomit or you don’t remember where you’re going?”
Is such caution truly necessary? “A very hard question,” said Thomas Oetting, an ophthalmologist at the University of Iowa School of Medicine and a spokesman for the American Academy of Ophthalmology.
Though liability fears clearly play a role, “how safe do we have to be?” he asked. He specializes in cataract surgery, which also often involves intravenous anesthesia. After the operation, “if there’s a one-in-a-million chance that someone falls and breaks a hip, should everybody have to have someone take them home?”
For now, though, they usually do, forcing older patients without nearby family, or friends who still drive, to scramble.
Some rely on religious congregations. In Boulder, Colo., Jan DeCourtney, 65, earned enough credits by volunteering through TimeBank Boulder to secure other volunteers to accompany her to and from cataract surgeries. In Beaverton, Ore., Gerry Lukos joined Viva Village, part of the Village Movement, which supports aging in place; she used volunteer drivers/escorts three times last year.
Trying to solve the escort problem can require considerable research, involving providers, local nonprofits and home-care companies. Some possibilities:
Talk to your medical provider. Policies vary. The surgeons to whom Mr. Lewinger was referred require escorts for Mohs procedures, but most don’t, said Terrence A. Cronin Jr., president of the American Academy of Dermatology. “The local anesthesia we use is usually lidocaine, which doesn’t disrupt the mental abilities of our patients, so they are able to drive themselves home,” he said in an email.
For cataract surgery, you may be able to avoid intravenous anesthesia, which is less often used in other countries. Dr. Oetting also practices at V.A. Iowa City, where cataract surgery involves a shorter-acting oral sedative (typically Valium) and patients remain in the clinic for two or three hours afterward. “Then we feel more comfortable having them leave on a van,” he said.
Colonoscopies can be done without sedation, too. Alternatively, the Cleveland Clinic and other providers sometimes allow patients with early morning appointments to remain for several additional hours after the procedure before going home on their own.
You can also screen for colon cancer annually with an accurate at-home FIT (fecal immunochemical test) and skip the colonoscopy, though the 5 to 6 percent of people who get a positive result will need one as a follow-up anyway.
Look for local nonprofit groups. The National Volunteer Caregiving Network connects about 700 community organizations nationwide, most of which provide door-through-door transportation without charge. “It’s neighbors helping neighbors,” Tammy Glenn, the executive director, said.
Shepherd’s Centers of America, which provides support services for older adults, has 55 affiliates in 17 states; most offer escorts to and from medical appointments without charge.
The roughly 250 local village organizations across the country often help with door-through-door, though there’s an annual fee — usually subsidized for lower-income seniors — to join the village.
You can also consult your local Area Agency on Aging or use the Eldercare Locator to find public or nonprofit transportation services.
Contact home-care companies. Medicare doesn’t cover medical escorts. “Nonemergency medical transportation,” including an attendant, is a covered Medicaid benefit, but state policies vary widely, Alice Burns of the Kaiser Family Foundation said.
But if you can afford out-of-pocket costs, you may find help. In New York, Westchester County and Long Island, VNS Health (formerly the Visiting Nurse Service of New York) provided medical escorts almost 1,800 times last year. Patients can book a certified home health aide to accompany them at about $140 for a four-hour block.
Many home-care companies, already scrambling to hire staff, won’t agree to such short one-time stints, which produce less income than continuing assignments for both the aides and the agency. But some companies will, sometimes charging slightly higher rates than for continuing care. Give plenty of notice before your appointment.
Executives at nonprofits and home-care companies said they glimpsed signs of change, with insurers and hospitals beginning to cover escorts or supporting local nonprofits that provide them.
It’s not happening fast enough for Mr. Lewinger, but he has decided on a plan.
He asked his doctor to prescribe an at-home FIT for colon cancer, instead of a colonoscopy. For cataract surgery, he’ll make an appointment, then call VNS Health; he can afford the charges.
To locate a surgical practice that doesn’t require an escort after Mohs procedures, he’ll have to start making calls.
He wishes Medicare and medical practices would simplify this process. After all, the costs of treating cancer, or injuries when a person with poor eyesight falls, would far exceed the expenses for door-through-door transportation.
He envisions “just a straightforward ‘Call this number and they’ll arrange it,’” he said. “It shouldn’t be up to the patient to figure it out.”
