Article never made clear what advantages HOSPITALS get from treating Medicare people "for observation" rather than admitting them. When I had surgery and spent 5 days in the hospital in 2012, it was only months later I found I'd been in there "under observation" the whole time. My husband and I only caught it because it apparently allowed the hospital to charge us astronomical fees for administered medicines above and beyond what they'd get from Medicare. I also have to assume hospitals get away with not having to report readmissions if patients were only there "under observation" the first time. THIS SUBJECT DEFINITELY NEEDS MORE INVESTIGATION!
28
Observation is intended as a relatively brief period for examination and tests to determine if hospitalization is necessary for treatment or care can be rendered in a less intense setting. Doctors, not hospitals, are responsible for admitting patients. Doctors should be asked "are you recommending that I go home or stay in the hospital?" Those that say stay here need to be challenged if they don't admit the patient.
14
I know this situation all too well. My mother, who passed away this past April, was in exactly this situation. Since she was "under observation" and we couldn't afford a nursing home, she was sent home. I no sooner got her home and she fell on the steps even though I was holding her. It became a vicious circle of in and out of the ER. Finally, she was admitted for diverticulitis and my sister and I made damn sure that it wasn't just "under observation". Her doctor told us, "Don't let them bully you. You make sure she stays there for three days so she can get into a nursing home under Medicare." I must say the second time around, the hospital staff and social workers were very kind in helping us negotiate the system. What are families supposed to do with elderly, very sick parents who need care? My sister and I did everything we could to care for our mother but there comes a time when you need help. You shouldn't have to be rich to get decent care. It is unconscionable that in this country we do not care for the sick of every age. Shame on us and shame on this Congress for not stepping up to help ALL of us - the poor, the working class and the middle class. I am disheartened by the hard heart of this Congress.
17
This would be a much better and more informative article if were to discuss the logic for the shift from 'In patient' to 'observation/outpatient'. Is it being driven by the hospitals for monetary reason (and explain how that operates in the hospitals favor) or is it the doctors doing it. Is there a medical standard used to determine a person status while in the hospital. Can a person demand that they be listed as one or the other status?
This story needs much more detail.
This story needs much more detail.
21
Mr. Palmer, to repeat a reply posted below:
Auditors, who work for companies that contract with the Centers for Medicare and Medicaid Services, scrutinize hospitalizations. If the auditors determine that a hospital deemed someone an INpatient who should have been an OUTpatient, Medicare can deny reimbursement and the hospital has to eat the cost.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
Auditors, who work for companies that contract with the Centers for Medicare and Medicaid Services, scrutinize hospitalizations. If the auditors determine that a hospital deemed someone an INpatient who should have been an OUTpatient, Medicare can deny reimbursement and the hospital has to eat the cost.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
22
Speak for my myself I'm certainly not as knowledgeable on the subject as I would like. Instead, I have to pass the buck and hope that a savvy person, politician, or organization will take on the responsibility to advise, organize and promote an honest, fair and credible healthcare system, with no hope of adulation or benefit. Can we truly expect this in America today?
4
I worked as a hospital lawyer for 30 years. This is an argument against a single payer "Medicare for all" system. Medicare is so money-focused that it shaves every penny it can, at the expense of quality patient care. The idea that Medicare rules will completely control the standards and delivery of health care is frightening. What the article missed was pointing to the re-admittance standard that Medicare imposes on hospitals. CMS "dings" hospitals if they have a certain number of re-admisions. This forces hospitals (which are already paid below cost by Medicare, thus forcing them to cost-shift the loss to private-pay patients and their insurers) to follow crazy guidelines that are basically set up to avoid re-admissions by charting the patient as being in "observation status". When the patient is returned multiple times for care the "observation status" is never counted as a re-admit under CMS rules, so the hospital is not punished. Rep. Courtney's proposed legislation is a start, but this is just one tiny, tiny story that tells us what health care will be like if the entire system is run only by the government, and not doctors or hospitals. I'm all for removing the insurance company middle men, but until CMS demonstrates is it better than them, the rally call of "Medicare for all" sends shivers up my spine.
10
My father would have been readmitted except that the hospital that received him via ambulance from a smaller hospital 2 hours away refused to take him! He didn't have his wallet as my mother planned to bring it the next morning once it was daylight. A hospital staff person gave my father a cot in a broom closet and another shared her sandwich with him. He had a form of dementia and so is lucky that he didn't leave the hospital and get lost.
3
It is not in the hospital's or the patient's best interest to keep a patient outpatient (http://www.fiercehealthcare.com/healthcare/centers-for-medicare-medicaid...
In order to get the ACA passed, the Obama administration had to promise that it wouldn't expand the federal healthcare budget. The administration promised to save money in Medicare in order to offset payments under the ACA. (https://obamawhitehouse.archives.gov/blog/2012/04/09/official-sources-ag...
The administration then allowed bounty hunters to deny Medicare inpatient admissions. The savings they generated would be used to pay for the ACA. Hospitals responded to this by keeping patients outpatient.
In sum, thank you, Mrs. Niemi, for personally helping to pay for the ACA.
In order to get the ACA passed, the Obama administration had to promise that it wouldn't expand the federal healthcare budget. The administration promised to save money in Medicare in order to offset payments under the ACA. (https://obamawhitehouse.archives.gov/blog/2012/04/09/official-sources-ag...
The administration then allowed bounty hunters to deny Medicare inpatient admissions. The savings they generated would be used to pay for the ACA. Hospitals responded to this by keeping patients outpatient.
In sum, thank you, Mrs. Niemi, for personally helping to pay for the ACA.
3
The health care in the U.S.A. is totally broken.
What better argument could there be for single payer health care.
What better argument could there be for single payer health care.
5
Agree with the sentiment of your comment but single payor will not solve dilemma of paying for custodial care of individuals. Lacking a qualifying acute medical problem no health insurance (Medicare or otherwise) covers cost to care for someone needing "help" such as cooking, feeding, bathing, wandering off, becoming more forgetful, etc. consider the price tag for such a system.
1
When we had to take my 100-year-old mother to the ER for severe edema, they tried to keep her "under observation." Luckily, I have her medical proxy and I am an epidemiologist, so i fully understood the scam (there is really no other word for it) that the ER doctor was attempting to perpetrate. I forcefully refused to have her stay under "observation," making it quite clear that if she needed to be admitted, then she could be officially admitted; otherwise, i was taking her home. The doctor was furious, made no attempt to explain herself, and refused to look at me or speak to me. While we were waiting for discharge, another doctor came in, saying she was moving my mother to a bed they were holding for her. She said nothing about whether this was for observation until i asked, when she said it was, as per the orders of the ER doctor, who had deliberately contravened my instructions and gone behind my back to do as she pleased. We couldn't get out of there fast enough.
22
Thank you Susan for your comment, as care takers we need to be very assertive with health care providers. I have a friend who is COO of large hospital and she advised me to call administrators whenever there is a problem.The physical is now an employee without much power to change anything. If you can't get them on the phone then go to their office and demand to be seen. I also always say I'm a lawyer and boy that helps.
I've left AMA with my mom on several occasions and I never sign any papers we just leave. Medicare always has paid the bill perhaps because we refuse to sign the papers stating we are leaving against medical advice.
Hospital are a battleground, be prepared.
I've left AMA with my mom on several occasions and I never sign any papers we just leave. Medicare always has paid the bill perhaps because we refuse to sign the papers stating we are leaving against medical advice.
Hospital are a battleground, be prepared.
9
This reminds me of the financial person (stinking of cigarettes) who came into my room demanding a payment while I was in low capacity to think straight. I did all of a sudden get riled up once I realized was going on . I m still paying off my ridiculous bill.
4
If a patient has been in the hospital for 39 days "under observation", my assumption is that the hospital has a financial incentive for that categorization. Please explain why hospitals do this. Otherwise the article is incomprehensible.
22
I agree with MSL. Why do hospitals do This?
4
Yet another problem that Congress could fix and thereby benefit Americans. Instead the legislation goes no where. Our government seems so profoundly dysfunctional.
6
Okay, the hospital determines that the patient doesn't need to be admitted although they are treating them like they are admitted. Seems like some semantics at the patients' expense. All of us are better off not being exposed to the bugs stalking hospitals so if the doctors don't believe that we need to be admitted then they should expedite our return home and put in place a system for observing and monitoring. The cost is likely cheaper and we are more comfortable.
I really think that we need to be better consumers when interacting with the health system. We need better explanations of the options, better guidance around the pros and cons of specific interventions, and a lot more acceptance that we are humans not diagnosis or treatment algorithms.
I really think that we need to be better consumers when interacting with the health system. We need better explanations of the options, better guidance around the pros and cons of specific interventions, and a lot more acceptance that we are humans not diagnosis or treatment algorithms.
13
We'd all love to be "better consumers"--if only the system was more transparent. It's hard to even know what questions to ask when the system is this incoherent. This exact situation happened to a friend of mine with her elderly mother. My friend is quite savvy (having had to deal with her husband 's cancer treatments as well as her mom's ailments) but this particular situation was a new one on her. Who would think that keeping someone in the hospital was NOT the same as "admitting" that person?
Do we have any hope that the Improving Access to Medicare Coverage Act will pass in this congress? After 7 years of "bipartisan support" but no forward movement, it doesn't appear likely.
Do we have any hope that the Improving Access to Medicare Coverage Act will pass in this congress? After 7 years of "bipartisan support" but no forward movement, it doesn't appear likely.
6
to be blunt the elderly are penny wise and pound foolish. years ago Congress passed a long term health bill with a $74 premium per month. the elderly and their organizations went bananas and Congress revoked the bill. unfoftunatelythe elderly proved to be penny wise and pound foolish.
4
This is purely an economic "gaming of the system". For profit hospital owned by a large corporation.
1. Make the most money,
proper medical care?
Refer to rule 1
Took my father and mother through non profit hospital care on Marthas Vineyard. Guess what they worked the system to the patients advantage, moved my father out of hospital care to hospice, outpatient, requalified.
Open and above board, but yes a game, but a balanced system.
At least no fat cats in suits lining their pockets. ( and adding significantly to costs , probably 25% plus lost to the system in the USA. THE OTHER 25% to pharmacutical co's suits.
Disgusting comes to mind.
Single payer,
1. Make the most money,
proper medical care?
Refer to rule 1
Took my father and mother through non profit hospital care on Marthas Vineyard. Guess what they worked the system to the patients advantage, moved my father out of hospital care to hospice, outpatient, requalified.
Open and above board, but yes a game, but a balanced system.
At least no fat cats in suits lining their pockets. ( and adding significantly to costs , probably 25% plus lost to the system in the USA. THE OTHER 25% to pharmacutical co's suits.
Disgusting comes to mind.
Single payer,
8
"As long as the Democrats want to keep one-size-fits-all Medicare like other health insurance was 70 years ago in 1946 when Medicare was proposed, nothing is going to change. Nor should it. Fix it all or let it rot as it has been for 50 years."
"Fix it all." All should be bold type. the same goes for the IRS. tax code.
my recommendation and from many others is to repeal both and start from scratch. make it simple and suitable for today's circumstances. yes, and protests to the contrary, it can be kept simple and fair.
"Fix it all." All should be bold type. the same goes for the IRS. tax code.
my recommendation and from many others is to repeal both and start from scratch. make it simple and suitable for today's circumstances. yes, and protests to the contrary, it can be kept simple and fair.
1
What rights, if any, do Medicare patients have other than appealing an observation status designation?
3
This article grossly understates nursing home costs. The type of care to which the author is referring is called custodial. Most Medicare beneficiaries do not received that care when being admitted to a skilled nursing facility; they receive post-acute care. The cost of that care generally would be between 400-600 per day and averages in the $450 area nationwide. Further, one of the reasons for the 3-day stay requirement is because this care is so expensive and the lack of a utilization control when one is admitted to a facility. The expansion of observation stays, while problematic from this limited perspective, does not solve what could be an explosive cost if we take this narrow view of the 3-day stay without putting in utilization controls to preclude wider use of skilled nursing care.
4
Remember hospitals are penalized when patients get re-admitted to the hospital within a certain time period. Keeping patients in extended observation status avoids the patient being classified as a re-admit. This entire fiasco is the fault of CMS, they have refused to effectively clarify inpatient vs observation over the years and it is a giant mess.
26
Inpatient or observation, two glaring points illustrate why America will be bankrupted by limitless care for the elderly:
1. Only in the U.S. would someone aged 84 get a coronary stent and be admitted to a full-fledged hospital for 39 days for blood pressure medication titration. EVERYONE had their hand in the Medicare purse on this one: the hospital, primary care physician or hospitalist getting paid for rounding notes, the numerous consultants she surely met and has no idea why, hospital physical therapists and dietitians, other contractors or revenue generators (ER, radiology, lab, anesthesiology), and even the parking garage and cafeteria. Medicare doesn't pay much for a lot of things, but in aggregate the wasted money spent on elderly "care" keeps many hospitals afloat in this country. In my opinion, at least half of all hospitals would be gone if this wasn't so. In the American health care system, the elderly are the ATM cards for getting at the Medicare slush fund. Ask yourself, what family isn't happy when Grandma or Grandpa is getting all that care and treatment (most not needed or not improving health or life expectancy in any way) for "free" by their caring doctor at the local hospital? It is a racket, people.
2. Only in the U.S. do we completely outsource family care (her son lives in MA) with limitless public money. For better or worse, we warehouse our elderly at the public expense of billions of dollars per year.
1. Only in the U.S. would someone aged 84 get a coronary stent and be admitted to a full-fledged hospital for 39 days for blood pressure medication titration. EVERYONE had their hand in the Medicare purse on this one: the hospital, primary care physician or hospitalist getting paid for rounding notes, the numerous consultants she surely met and has no idea why, hospital physical therapists and dietitians, other contractors or revenue generators (ER, radiology, lab, anesthesiology), and even the parking garage and cafeteria. Medicare doesn't pay much for a lot of things, but in aggregate the wasted money spent on elderly "care" keeps many hospitals afloat in this country. In my opinion, at least half of all hospitals would be gone if this wasn't so. In the American health care system, the elderly are the ATM cards for getting at the Medicare slush fund. Ask yourself, what family isn't happy when Grandma or Grandpa is getting all that care and treatment (most not needed or not improving health or life expectancy in any way) for "free" by their caring doctor at the local hospital? It is a racket, people.
2. Only in the U.S. do we completely outsource family care (her son lives in MA) with limitless public money. For better or worse, we warehouse our elderly at the public expense of billions of dollars per year.
19
As a senior with no children, I'm glad to have senior care if needed. Where should I go after contributing taxes forever and then spending down all my funds? The streets? I quit my job and took care of my mother for four years until she died at age 90. That's four years of earnings gone for me -- forever. The problem in this country is the cost of adequate health care, and that cost would be a fraction of what it is now if we eliminated the insurance middle man. It's time for single-payer. Now.
20
Obviously, you have never been a caregiver, and are clueless about what a difficult grinding job it can be. I was a sole caregiver for over 4 years for a spouse with severe dementia, barely surviving on 3-4 hours of sleep a day. I had to spend us into poverty in order to get help. He was ultimately placed in a nursing home when it became unsafe for both of us to keep him at home.
This is NOT a "free ride" or a racket. Am I happy that he is getting all this "free" care? Not really - I've lost the loving husband I had, will never recover the things lost or sold to pay for his care, and will grow old without him on a greatly reduced standard of living.
This is NOT a "free ride" or a racket. Am I happy that he is getting all this "free" care? Not really - I've lost the loving husband I had, will never recover the things lost or sold to pay for his care, and will grow old without him on a greatly reduced standard of living.
18
Only a young man, who probably thinks he will have to care for a severely disabled relative, could write a comment like this. What you call family care works only when several relatives live close by, are healthy enough to do the heavy lifting and at least one of them doesn't work outside the home. Otherwise the caregiver will have to quit his/her job, lose years of income and retirement contributions, a sure road to poverty in old age. And what about people without children or other relatives? I rather spend my tax dollars on the care "racket" for our children and elders than on the endless wars, that only benefit politically connected weapons peddlers and the military brass looking for a second career in lobbying congress. Now there is a racket worth looking into!
9
Nancy Niemi obviously met the "Medical Necessity" criteria for admission as an inpatient. It was the hospital that chose to "Hold" her in observation for these extended stays so that they could MAXIMIZE their revenues.
I hope this class action pressures the Centers for Medicare and Medicaid to penalize All inpatient facilities that use these tactics to fatten their coffers. And publish lists of those offending facilities so that we are all in the know.
I hope this class action pressures the Centers for Medicare and Medicaid to penalize All inpatient facilities that use these tactics to fatten their coffers. And publish lists of those offending facilities so that we are all in the know.
17
Let's face it hospitals don't care about patient health; they care about profits. No doctor should allow any patient to be categorized as "under observation" for 39 days. Unfortunately, doctors don't make those decisions hospital administrators do. And they really don't care.
17
Thank you Republicans for this horrendous effort to gut Medicare for inpatient and nursing home care. All seniors and those who care for the elderly need to organize in support of Rep. Courtney's bill. The elderly should not be conned into thinking they have coverage when they don't.
16
In fairness, Maya, the observation versus inpatient problem has existed under both Republicans and Democrats.
6
In fairness Maya, the "horrendous" gutting of Medicare Part A inpatient and skilled nursing facility (see Note) funds was done in the Patient Protection and Affordable Care Act of 2010 as amended. Not one Republican voted for it and in the House, even 30 Democrats voted against it.
The rule on which this issue rests was put in Original Democratic Party Medicare in 1965 (section 1861). Republican Medicare, which was passed in 1997 does not include this rule. The only senior citizens (we do not like being called elderly) are those that believe Democrats care about them. There are -- thankfully -- fewer and fewer such seniors every election.
(Note: Medicare does not pay for nursing home care.)
The rule on which this issue rests was put in Original Democratic Party Medicare in 1965 (section 1861). Republican Medicare, which was passed in 1997 does not include this rule. The only senior citizens (we do not like being called elderly) are those that believe Democrats care about them. There are -- thankfully -- fewer and fewer such seniors every election.
(Note: Medicare does not pay for nursing home care.)
5
Shouldn't the Hospital be responsible for changing the status from "outpatient" to "inpatient"t. It used to be that after 24hours, if you weren't released your status was changed to inpatient by the hospital Isn't the hospital somehow responsible
14
I am a current University of Florida Graduate student in Arts in Medicine. We have been researching about the benefits of arts in medicine in the healthcare setting. Studies show that incorporating art into a healthcare setting can reduce patients use of pain medication and length of stay in the hospital, and improve compliance with recommended treatments-offering substantial savings healthcare costs. Having an artist in residence in a hospital may help reduce a lot of cost of the hospital and the bills a patient may be faced with. I understand there is an inpatient outpatient difference when it comes to billing policy, but if arts were implemented during admission into the hospital it may help the health professionals help patients faster and more effective.
2
I hate to be cynical but your comment is so totally off topic that it seems more like an advertisement that a comment.
34
I have always asked if I am being admitted for observation. I absolutely refuse to be admitted if they say yes. Simply cannot afford that kind of a bill. Thank you for this article.
32
Any patient who makes it past the ER is an inpatient in my book. The "observation" designation was never more than a naked attempt to make patients pay more for their care, thus robbing them of an insurance benefit, Medicare or private. There are way better ways to save money on health care, as every person who reads this newspaper knows.
24
I first heard about this in a Fresh Air episode about Elisabeth Rosenthal's book on the American healthcare system. There are a lot of pitfalls in our healthcare system. http://www.npr.org/books/titles/523005656/an-american-sickness-how-healt...
6
By the time I quit treating hospital patients, about five years ago, I had counted at least six different definitions of "observation" status. Medicare kept changing the criteria to try to save money, and hospitals kept finding ways to game the new rules. Early on, hospitals created observation wards, but when observation status was opened up for any bed in the hospital the distinction between being admitted vs being an observation patient became medically irrelevant. After that I got one phone call from a "utilization review nurse" who tried to scold me for not putting the designation the hospital wanted on a patient. For the next call, I was ready.
I said as long as the patient was in the medically appropriate nursing unit, it didn't matter whether we said she was under observation, admitted, lying-in, or Waiting For Godot. Admission vs observation was an accounting distinction, not a medical one; and if I'd wanted to act as an accountant I wouldn't have gone to medical school. Don't bother me with accounting questions.
The last time I checked, what I got paid from Medicare was almost exactly the same whether I called a patient observation or admitted, so I didn't have a dog in that fight. The financial ramifications to the patient hadn't become evident back then.
I said as long as the patient was in the medically appropriate nursing unit, it didn't matter whether we said she was under observation, admitted, lying-in, or Waiting For Godot. Admission vs observation was an accounting distinction, not a medical one; and if I'd wanted to act as an accountant I wouldn't have gone to medical school. Don't bother me with accounting questions.
The last time I checked, what I got paid from Medicare was almost exactly the same whether I called a patient observation or admitted, so I didn't have a dog in that fight. The financial ramifications to the patient hadn't become evident back then.
29
I would love it if the NYTimes would now follow this legislation. It has bipartisan support and yet it never gets considered or passed.
I would love to know why. Broadly, it probably could be chalked up to congressional disfunction and partisan gridlock. However, it still would be interesting to know the specific disfunction and the names of those responsible. This is so clearly a bill that would benefit the poor, but also the middle class. No one likes to get an unexpected bill for thousands of dollars because hospitals are gaming the rules.
I remember several administrations ago, when this partisan disfunction started to set in, there were articles about how -- yes, some bills get caught up in this partisan gridlock, but most legislation makes it through. Doesn't seem to be true any more.
I would love to know why. Broadly, it probably could be chalked up to congressional disfunction and partisan gridlock. However, it still would be interesting to know the specific disfunction and the names of those responsible. This is so clearly a bill that would benefit the poor, but also the middle class. No one likes to get an unexpected bill for thousands of dollars because hospitals are gaming the rules.
I remember several administrations ago, when this partisan disfunction started to set in, there were articles about how -- yes, some bills get caught up in this partisan gridlock, but most legislation makes it through. Doesn't seem to be true any more.
19
Katie Larsell
This -- "feature" of Medicare (which is in the original 1965 Democratic Medicare law, Section 1861 despite some comments here) will not get acted upon until the Democrats agree to reform Medicare from the 50-year-old disaster that it is.
As long as the Democrats want to keep one-size-fits-all Medicare like other health insurance was 70 years ago in 1946 when Medicare was proposed, nothing is going to change. Nor should it. Fix it all or let it rot as it has been for 50 years.
This -- "feature" of Medicare (which is in the original 1965 Democratic Medicare law, Section 1861 despite some comments here) will not get acted upon until the Democrats agree to reform Medicare from the 50-year-old disaster that it is.
As long as the Democrats want to keep one-size-fits-all Medicare like other health insurance was 70 years ago in 1946 when Medicare was proposed, nothing is going to change. Nor should it. Fix it all or let it rot as it has been for 50 years.
4
Just when I think the US healthcare system can't get any more perverse, I learn about this Kafkaesque definition of in-patient vs. outpatient. How is a patient occupying a hospital bed not receiving care and therefore an outpatient?!! Bizarre. Is America going to continue to be a culture of lying for profit?
26
Seems to me that once you're moved out of Emergency into a medical care ward, that's it. You've been admitted. Observation should apply only to the Emergency Department.
If part of the problem is the readmission issue, perhaps that needs to be revisited. But it's possible that giving patients the wherewithal to shift into rehab would stop many of them calling 911 the second time.
If part of the problem is the readmission issue, perhaps that needs to be revisited. But it's possible that giving patients the wherewithal to shift into rehab would stop many of them calling 911 the second time.
12
And that is in fact the standard many private/employer insurers use -- that is, many of them have one copay, often a large one, for an ER visit, but that copay is often waived if you are "admitted" to the hospital (for which there is a different copay), with no distinction, at least as I can recall, between "regular" admissions and some other type of admission that may not be "regular,' like "observation."
5
I got caught in this situation last year when the physicians billed for inpatient care and the hospital for outpatient. Private health insurance hit me for both the ER copay and inpatient deductible. Neither hospital or physicians had any motivation to change billing codes and insurance company didn't have to pay as much in claims.
9
I feel that when patients are being observed for treatment the patient should still be considered as an inpatient and there shouldn't be any billing differences in the patient status of outpatient vs inpatient. If there is going to be a difference the patient should be informed of what the difference is going to mean for them and offer them alternative treatments that could benefit them without costing them anything. As someone studying Arts in Healthcare, studies show the benefits of the arts to the humanization of healthcare setting. As well, Arts in medicine has proven to reduce the stay, and use of medications when in a hospital. Ultimately this could reduce the cost of a patients stay and the cost of the hospital. Not entirely solving the billing issue but could benefit the patient through healing.
1
Given the very low reimbursement rates from Medicare to hospitals for medical care and inpatient hospitalizations, is it any wonder that hospitals and doctors - who unilaterally make the decision as to whether a hospitalization is inpatient or outpatient - impose outpatient status on those seniors on Medicare? Not only can they charge more than Medicare allows but they can charge those higher and/or unreimbursed costs to their unfortunate elderly patients. Since it's well-known that you get the behavior you reward and, human nature being what it is (i.e., generally greedy and selfish), hospitals and doctors have found, and readily use, a loophole in the Medicare regulations that incentivizes them to declare that a hospital stay is outpatient. This is the result of the "unintended consequences" of careless legislation and regulation at work.
15
There is no difference in the "care" provided to patients that are admitted to inpatient or placed in observation. The patient placed in observation will receive the same nursing care, diagnostic tests, medications, etc.... as the patient admitted to inpatient. The difference between observation versus inpatient is the length of time the patient will require medical care, less than 2 midnights, the patient is observation, if the patient requires medical care for longer than 2 midnights, admit to inpatient. CMS now requires that patients are notified if they are being placed in observation. No patient should remain in observation for longer than 48-36 hours. If a patient is in a hospital for longer than 2 midnights receiving medical treatment, that patient should be admitted to inpatient. If the hospital kept a patient as observation for 4-5 or more days, the hospital screwed up!
11
Even if you're hospitalized for weeks, such as in intensive care, 20 days is not even in the realm of typical so-called skilled medical facility, although short stays are not usual and many times because the patient was no longer wanted by the hospital. When the person's coindition deteriorates in the nursing home, she must be taken back by the hospital. And later, if she is stabilized in the hospital, the nursing home takes her back to spend the remaining few months of her life.
As for the per diem costs there is no comparison to actual critical care nursing that is afforded to residents on a caretaker regimen. That these large major facilities with their expensive administrative bureaucracies and floors and departments that are vacant must must be heated and cooled and cleaned should not have these costs laid on the backs of patients who have only Medicaid for help once their property and income and resources have been drained and confiscated.
At that point nursing home residents lose even the respect that is afforded those who are seen as paying, although in my case for 17 months my lower middle class income of $50,000 per annum was insufficient for the stay. It's certainly sufficient for independent living in a respectable pensione but only because I am able to manage a modest lifestyle and not in need of personal services except for the occasional that relatives and friends provide by being neighborly.
Is hospice care even considered hospitalization?
As for the per diem costs there is no comparison to actual critical care nursing that is afforded to residents on a caretaker regimen. That these large major facilities with their expensive administrative bureaucracies and floors and departments that are vacant must must be heated and cooled and cleaned should not have these costs laid on the backs of patients who have only Medicaid for help once their property and income and resources have been drained and confiscated.
At that point nursing home residents lose even the respect that is afforded those who are seen as paying, although in my case for 17 months my lower middle class income of $50,000 per annum was insufficient for the stay. It's certainly sufficient for independent living in a respectable pensione but only because I am able to manage a modest lifestyle and not in need of personal services except for the occasional that relatives and friends provide by being neighborly.
Is hospice care even considered hospitalization?
7
No hospice care is not considered hospitalization. Hospice is intended as palliative care for patients with less than six months to live.
2
Frank: I agree with you on the long term, sub-acute, whatever places. One thing I noticed when my elderly mother was in rehab for 99 days following 3 weeks in intensive care was that there were actually a number of younger people -- like 30s, 40s, 50s -- in my mother's subacute facility, as many private health insurers don't want people (say someone who's broken a leg) to spend too long in acute care hospitals so they offload them to these nursing homes sub-acute rehab places.
I also agree with you on the quality of care in the sub acute places. I chose very carefully as my mother was still sick with an open wound when she went to "rehab," but nothing prepared me for what I encountered there at what was allegedly one of the best places in NYC. Coping with the life and death stress of the ICU was nothing compared to this places, where I Iiterally had to run around tracking people down (including taking a taxi up there at nearly 11PM one night) to get them to do there jobs. Many of the "RNS" were temps; many had recently arrived from other countries, where attitudes toward the elderly were different. In one case, when my mother challenged a nurse on a medication she wanted to give her as she didn't think it was on her list of meds, the nurse responded "You take medicine, lady. Medicine make you feel good," as if my mother were some sort of incompetent fool who didn't even deserve to have her question answered.
I also agree with you on the quality of care in the sub acute places. I chose very carefully as my mother was still sick with an open wound when she went to "rehab," but nothing prepared me for what I encountered there at what was allegedly one of the best places in NYC. Coping with the life and death stress of the ICU was nothing compared to this places, where I Iiterally had to run around tracking people down (including taking a taxi up there at nearly 11PM one night) to get them to do there jobs. Many of the "RNS" were temps; many had recently arrived from other countries, where attitudes toward the elderly were different. In one case, when my mother challenged a nurse on a medication she wanted to give her as she didn't think it was on her list of meds, the nurse responded "You take medicine, lady. Medicine make you feel good," as if my mother were some sort of incompetent fool who didn't even deserve to have her question answered.
12
Where I live short term rehab staysin nursing homes are often $400-$450 per day and I live in a rural area. This is definitely unaffordable for most patients. And to clarify a question asked re what was meant by "Medicare fraud" by another person who commented, if a medical provider bills for a level of care that does not follow the criteria set by Medicare for that level of care, it is considered fraudulent billing and can have serious consequences.
6
And they can be three times that in metro areas like New York.
5
I am disappointed by the many commentators here blaming corporate greed for the pain that is actually being inflicted by the government on them. Medicare makes rules for how much a patient can be charged for a service, it also makes rules for when it will cover a service (such as rehab) or not. many people seem to be misled into thinking that healthcare providers should fudge facts to get them covered for services that medicare would not otherwise cover. When medicare refused to pay for a nursing home or hospital stay for someone, do you think the hospital makes more money? - this is the ignorance we are up against.
9
Don't be naive, hospitals whether for profit or classified non-profit use the system to maximize payments.
3
glad I live in Canada.ripoff artists in the states.
9
@richard: And your point is??
2
I live in Northern Michigan and a lot of Canadians come acres the boarder for medical car.
4
The fact is that there is no solution to this. Hospitals get penalized for re-admissions and long patient stays - they have been coerced by CMS into not admitting patients. Also, doctors have to shake a crystal ball and 'guess' how long a patient may be admitted for. and need to decide if they will stay 'two midnights.' A time frame I can tell you means absolutely nothing. These rules are written by idiots not clinicians. Meanwhile we have an aging population and every force in medicine is driving up the cost- nothing more so than defensive medicine. We need tort reform and a strict rationing of resources if our medical system is to survive. Patients will need to have patience and realistic expectations. We also need to significantly limit the treatments we offer in terminal patients.
15
The patient was there for 4 nights, had a stent put in to manage her condition. No way that should be considered "observation"! Clearly she should have been in "admitted" status.
12
This article needs a follow-up. We still need to learn why hospitals classify so many patients as under observation rather than as inpatients. I expect hospitals or doctors must gain financially in some way from that decision, but it would be good for a Times reporter to spell it out.
18
Hardly the case, actually, Richard. As a physician myself, I assure you neither the hospital nor doctor benefits-the hospital, in particular, loses big time. Most of the time the decision for observation status is made by a third party that administers benefits for Medicare ( usually an insurance company) so they pay only for the first 23 hours of care, while the Hospital absorbs the rest of the costs themselves, and then the patient is responsible for the rehab costs. The rules that define what constitutes "Obs status" are quite arbitrary, and don't allow any flexibility for the challenges encountered in caring for elderly, chronically ill patients, many of whom don't have an immediately accessible support network to help them recover from even the most minor illness. And sadly, many of these insurance companies deliberately encourage their "utilization management teams" ( usually nurses employed to review the records of currently hospitalized patients) to demand they be classified as "Obs status" for financial gain.
10
Mr. Lachmann, to repeat a reply posted below:
Auditors, who work for companies that contract with the Centers for Medicare and Medicaid Services, scrutinize hospitalizations. If the auditors determine that a hospital deemed someone an INpatient who should have been an OUTpatient, Medicare can deny reimbursement and the hospital has to eat the cost.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
Auditors, who work for companies that contract with the Centers for Medicare and Medicaid Services, scrutinize hospitalizations. If the auditors determine that a hospital deemed someone an INpatient who should have been an OUTpatient, Medicare can deny reimbursement and the hospital has to eat the cost.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
21
This is valuable information Paula. Thank you. I wish the Times article had explained these pressures on hospitals.
5
We all need to push our Representatives and Senators to support the Improving Access to Medicare Coverage Act! Who could be against this? Hospitals and doctors hate this situation. No one planned this outcome. This is common sense legislation and badly needed.
Appeal rights are not the answer. No one has time to figure out how to appeal these things. I will contact my DC representatives and please ask others to do the same.
Appeal rights are not the answer. No one has time to figure out how to appeal these things. I will contact my DC representatives and please ask others to do the same.
13
As a physician I do my utmost to admit my patients as INpatient. However I will not commit Medicare fraud by not following the rules. I explain to patients my reasoning and if they disagree, I tell them to contact their Congressman.
11
@Budoc: You need to explain what you mean when you say you "will not commit Medicae fraud by not following the rules." What rules prevent you from insisting that a patient be admitted as a INpatient? I and many others would like to know the answer, seriously.
9
Or Congresswoman.
4
First, do no harm.
2
I fought this on more than one occasion for my mother. At least three times, they tried to hold her for "observation". She had just had a stroke and her blood pressure was not controlled. I demanded that the hospital ombudsman (which I knew her hospital have) become involved in the conversation. (One was at 2 am) I then put on my lawyer hat and said, I know you are doing this so that if she requires re-admission within 30 days, you will not be paid under Medicare rules and I don't care. This borders on malpractice and it doesn't cost me anything but time to file suit and $157.50.
It was horrific. It is, in large part, driven by the policies about "good care" and "good outcomes". If you never admit, it can't be held against you in statistics.
Each time, they gave in. At one point, her cardiologist and neurologist joined me in the fight because she wasn't stable to be sent home. What about all those who do not have an advocate? It is a crime and we, as a nation, should be ashamed of how we are treating the greatest generation.
It was horrific. It is, in large part, driven by the policies about "good care" and "good outcomes". If you never admit, it can't be held against you in statistics.
Each time, they gave in. At one point, her cardiologist and neurologist joined me in the fight because she wasn't stable to be sent home. What about all those who do not have an advocate? It is a crime and we, as a nation, should be ashamed of how we are treating the greatest generation.
77
As a retired neurologist, I can testify that this comment is spot on. However the Medicare/ CMS rules are written, the way both the hospitals' and CMS reviewers have applied them encourages physicians and PA's/ARNP's to administratively classify stays as observation to save the public purse. The incentive is that if an admission is deemed "observational" because it does not persist long enough, physician send institution are not paid, or if paid, have to return any moneys received from MCS or other insurer. Ironically, while supposed to be easier work than admitting, the reality is that urgent exams, lab tests and anticipating an inscrutable future of what will as opposed to what may happen to the patient ends up being harder work. The rules are set up this way to discourage provider-gaming of the system, but instead, the system "games" the providers and patients.
20
Meanwhile podiatrists are performing ankle replacements, and a PA with as little as three-years training is often who examines you in the doctor's office. Of course you are billed as if the doc saw you! Small wonder Americans seek hospitalization abroad.
14
PAs have a minimum of 6 years of education (Bachelors and Masters degrees are required for certification). It's possible you may see a new PA who has recently graduated but to say is they receive "as little as 3 years of training" is not accurate. PAs are trained by and work closely with their physicians. Patient's are not billed the same rate as when they are seen by a physician.
6
@prunella: My orthopedist's PA works very closely with him (including assisting him in surgery). I have the greatest faith in her, and she has the requisite training and many years of literally hands-on experience. I trust her as much as I trust my doctor himself.
4
This once nearly happened to me. However, at the admissions office I insisted that I had a right to be admitted as an inpatient, not as an outpatient, if I was going to spend a single night in the hospital. I threatened to contact the Office of the Inspector General of Health and Human Services and file a complaint of fraud.
The hospital admitting staff probably thought my mental health was questionable. They admitted me as an inpatient. Three nights later I was discharged.
The hospital admitting staff probably thought my mental health was questionable. They admitted me as an inpatient. Three nights later I was discharged.
17
Another scam by the medical industry. No other industry is allowed to scam its customers without being investigated by the government. Not only do they not post prices to allow comparison shopping, but they cheat on what you pay exorbitant prices for. While you are asleep, who is actually performing your surgery, the doctor you hired or some other lower paid student you never met. Americans have the highest cost for health services but we do not have the best care. Doctors are rewarded by their employers to order too many unnecessary tests and the customers are afraid to ask any questions. You would not do business with any other company that treats you like a this. Don't be afraid to ask questions and demand answers before you fork over money for the overpriced services you may not actually need. Their newest scam; you are a patient in the hospital but you are not admitted. Only the medical industry could come up with an oxymoron like that.
25
while I agree with you;nobody seems to care about mal practice insurance costs and scare! and what effect it actually has in ramping up the cost of health care and fattening up lawyers bank account!!!!.
2
how is this a medical industry scam my friend? If medicare refuses to pay for your healthcare/rehab/nursing home stay - is the medical industry making more money in any way?
4
If you read the article you would know why hospitals use observation instead of admission. If the patient is re-hospitalized within 30 days the hospital has to pick up the tab. This is not a trivial matter. There is so much carelessness, wrong diagnoses and wrong treatment in hospitals that they are frequently responsible for the bad outcomes. They dodge the danger by pretending the customers are not admitted so they don't have the financial burden of the errors if they are readmitted within 30 days.
4
Medicare does not pay for custodial care. It pays for rehabilitative care after hospitalization if the patient is expected to recover. And the co-pay for a 100 day stay is over $20,000.
Ms Niemi did not need skilled nursing care, she needed a nursing home (custodial care) because she was too frail to return home and live independently. She could afford to pay for her own care. If she had exhausted her resources, she would have been covered by Medicaid.
There is a safety net in place. She and her son object to paying for care she can afford, and want Medicare to cover custodial care.
For all of those out there rooting for single payer Medicare-for-all, keep in mind that Medicare has a 20% co-pay after a small deductible and has no out-of-pocket maximum. There is not limit on what Medicare will pay, but the patient gets popped for 20%.
How thrilled will the people with employer provided health insurance be with the prospect of an unlimited 20% co-pay for catastrophic medical costs?
Ms Niemi did not need skilled nursing care, she needed a nursing home (custodial care) because she was too frail to return home and live independently. She could afford to pay for her own care. If she had exhausted her resources, she would have been covered by Medicaid.
There is a safety net in place. She and her son object to paying for care she can afford, and want Medicare to cover custodial care.
For all of those out there rooting for single payer Medicare-for-all, keep in mind that Medicare has a 20% co-pay after a small deductible and has no out-of-pocket maximum. There is not limit on what Medicare will pay, but the patient gets popped for 20%.
How thrilled will the people with employer provided health insurance be with the prospect of an unlimited 20% co-pay for catastrophic medical costs?
6
She actually needed physical therapy to regain her mobility. That is part of what a skilled nursing facility is supposed to provide for rehabilitation.
17
Presumably, if single payer Medicare-for-all was available, people would be able to purchase additional insurance (as current Medicare beneficiaries often do) that covers much of the 20% copay. Which, of course, just kicks the can down the road for anyone who can't afford the additional insurance - or who could afford it, but chooses to risk bankruptcy (thus dumping their costs onto everybody else) . . . but it's a start.
14
I've been a Geriatrician for nearly 30 years. The 3 day stay rule is an arbitrary rule with no clinical support or orientation. In the late 90's, our geriatric practice would admit frail older adults directly to skilled nursing facilities (they belonged to Medicare Advantage plans that could waive the 3 day stay) with great success. This practice successfully continues to this day. CMS is presently allowing ACO's to waive the 3 day stay. What does this say to older adults who are not part of such programs? CMS talks about delivering person centered care and this rule is anything but person centered. Congress gave CMS the authority to get rid of this rule some time ago, but no one has taken the initiative to just make the decision to do so. Convene a group of geriatricians and we'll be happy to advise Secretary Price and Ms. Verna on how to implement the change!
25
Dr. Wasserman - the problem is money. you are very right that the "3 day stay" rule is arbitrary. But its intent is clear - rejecting insurance claims! so the question is if they allowed everyone into a nursing home - whose going to pay for it???
This is socialism my friends - we have run out of other peoples money
This is socialism my friends - we have run out of other peoples money
5
Doug, Charlotte and others wondering why hospitals so frequently classify patients as OUTpatients: Auditors, who work for companies that contract with the Centers for Medicare and Medicaid Services, scrutinize hospitalizations. If the auditors determine that a hospital deemed someone an INpatient who should have been an OUTpatient, Medicare can deny reimbursement and the hospital has to eat the cost.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
25
It's really sad that, in this country we have to worry about being scammed and abused when we are at our most vulnerable. If only the people who vote Republican, over and over, knew how people live in civilized countries. They have no idea, which is why they put up our substandard society, with the decimation of unions, no paid parental leave, banks like Wells Fargo that scheme to steal from their customers, climate deniers, religious fakers, and our unbelievably cruel medical system.
47
If Ms Niemi had been admitted to skilled nursing care after her hospitalization covered by Medicare, the nursing home would have charged a higher rate, would have received more revenue per day than Ms Niemi paid, and her co-pays would have been $20,000 for a 100 day stay.
The thousands of people engaging in the class action suit think that they would be better off if Medicare had covered their stay in a nursing home.
Follow the money. The Medicare Advocacy is financed by the nursing home industry who want higher reimbursement rates paid by Medicare for 'skilled nursing' than they get for custodial care. The members of the aggrieved class do not realize that they would have paid more in co-pays had they been covered by Medicare, and the nursing homes would have collected more revenue.
The "most costs" Medicare pays for days 21-100 leaves $20,000 for the beneficiary to cover through a co-pay. The patient $250/day co-pay, or $7500 per month, is more than the patient would self pay for nursing home care. The Medicare payment is pure gravy to the nursing home.
Medicare payment of skilled nursing care is intended for someone who has hip surgery and it is cheaper for the government to have them move to a skilled nursing home for rehabilitation, instead of keeping them in the hospital. It was never intended to be custodial care for people too frail to live independently while they recuperated from an illness.
Big medicine wants higher reimbursements from the taxpayers.
The thousands of people engaging in the class action suit think that they would be better off if Medicare had covered their stay in a nursing home.
Follow the money. The Medicare Advocacy is financed by the nursing home industry who want higher reimbursement rates paid by Medicare for 'skilled nursing' than they get for custodial care. The members of the aggrieved class do not realize that they would have paid more in co-pays had they been covered by Medicare, and the nursing homes would have collected more revenue.
The "most costs" Medicare pays for days 21-100 leaves $20,000 for the beneficiary to cover through a co-pay. The patient $250/day co-pay, or $7500 per month, is more than the patient would self pay for nursing home care. The Medicare payment is pure gravy to the nursing home.
Medicare payment of skilled nursing care is intended for someone who has hip surgery and it is cheaper for the government to have them move to a skilled nursing home for rehabilitation, instead of keeping them in the hospital. It was never intended to be custodial care for people too frail to live independently while they recuperated from an illness.
Big medicine wants higher reimbursements from the taxpayers.
4
@ebmem: Maybe it's true in Tennessee, but $7,500/month does NOT get you a month in a nursing home in or around the NYC area. Not even close.
It's about $12,000/month for a nursing home in the NYC area.
It's about $12,000/month for a nursing home in the NYC area.
8
this is simply fraud by government. hospitals get penalized for readmissions so admitting has a cost risk to them. three days and more benefits kick in for rehab and nursing home care so Medicare cost go up
How is it solved: don't call the need to stay in a hospital an admission call it something else. It the old lawyers trick; name it something else. Wizard of Oz stuff here.
So Medicare is in trouble, hospitals are in trouble; so kick it back to the patient!! Rationing by government isn't new, it will grow and is no different than other more socialized systems. It is a deception, if not a legal fraud. Either way trust in government goes down, down, down.
How is it solved: don't call the need to stay in a hospital an admission call it something else. It the old lawyers trick; name it something else. Wizard of Oz stuff here.
So Medicare is in trouble, hospitals are in trouble; so kick it back to the patient!! Rationing by government isn't new, it will grow and is no different than other more socialized systems. It is a deception, if not a legal fraud. Either way trust in government goes down, down, down.
6
I know about this observation thing and made sure my mother was always admitted as an inpatient. Related--when my 35-yr-old daughter needed emergency gallbladder removal, she had no insurance and was put in a little curtained area of the ER for post-op of 2 days...the cheap seats, I guess.
5
After many years of indecision, I now firmly believe that all medical and dental expenses that are not cosmetic except in rare circumstances (e.g., disfigurement resulting from disease or accident) should be covered by universal medicare for all US citizens regardless of age. How to pay for it? Forget the stupid wall and concentrate on more rigorous enforcement, and stop minding the business of every other country and fomenting regime change, including getting out of Afghanistan and Iraq.
20
It would all be covered if she had Medicaid. Welfare. Something is very wrong!
5
Not every nursing home facility will take medicaid, and certainly not every provider. What is much more important is that it is not unusual ,at all, in fact it is very common that the the very old will exhaust every bit of resource they have and be on medicare\medicaid towards the end. It is not "welfare" in a perjorative sense.
6
When will the discussion shift to the absurd cost of medical care in this country instead of fighting over who will pay for it? The answer to that is one is all of us. And at over $10,000 per capita per year, we can't afford it.
8
I have done a health blog daily for 11 yrs and I follow this, but when my primary asked me did I want a Prevnar pneumonia shot, I agreed, only asking about the side effects. When the EOB came, the doc had billed $450 for that shot and $51 for the nurse to inject it. He got $200/$12 but still, one shot--I should have asked. Are we responsible for some of this? I could still get pneumonia--as I did twice on the old shot.
9
Were you there for mrs than a flu shot?
This is a perfect example of single payer healthcare, which is what Medicare is. Single payer advocates are seeking Medicare for all. The problem is that under single payer the organization that pays the bills also makes the rules. A much better answer is seen in the top quality rated nonprofit health plans, such as Tufts, Kaiser, Harvard Pilgrim and some of the nonprofit Blue Cross and Blue Shield plans. They have state and federal regulators looking over their shoulders all the time. And they compete with each other on customer satisfaction, quality ratings and price. Many of the commenters don't seem to realize that Medicare is single payer.
7
I live in New York. Tufts, Kaiser and Harvard Pilgrim are not available here and New York's Empire BCBS is a subsidiary of Anthem, a for-profit company. In short, for-profit insurers, which comprise the vast majority of insurers in the US, have always written the coverage rules for which they pay claims. Ergo, the need for the ACA, which imposed basic coverage requirements such as elimination of the pre-existing condition clause and payment for annual physicals, vaccinations, mental health problems, etc.
I am on Medicare, a single payer system, and although there are many rules and regulations that are unfair or wasteful, reform is at least possible with effective lobbying and a willing Congress. The same cannot be said for the for-profit insurers which will be free once again to do whatever they wish should this administration succeed in sabotaging or abolishing the ACA.
I am on Medicare, a single payer system, and although there are many rules and regulations that are unfair or wasteful, reform is at least possible with effective lobbying and a willing Congress. The same cannot be said for the for-profit insurers which will be free once again to do whatever they wish should this administration succeed in sabotaging or abolishing the ACA.
4
I agree with Cordelia on the absence of good nonprofit plans in New York.
Also, regarding BCBS, thought I would share that when I turned 65 five years ago I chose the Medicare supplement ("Medigap" plan) known as High Deductible Plan F (same as all-inclusivve Plan F, except doesn't kick in and start paying until you have paid the first $2300 or so in Medicare deductibles, coinsurance, etc.) I thought it was a good deal, costing about $200 a month than the cheapest regular Plan F. Not only have my monthly BCBS premiums for this plan,(which are regulated by NY insurance dept. w/ any ncreases in premiums requiring proof of claims increases) not increased under High ded. Plan F, they have actually gone down, from about $77 a month to about $71 the last two years.. Further, BCBS has abandoned Medigap plans in NY, now offering only Medicare Advantagae plans, which are apparently far more profitable for them, though the state requires they cannot abandon existing Medigap customers like me.
I think it's also interesting to note that AARP's "approved" insurer -- United Healthcare -- refuses to offer High Deductible Plan F in its "expertly and carefully" selected menu of Medigap and Medicare Advantage plans, at least in NY. I have written to AARP about this many times, and no longer even get answers, as they seem also to be driven by the profit motive these days.
Also, regarding BCBS, thought I would share that when I turned 65 five years ago I chose the Medicare supplement ("Medigap" plan) known as High Deductible Plan F (same as all-inclusivve Plan F, except doesn't kick in and start paying until you have paid the first $2300 or so in Medicare deductibles, coinsurance, etc.) I thought it was a good deal, costing about $200 a month than the cheapest regular Plan F. Not only have my monthly BCBS premiums for this plan,(which are regulated by NY insurance dept. w/ any ncreases in premiums requiring proof of claims increases) not increased under High ded. Plan F, they have actually gone down, from about $77 a month to about $71 the last two years.. Further, BCBS has abandoned Medigap plans in NY, now offering only Medicare Advantagae plans, which are apparently far more profitable for them, though the state requires they cannot abandon existing Medigap customers like me.
I think it's also interesting to note that AARP's "approved" insurer -- United Healthcare -- refuses to offer High Deductible Plan F in its "expertly and carefully" selected menu of Medigap and Medicare Advantage plans, at least in NY. I have written to AARP about this many times, and no longer even get answers, as they seem also to be driven by the profit motive these days.
3
The article fails to mention the significant amount of work that hospitals must do to make sure patients are under the correct level of care (inpatient versus observation). If the hospital gets it wrong and is audited, it is considered Medicare fraud and there can be big penalties, not to mention the non-payment of the claim. I have worked in hospital utilization management on both hospital and insurance sides.
11
All the more reason to have more "observation" done at home, which is possible with today's electronic devices and would likely cost much less.
6
There are many situations where home observation would not be pracctical...for starters IV fluids and frequent labs.
7
But why does that distinction exist to begin with? If you need to stay overnight in a hospital, then by definition you are not an out patient.
6
It seems to me that hospitals try to get rid of patients as fast as they can, so this issue can't happen all that frequently, can it? Who gets to stay three days anymore? I have friends that have had hip replacements and are still sent home the day after surgery--unable to do anything for themselves and in tremendous pain. One friend had abdominal surgery and was sent home the next day. I don't know how patients without families are supposed to manage. Patients are barely awake from surgery, and they're shown the door. If hospitals are anxious about readmittance numbers, you'd think they'd keep people a little longer to recover, but on the other hand, if patients can't pay the bills, maybe they're better off. I guess the answer is to just try to stay out of the hospital as long as we can.
12
Maybe that is due to the fact that they make more profit on procedures, and some procedures assume a stay of a certain number of days and some don't
5
Under Medicare, if pts return, the hosp eats it.
6
Good article disclosing arbitrary Medicare rules and how they are manipulated. But in my experience with my parents, the bigger issue was with nursing homes, many of which are horrible storage places where the elderly deteriorate rapidly. There are very few options for someone who needs care and rehab, and home care is hugely expensive, whether a family member gives up a job or an aide with basic skills is used. Dying in the U.S. is simply a hugely sad and expensive process. I'm not sure what the solution might be, my hope for myself is to make caring use of right-to-die laws.
15
Yes, Medicare generally won't pay for acute, or higher level, rehab, the kind of care a working person with a good employer medical plan gets. So the elderly are unloaded on these "subacute rehab" places which, if you are lucky, give 25 or 30% of the amount of rehab you would get at a higher level place. It can be devastating for, say, someone who has had a middling stroke and really needs some therapy to get back the life he or she had. Actually, it often doesn't happen and people leave "rehab" seriously diminished. As a child, one of the most challenging aspects of overseeing my mother's care, was when she spent 99 days in rehab after almost dying of sepsis and spending 3 weeks in intensive care. I felt I was always fighting with the rehab people, supposedly one of the best in NYC, over giving her the therapy she needed to resume a normal life ("no, she's not going home in a wheelchair in your facility van; she's going home in a cab with me, and she damn well better be able to get into and out of a cab," which initiated a great flurry of activitiy at her facility, as it had apparently never occurred to them that someone who lives in Manhattan would need to get into and out of a cab). They simply seem to have been able to get away with assuming, and providing, lesser lives for older people.
Long term care in these facilities is even worse, as the reimbursement levels are much less than for for "sub-acute rehab."
Long term care in these facilities is even worse, as the reimbursement levels are much less than for for "sub-acute rehab."
9
@ellie: You've just said it ALL in your sentence: "They simply seem to have been able to get away with assuming, and providing, lesser lives for older people."
That is precisely this issue: Older people are considered "less than" and are presumed to not need, or want, or even *deserve* to be rehabbed to the level and life they had been at (or better). It is one of the main ways this society tells the elderly that they are worthless. And it's wrong: morally, ethically, and objectively wrong.
That is precisely this issue: Older people are considered "less than" and are presumed to not need, or want, or even *deserve* to be rehabbed to the level and life they had been at (or better). It is one of the main ways this society tells the elderly that they are worthless. And it's wrong: morally, ethically, and objectively wrong.
5
My mother was in a nursing home in Utah where she got excellent care. I was always called when a problem arose.
So even when you're arrested you have to be charged within a limited amount of time or you have be released. There should be a similar rule for hospitalization. After 48(?) hours you should have to be admitted.
10
Health care cannot be fixed. New doctors and nurses cannot be trained fast enough to keep up with the patient demands of an aging population. The administration, financing and management of health care services is a secondary issue in the face of these profound demographic changes.
Projections for percentage of U.S. Population aged 75 and over:
2017 6.6
2020 6.9
2030 9.5
2040 11.7
In raw numbers:
2017 21.6 Million
2020 23.2 Million
2030 34.2 Million
2040 44.3 Million
Any increase in the size of the medical labor force will be more than offset by the tidal wave of older people.
Hospitals are dangerous places. See a doctor only when it is absolutely necessary.
Projections for percentage of U.S. Population aged 75 and over:
2017 6.6
2020 6.9
2030 9.5
2040 11.7
In raw numbers:
2017 21.6 Million
2020 23.2 Million
2030 34.2 Million
2040 44.3 Million
Any increase in the size of the medical labor force will be more than offset by the tidal wave of older people.
Hospitals are dangerous places. See a doctor only when it is absolutely necessary.
17
I am a physician and I agree with Dan.
8
The rules are assinine and archaic. This shouldn't be the case in a highly developed country but then again as far as health care is concerned the US iis in many respects, in the dark ages.
12
This article omits an important, sleazy reason for the rising use of observation status by hospitals. Under rules intended to improve quality of care, there are financial penalties applied to hospitals who have high readmission rates. So in a scam maneuver, hospitals creatively started using "observation" status to dodge the intent of the penalties. A patient who was never admitted in the first place cannot be readmitted, so voila! No penalty! Only in America, where we use creativity to hurt people and dodge accountability, instead of solve problems. I am disgusted.
110
Don't blame the hospitals, or the doctors! Be aware -- especially those of you who want our government to totally run healthcare -- "observation status" was created by Medicare and is enforced by Medicare. Hospitals/doctors must follow Medicare rules in determining a patient's status. There is widespread belief among providers (and patient families!) that Medicare did/does this to shift expenses to Part B and supplemental insurance plans, and even more important, to reduce its own coverage/expenses for post-hospital care in nursing homes. Remember, a government that is big enough to give you everything you want, is big enough to take everything you have.
11
Not so. Hospitals came up with "outpatient" status to avoid 3 day readmission rule if the patient comes back, also to avoid having to provide adequate hospital care. Outpatient floors are barely more than kennels.
10
Because big for-profit hospitals only have the patient's best interest in mind?
The profit motive necessarily leads to better care (at least, better than can be provided by any government agency, admittedly a very low bar) lest the patient take his business elsewhere.
Paula
I've been reading about this issue for years. This article tells me nothing new. I want to know the following.
If CMS makes the rule requiring observational status, what is their rationale?
If only Congress can change the rule, who is against changing the rule and what is their rationale?
I've been reading about this issue for years. This article tells me nothing new. I want to know the following.
If CMS makes the rule requiring observational status, what is their rationale?
If only Congress can change the rule, who is against changing the rule and what is their rationale?
20
Excellent question, Paula. I am new to this issue and am flabbergasted! More coverage on this issue, please!
2
Doug and others wondering why hospitals so frequently classify patients as OUTpatients: Auditors, who work for companies that contract with the Centers for Medicare and Medicaid Services, scrutinize hospitalizations. If the auditors determine that a hospital deemed someone an INpatient who should have been an OUTpatient, Medicare can deny reimbursement and the hospital has to eat the cost.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
Thus, even though the reimbursement is actually higher for INpatients, hospitals don’t want to risk having payment denied. They go the safer route and say people are on observation, or OUTpatients. Bonus: That insulates them from the penalties Medicare now imposes when patients bounce back to hospitals shortly after being discharged. Hospitals don’t have to pay penalties for readmission within 30 days for OUTpatients, who were never officially admitted in the first place.
Moreover, if the Justice Department decides that a hospital is billing what should be OUTpatient stays as INpatient ones, thereby overbilling Medicare, it can recover millions of dollars.
Doctors are constrained by these practices. Even if they urge that certain patients be admitted as INpatients, a hospital’s utilization review committee can overrule them, and often does. Hospitals try to comply with what Medicare wants.
Advocates have argued that Medicare can change this practice administratively, but it has resisted. Hence, the lawsuit.
4
Franz Kafka is alive and well and working for CMS. The article should have given a brief review of how we came to this tragic situation where patients and their families have to shoulder liabilities of tens of thousands of dollars because of the actions of a coding clerk, hospital administrator or reviewer at Medicare or the agencies it hires to find "fraud and abuse"and pocket "savings" (i.e. cost shifting).
Under the Medicare funding mechanism of Diagnosis Related Grouping, hospitals had gotten pretty smart at finding the highest-reimbursed codes for Medicare hospitalizations. Hospitals were reimbursed by diagnosis, regardless of length of stay or intensity of services. And sometimes hospitals did very well with getting the full DRG for a short stay. So along came the audits, clawbacks, fines, bounty hunter companies, and the consequent cost shifting to hospitals and patients. The natural flow of events is such that hospitals are over-cautious and "outpatient observation" is invoked more and more frequently. The end result is the hospitals get a lot less money for providing the same services, and patients are faced with ruinous debts.
The law of unintended consequences - or intended consequences - is alive and well.
Please call your elected officials to correct this insanity!
Under the Medicare funding mechanism of Diagnosis Related Grouping, hospitals had gotten pretty smart at finding the highest-reimbursed codes for Medicare hospitalizations. Hospitals were reimbursed by diagnosis, regardless of length of stay or intensity of services. And sometimes hospitals did very well with getting the full DRG for a short stay. So along came the audits, clawbacks, fines, bounty hunter companies, and the consequent cost shifting to hospitals and patients. The natural flow of events is such that hospitals are over-cautious and "outpatient observation" is invoked more and more frequently. The end result is the hospitals get a lot less money for providing the same services, and patients are faced with ruinous debts.
The law of unintended consequences - or intended consequences - is alive and well.
Please call your elected officials to correct this insanity!
18
"Money is the root of all evil". Getting medical care in America is much too complicated, or should I say, paying for it is much too complicated. I am glad that I came across this article because I was suffering under the delusion that if I spent the night in the hospital that I was an in-patient. One has to be a legal professional to understand all of the ins and outs of how much their so-called insurance will pay. Single payer, now.
12
@Susan: The full quote is "The LOVE of money is the root of all evil."
2
You are correct. Compared to England and Western Europe America is way behind in health care services.
Call Trump and your Congress Person to begin a change. Lots of luck.
Call Trump and your Congress Person to begin a change. Lots of luck.
1
This happened to me a few years ago. The hospital social worker came around and explained that i would be under observation and not officially enrolled. But she did not explain what this would mean to me financially. My insurance had always paid for everything. Why should this be different. We're still paying off the huge bill.
31
Sorry for your situation and huge bill. Curious whether you had a companion plan insurance that covers Medicare Part B co-pays. It is important to understand that Part B leave you responsible for 20% copays on all services. This might not amount to much on a $100.00 doctor's office visit but it is now a substantial item since more and more hospital services are being shifted to "outpatient" status and billed under Part B. I don't think there is a clear understanding of this cost shift among patients or lawmakers. The doctors are aware since they most likely hear about it from their patients. Also, I would like to know what chicanery the hospital in this article got away with to classify at "39 day" stay as "observation." I thought there was a 2 midnite rule ??
7
- this 'observation status' racket is one of many medical rackets, discussed in the book 'An American Sickness' by NY Times writer Dr. Elizabeth Rosenthal. Everybody needs to read it. It not only exposes the rot in our medical system (among the civilized world's worst), but gives specific ways individuals can avoid many of it's trapls.
- that this legal appeal is in it's 7th year and still unresolved, doesn't speak well of the U.S. legal system either.
- that this legal appeal is in it's 7th year and still unresolved, doesn't speak well of the U.S. legal system either.
42
Commercial health care; that's what you have in the US; it is COMMERCIAL - meaning you and your sickness exist, in their minds, to keep hospitals and their doctors in the money. (at least that's what it seems to be.)
Until you get rid of unscrupulous hospitals and their billing practices - think about spiders beckoning flies into their webs - you'll be paying paying paying until your dying day - and after, I bet.
Until you get rid of unscrupulous hospitals and their billing practices - think about spiders beckoning flies into their webs - you'll be paying paying paying until your dying day - and after, I bet.
15
It is the insurance companies far more than hospitals or physicians that cause this corruption of heath care in the USA. You spout the talking points insurance companies want you to believe. Doctors are forced to play by Medicare rules or their hospitals will lose Medicare reimbursement for all patients.
11
So you want to pay doctors what? Those in it for the money are often found fraudulent.
The article says that Part B covers outpatient ("Observation") treatment. So, does that mean that if you buy Part B you are covered?
What is means is that while some may be covered, it does not cover if you are transferred to a rehab facility or nursing facility. they you will pay a substanial chunk. Medicare.gox can explain more fully. Hopefully you have a supplement too.
5
Part B, which is optional,and which you pay SS for if you want it, was generally designed to cover things you expect to have done outside a hospital -- like visits to a Dr. office, and they are generally covered at 80%, with you paying the rest unless you have a private Medicare supplement that pays the 20%.
The Part A nursing home rehab benefit was intended to be a followup to inpatient hospital stays covered by Part A. But they are ONLY paid if you had an inpatient hospital stay covered by Part A. If you stay overnight in a hospital but are not "admitted" and have you stay covered by Part A, then no rehab stay will be covered. and even if you have a "Medigap" policy that picks up the nursing home post-20 day coinsurance, it will pay NOTHING for any part of the nursing home stay because it only pays when a service is covered by Medicare, and this would be a service not covered by Medicare since it was not preceded by a qualifying inpatient hospital stay.
The Part A nursing home rehab benefit was intended to be a followup to inpatient hospital stays covered by Part A. But they are ONLY paid if you had an inpatient hospital stay covered by Part A. If you stay overnight in a hospital but are not "admitted" and have you stay covered by Part A, then no rehab stay will be covered. and even if you have a "Medigap" policy that picks up the nursing home post-20 day coinsurance, it will pay NOTHING for any part of the nursing home stay because it only pays when a service is covered by Medicare, and this would be a service not covered by Medicare since it was not preceded by a qualifying inpatient hospital stay.
14
You are covered for the hospitalized observation itself as you are with any Part B benefit (there are deductibles and co-pays) but that part B hospital stay doesn't count toward the 3 days of Part A hospitalization needed to qualify you for Medicare provided skilled nursing facility care.
8
This shouldn’t come as a surprise—when is something not what common sense dictates it is? When a corporation will make more money (or buff up its stats) by mischaracterizing it.
It’s not just the observation vs admission scam. The latest variation is the Alternative Universe Dictionary apparently used by Medicare Part D carriers to pay as little as possible, jack up your co-pays and toss you into the "donut hole" as soon as they can. How else to explain a plainly generic drug (the label on the Rx bottle declaring it as such) being called a “preferred brand” so that the carrier pays less and you pay more?
And what throws one into said “donut hole?” The aggregate of what you and your carrier spent on drugs. But how do you climb out? Only by then spending out of pocket an amount nearly equal to that aggregate that pushed you into it in the first place. Oh, I know that’s a Medicare regulation, not a caprice of any one particular Part D carrier…but wait—who had major input into drafting that legislation in the first place? And on which industry does Congress depend for campaign contributions? Riiiight….
It’s not just the observation vs admission scam. The latest variation is the Alternative Universe Dictionary apparently used by Medicare Part D carriers to pay as little as possible, jack up your co-pays and toss you into the "donut hole" as soon as they can. How else to explain a plainly generic drug (the label on the Rx bottle declaring it as such) being called a “preferred brand” so that the carrier pays less and you pay more?
And what throws one into said “donut hole?” The aggregate of what you and your carrier spent on drugs. But how do you climb out? Only by then spending out of pocket an amount nearly equal to that aggregate that pushed you into it in the first place. Oh, I know that’s a Medicare regulation, not a caprice of any one particular Part D carrier…but wait—who had major input into drafting that legislation in the first place? And on which industry does Congress depend for campaign contributions? Riiiight….
21
The compensation of the CEOs of hospitals has increased dramatically. Administrative staffs are growing too. Maximizing their revenue flow by using the "under observation" category is a clever way to game the system to their benefit. In some ways, it is like a consumer product company reducing the net weight contents of a box but keeping it the same size. The consumer thinks they bought the same box of something as they had before....but no they haven't. Similarly, the ill person is in a hospital bed and stupidly believes he/she is "hospitalized" as before. No say the administrative staff. At year end, they dole out their fat bonuses. It is an outrageous and must be stopped.
29
If you take away profit driven health care and add health care as a right, this article wouldn't have been written.
24
Good point!
1
This widespread practice of quietly admitting medicare patients into observation status rather than inpatient status regardless of level of care needed has been occurring for years -sometimes with and sometimes without the tacit approval of the providers who admitted the patient. The question the article asked" :Why does the classification matter? " and then answered from the patient and family standpoint. Rightfully so, the impact can be devastating. Still, it is important to understand the reason for the classification shell game, the why it matters to providers. Facilities generate much more revenue from observation (outpatient) admissions for Medicare patients, than inpatient. Most if not all facilities have people or even whole departments (patient placement. etc) that not only direct patients into various beds but also manage the status of patients.
No matter how long the patient has been admitted, no matter even the intensity of care, a patient can be on a inpatient floor and have no idea that they are classified as outpatient observations and days or weeks later be discharged home to another level of care, etc. It looks the same, nurses provide the same care etc... the only different thing they will experience is the shock of paying huge bills later. There have been investigations and fines for the more egregious practices. but the practice will continue unabated - because providers can continue it - until there is teeth to stop it. .
No matter how long the patient has been admitted, no matter even the intensity of care, a patient can be on a inpatient floor and have no idea that they are classified as outpatient observations and days or weeks later be discharged home to another level of care, etc. It looks the same, nurses provide the same care etc... the only different thing they will experience is the shock of paying huge bills later. There have been investigations and fines for the more egregious practices. but the practice will continue unabated - because providers can continue it - until there is teeth to stop it. .
31
Why aren't hospitals admitting these patients? Who is benefiting from this situation? It looks like a shakedown, but I can't figure out who would profit except for Medicare, and they're not making the admission decisions.
8
Medicare has "Conditions of Participation" which hospitals must comply with or lose Medicare Reimbursement for all Medicare patients. That is a huge threat hanging over every non-profit hospital. It they lost that they would have to close.
There is also RAC review of all admissions and Observation stays and Hospitals can be fined or dropped from the program while the RAC Review organizations profit by incentives.
There is also RAC review of all admissions and Observation stays and Hospitals can be fined or dropped from the program while the RAC Review organizations profit by incentives.
9
Mimi, Facilities profit from this shell game, alot. Correct Full, , but it is still done, routinely. The most egregious will get disciplined but then just pay a fine
3
But WHY?
1
Health care is a major % of GDP and growing exponentially. Best method of looking at it is a pie graph of the total outlay and another pie graph of what the various disciplines take from the pot. Insurance companies, AMA, for profit Hospital corporations, and the Drug industry. As all the participants continue to raise their fees coupled with so so many Boomers retiring it is not sustainable without new major tax increases.
7
I have gone through this issue, not with a need for nursing care but with other costs, such as for drugs. I have now found that it is the hospital that decides what code to select for the care you are getting. By selecting the code for "observation" they are free to charge the patient more for drugs they take at home but are not allowed to bring into the hospital. In my case $5 per pill when my drugs for 90 days cost $10. It is very selective and a basis to increase profits. Even though I have insurance that is supposed to pay 100% of my hospital care, I received a bill for $340. Might seem small but I am on a fixed income. I believe it is the hospitals that should be pursued to change their code for the services. Does anyone monitor what the hospitals do? I think not and like our whole healthcare system, it is profits before healthcare. Only those that can afford it get the best care, no matter how much you need it. This has to change.
17
If you're on Medicare every year you will receive a copy of "Medicare and You" which explains how it works. They have a section for 2017 entitled "Am I an Inpatient or Outpatient" on page 34 which emphasizes the importance of asking if you are an inpatient in determining how much you pay. The entire booklet is quite good and everyone should at least skim it every year (especially those not reading the NYT).
14
It is good to ask, but it does not mean the status will change. What you can do is be very noisey and demand to talk to case management (patient placement etc) and ask very firmly why this is happening... and you then complain to CMS while there.
7
Right... we're going to do this while we are in pain or whoozy from surgery.
10
When patients have been in the hospital already and return because of complications, there is a big incentive for hospitals not to read it patients. They get penalized for readmissions and therefore want to keep these patients on outpatient status. Lack of transparency in billing is a huge problem in healthcare in general. It isn't especially a problem for urgent and emergent care when people don't have the time or ability to shop around for either the best price or the best care. When deductibles and coinsurance were low this didn't affect individuals, now with so many high deductible plans, consumers are aware of the cost of this lack of transparency.
9
Hospitals make more from Medicare when the patient is classified as INpatient. So Medicare will penalize them severely if a patient is classified INpatient incorrectly. Out of an abundance of caution, hospitals over-classify patients as OUTpatient. This is not in the hospitals' self-interest, as it angers the patients (their customers) and reduces their Medicare reimbursement. So please don't blame the hospitals, blame CMS which manages Medicare.
12
Actually, no. Facilities make more revenue with Medicare patients who are out patient obs.
2
You can bet that all efforts to help these folks will fail, with Trump and Republican politicians in charge.
14
Well it sure didn't progress under Obama or other presidents either apparently, so I don't know that Trump deserves any special criticism - at least on this.
8
Don't know if my 85 year old friend who went to ER where they discovered her sugar was 425 was considered inpatient or outpatient, but the hospital tried real hard to get her out of hospital in 1 or 2 days. She was recovering from shoulder injury that the hospital had treated with cast when first happened and then 6 weeks later gave her shoulder surgery for 2 broken bones in her upper arm.
They released the second day while her sugar was still 425 without any medication.
Best we could do is tell everyone NEVER go to that hospital.
They released the second day while her sugar was still 425 without any medication.
Best we could do is tell everyone NEVER go to that hospital.
14
Or report them to your state health department. Write them up on social media.
11
The outrage underlying this article may reveal a disconnect between what we want for our own families and what we are willing to pay for, either privately or in taxes. Fixing this will cost money. Lots of it. There have never been so many frail elderly adults relative to the number of employed young people. Medicare was intended as health insurance for elderly and disabled people when their proportion of the population was much smaller than it is now. It may be debatable whether Medicare is adequately funded to meet the acute care medical needs of those who depend on it, but there should no doubt about whether Medicare can pay for everyone who needs long-term nursing care: it can't. Increasingly, hospitals are being asked to provide three days of costly "inpatient" care specifically so that someone who needs longterm nursing can get 20 days of it for "free" under Medicare's rehabilitation rules, even if their rehabilitation potential is low. There is more than one "scam" here, but perhaps the biggest is the one we play on ourselves. We pretend that there is an infinite pot of money out there that will pay for the longterm care of our elderly and disabled relatives without any cost to them, their family members, or taxpayers. We profess shock! dismay! anger! when "they" deny funds for nursing home care, but I don't hear a lot of passion for "them" raising medicare taxes to a level that could pay $200 a day for nursing care for every elderly and disabled person who needs it.
59
The reason people are referred to these nursing homes is not just because they need longterm nursing home care. WHen people need "rehab" -- physical,occupational,etc. -- these are the places that generally provide the "subacute" rehab that Medicare will pay for. As a matter of fact, it is a big business for many of the facilities and handled in separate units and on separate floors. Medicare pays nothing for people with no expectation of recovery, for whom it is now time to go to a nursing home. But it does pay for rehab to restore functioning to a person who is capable of a restoration of functioning and a return home. Proper rehab -- and it can be hard to find, as the quality can vary greatly -- can make a huge difference in the quality of a person's life.
16
Also, keep in mind Medicare covers only 20 days in full for this type of rehab (and Medicare Advantage plans generallly cover much less), with the patient copay for any days from 21 to 100 being really substantial, so substantial that good nursing home rehab units in the NYC area review prospective patients' insurance arrangements carefully before admitting them and often discourage those who don't have good Medicare supplements that guarantee payment of that huge copay.
I think the point of this article is less about "we need more money to provide more benefits" than it is about "we need more transparency so people know what their status is in a hospital and maybe won't be quite as upset when they find out what it reallly is." Keep in mind that many of these people, in addition to paying premiums for Medicare Part B (which is keeping them on outpatient status), are also paying hundreds of dollars a month for private "Medigap" insurance that supposedly picks up the copays and other gaps in nursing home rehab stays, and it is quite upsetting to find they have been paying all those premiums only to get nothing in return.
I think the point of this article is less about "we need more money to provide more benefits" than it is about "we need more transparency so people know what their status is in a hospital and maybe won't be quite as upset when they find out what it reallly is." Keep in mind that many of these people, in addition to paying premiums for Medicare Part B (which is keeping them on outpatient status), are also paying hundreds of dollars a month for private "Medigap" insurance that supposedly picks up the copays and other gaps in nursing home rehab stays, and it is quite upsetting to find they have been paying all those premiums only to get nothing in return.
38
Wow, great comment. Tragedy of the commons.
2
92 year old into ER 3 times in one week for falls and headaches. Doctors and social workers tried to find ways to admit but the algorithms won out. Paid out of pocket for home care and, with other family members, had to schlep her back and forth to doctors and lab tests.
The licensed medical and social welfare professionals should have the final say, not the unlicensed beancounters.
The licensed medical and social welfare professionals should have the final say, not the unlicensed beancounters.
47
It is ludicrous that a 39 day stay is considered an "observation" visit, and I would expect that this is an outlier.
For the more typical observation vs. inpatient stay of a few nights, there is a misconception here that somehow the hospital is gaming the system by making the patient an "observation". The CMS rules are strict, often require highly paid consultants or expert administrators to advise, and result in potentially severe financial penalties to the hospital for inappropriate inpatient admissions. Oh, and the hospital usually makes less on the outpatient stay (compared to the inpatient). The hospital is caught in the middle.
For the more typical observation vs. inpatient stay of a few nights, there is a misconception here that somehow the hospital is gaming the system by making the patient an "observation". The CMS rules are strict, often require highly paid consultants or expert administrators to advise, and result in potentially severe financial penalties to the hospital for inappropriate inpatient admissions. Oh, and the hospital usually makes less on the outpatient stay (compared to the inpatient). The hospital is caught in the middle.
17
Hospitals do this because observed patients are handled differently when calculating readmission rates. Hospitals are penalized for readmitting too many people too soon. So they game the system by claiming these patients weren't really admitted.
In any other industry this would be outright fraud and people would go to jail. Hospitals are completely free of accountability. They get paid for actions leading to a negligent error. Then they get paid to fix the error. Where else is this tolerated?
Hospitals have well-paid lobbyists. They're not much different from the mafia and it's time to treat them accordingly.
In any other industry this would be outright fraud and people would go to jail. Hospitals are completely free of accountability. They get paid for actions leading to a negligent error. Then they get paid to fix the error. Where else is this tolerated?
Hospitals have well-paid lobbyists. They're not much different from the mafia and it's time to treat them accordingly.
159
Hospitals are big losers in the observation vs. inpatient decision. They pay consultants to guide patients appropriately, pay large penalties if admit patients that should be observation to inpatient status, get reimbursed considerably less for observation patients, and lose the PR war, too, because people falsely believe that they are gaming the system for their own benefit.
11
Good letter Catharine in Philadelphia - by the way - 'City of brotherly love'. It suits you.
2
This is a stunning article by the Times. But with all due respect, only half of your job as a public watchdog has been fulfilled by this article.
Sure, now we know that hospitals have (and routinely exercise) the ability to make apparently arbitrary decisions that can cost Medicare patients tens of thousands of dollars depending solely on whether the patient is classified as "inpatient" vs. "outpatient". And now we also know that the trend is to classify more and more hospital patients as "outpatients" - even thought they may be continuously confined to a single hospital bed and extensively "treated" for weeks before being discharged to subsequent nursing home care.
But what we don't have any clue to after reading this article is "Cui Bono"?
WHO BENEFITS from this seemingly arbitrary classification decision by hospitals every day in America? And WHY is this specific arbitrary decision totally beyond the reach of the standard Medicare appeal process?
Of course we can deduce with utter certainty that powerful special interests (with lots of "juice" on K Street) are making a killing on this scam - at the expense of Medicare patients who largely can't afford to pay for necessary nursing home care from their own pockets. But these powerful special interests are completely immune from public pressure until our Fourth Estate identifies them.
C'mon, NYT. Please finish your job here. "All the News That's Fit to Print", right?
Sure, now we know that hospitals have (and routinely exercise) the ability to make apparently arbitrary decisions that can cost Medicare patients tens of thousands of dollars depending solely on whether the patient is classified as "inpatient" vs. "outpatient". And now we also know that the trend is to classify more and more hospital patients as "outpatients" - even thought they may be continuously confined to a single hospital bed and extensively "treated" for weeks before being discharged to subsequent nursing home care.
But what we don't have any clue to after reading this article is "Cui Bono"?
WHO BENEFITS from this seemingly arbitrary classification decision by hospitals every day in America? And WHY is this specific arbitrary decision totally beyond the reach of the standard Medicare appeal process?
Of course we can deduce with utter certainty that powerful special interests (with lots of "juice" on K Street) are making a killing on this scam - at the expense of Medicare patients who largely can't afford to pay for necessary nursing home care from their own pockets. But these powerful special interests are completely immune from public pressure until our Fourth Estate identifies them.
C'mon, NYT. Please finish your job here. "All the News That's Fit to Print", right?
136
When "Under Observation" Hospitalised Patients are never admitted into a hospital and classified as "outpatients" rather than "Inpatients" the change in classification made because they are Under Observation...the ONLY difference between one patient in a hospital versus another...they cannot be told apart.
But for the one "Under Observation" subsequent rehab and /or Nursing Home Care and many other Normally covered Medicare benefits will not apply and financially tear apart their savings, equity or legacy, all caused by a tick on a box somewhere on the patient form or "admission papers that aren't really admission.
They are just another of the many ,varied and greed generated loopholes, scams and exploitations that American companies and corporations use,abuse and ensure always almost lose, the financial cannon fodder that are their customers, patients and target... the ordinary often vulnerable, struggling Americans that when all is said, billed and done, are one and all their many victims.
Peoples lives aka "The Great American Turkey Shoot" is a never ending obstacle course of exploits, traps, pitfalls, minefields and crimes committed against, from Woe to Go...and there by the grace of God most go...punchdrunk, abused and most of all far to commonly...Bankrupt.
This issue however is not the usual suspect (kind of) It is of the Government and it's members continued failure to repair a Clerical breach that causes so many so much angst. by delays in fixing it.
DO IT NOW.
But for the one "Under Observation" subsequent rehab and /or Nursing Home Care and many other Normally covered Medicare benefits will not apply and financially tear apart their savings, equity or legacy, all caused by a tick on a box somewhere on the patient form or "admission papers that aren't really admission.
They are just another of the many ,varied and greed generated loopholes, scams and exploitations that American companies and corporations use,abuse and ensure always almost lose, the financial cannon fodder that are their customers, patients and target... the ordinary often vulnerable, struggling Americans that when all is said, billed and done, are one and all their many victims.
Peoples lives aka "The Great American Turkey Shoot" is a never ending obstacle course of exploits, traps, pitfalls, minefields and crimes committed against, from Woe to Go...and there by the grace of God most go...punchdrunk, abused and most of all far to commonly...Bankrupt.
This issue however is not the usual suspect (kind of) It is of the Government and it's members continued failure to repair a Clerical breach that causes so many so much angst. by delays in fixing it.
DO IT NOW.
11
Based on this shameful "Loopy Hole"I think they should rename Hospital patient Classifications as either "IN Patients" or "OUT of luck Patients"...leaving the majority of everybody else in the country as " OUT of Patience" with the shambles that is the American Health Care/Insurance System.
Single Payer Now.
Single Payer Now.
38
As an internist geriatrician I see no circumstances where a 39 day hospital stay does not include three in patient days. The admitting physician deserves to be drawn and quartered, fined and suspended by his state medical board and placed in a position of having to pay his or her parents post hospital care bills when some other criminal treats his folks that way.
I suspect the admitting physician was a hospital employee or ACO employee guarding his firms bottom line ahead of his patient's legitimate needs. Disgraceful. Andy Slavitt formerly of CMS deserves a special place in hell for his support of observational status
I suspect the admitting physician was a hospital employee or ACO employee guarding his firms bottom line ahead of his patient's legitimate needs. Disgraceful. Andy Slavitt formerly of CMS deserves a special place in hell for his support of observational status
183
Do you seriously believe doctors are behind these decisions? Last time I worked in a hospital a team of nurse-administrators met with me every morning to discuss discharge plans for all of my patients; they made it clear the hospital wanted a high turnover rate, regardless of the patient's condition.
Most hospitals employ "hospitalists" - doctors and lesser trained clinicians - who take care of hospitalized patients. The days when doctors would round on their own patients in the hospital are long gone.
Most hospitals employ "hospitalists" - doctors and lesser trained clinicians - who take care of hospitalized patients. The days when doctors would round on their own patients in the hospital are long gone.
2
Hospitalist here - I can see circumstances where a 39 day hospital stay would all be observation. One example would be the patient with severe dementia brought to the hospital by a neighbor who realized the patient wasn't safe to be at home. No family, no power of attorney, and now the hospital must go through the legal process of conservatorship, which can take weeks. The patient isn't sick at all - just unsafe to return home. The hospital is legally obligated to warehouse the patient until a safe discharge plan is in place. That would not qualify for inpatient status regardless of how long it took to obtain conservatorship.
I believe there is more to the story, as a 39 day stay under observation status does not make a lot of sense, though if all they were doing was trying different oral BP meds, I can see where she would not meet criteria. I would politely urge you to withhold judgement until all the facts are known. One patient like this does not make a significant enough difference to a hospital's bottom line.
I agree that the whole thing appears to be a scam. I also believe that it is probably in response to past abuses of the system, like a family deciding they don't want to take care of an elderly family member anymore, dropping them off at the hospital despite not being ill, and having Medicare pick up the tab for a nursing home stay.
I believe there is more to the story, as a 39 day stay under observation status does not make a lot of sense, though if all they were doing was trying different oral BP meds, I can see where she would not meet criteria. I would politely urge you to withhold judgement until all the facts are known. One patient like this does not make a significant enough difference to a hospital's bottom line.
I agree that the whole thing appears to be a scam. I also believe that it is probably in response to past abuses of the system, like a family deciding they don't want to take care of an elderly family member anymore, dropping them off at the hospital despite not being ill, and having Medicare pick up the tab for a nursing home stay.
1
Take a good look at the comments below-- especially those made by people "inside" the system.
This started in the 1980's and is a direct financial outgrowth of the DRG system ("diagnostic related groups") -- which meant Medicare no longer paid by the hospital day, as they did before prospective payment [DRGs] , but by a single payment based on the severity of the diagnosis (or "diagnostic group"). What this meant was that the hospital got a single, set payment for an admission-- meaning that a lengthy stay meant the patient became a financial "loser"--one the hospital lost money on. Hospitals developed various ways to cope with this-- the most popular of which (with the hospitals) being to declare in the chart that the patient was no longer at an acute care level. This meant that they were no longer covered by Medicare for the hospital stay and could be charged a la carte as it were for any further services received.
Bottom line-- money drives this. Do not think for a moment that hospitals do not look after their bottom line.
In the event that a large balance is run up, patients should not be surprised if the hospital tries to bring legal action against them for the balance or to put a lien against their house.
How aware do you think the average patient is of all this?
This started in the 1980's and is a direct financial outgrowth of the DRG system ("diagnostic related groups") -- which meant Medicare no longer paid by the hospital day, as they did before prospective payment [DRGs] , but by a single payment based on the severity of the diagnosis (or "diagnostic group"). What this meant was that the hospital got a single, set payment for an admission-- meaning that a lengthy stay meant the patient became a financial "loser"--one the hospital lost money on. Hospitals developed various ways to cope with this-- the most popular of which (with the hospitals) being to declare in the chart that the patient was no longer at an acute care level. This meant that they were no longer covered by Medicare for the hospital stay and could be charged a la carte as it were for any further services received.
Bottom line-- money drives this. Do not think for a moment that hospitals do not look after their bottom line.
In the event that a large balance is run up, patients should not be surprised if the hospital tries to bring legal action against them for the balance or to put a lien against their house.
How aware do you think the average patient is of all this?
46
That is why ordinary people need lawyers to defend them.
4
At the bedside.
4
Hospitals know exactly what they are doing. Observation status most likely means more money or them or "less people admitted to the hospital". Must make them look better than their competitors. 39 days admitted on observation sounds ridiculous and not ethical. Patients and their advocates need to ask the questions and not trust that hospitals are looking out for their best interest. I worked many years in a hospital as a social worker. We can help you get the information you need. That is our job. Don't be a victim. You can blame medicare for having the rules of 3 days of hospitalization before qualification for nursing home but it is truly the responsibility of the hospital to inform patients and their families of their status.
38
You are incorrect. Observation status means less money for the hospital. The hospitals are trying to comply with Medicare regulations and pay stiff penalties when they inappropriately admit to the inpatient service.
7
Whateaver it means for hospitals, the fact remains that hospitals are doing a terrible job communicating to patients what it means to patients -- i.e., that it may cost them a lot of money out of pocket. (One commenter here said when she was in the hospital a social worker went to her and said she was an observation patient, without saying anything about what that might mean financially, and a year later she is still paying off the bill.) That needs to change -- people need to have it explained in at least general terms what the financial consequences of the different status may be and be given the option to go to another hospital or to go home.
1
Yes it doesnt matter what status your physician orders. Its matter what Utilization bills the visit as.
So, what is the benefit to Medicare and to the hospital? Any sane person would think that a woman who spent 39 days at a hospital was "in" the hospital, i.e., admitted as an inpatient. If hospitals are carrying on like this, there must be some payoff for them. If the patient is getting appropriate care, what possible difference can the administrative category make to Medicare?
As a pastor, have known of this situation for a while. Older adults are told to ask about their status as "observation" happens with the patient taken to an ordinary looking hospital unit and put in a regular looking hospital room (they are not still in or by the ER). However, it does no good to ask if they have no power to change it. So, what is the payoff and who gets it???
As a pastor, have known of this situation for a while. Older adults are told to ask about their status as "observation" happens with the patient taken to an ordinary looking hospital unit and put in a regular looking hospital room (they are not still in or by the ER). However, it does no good to ask if they have no power to change it. So, what is the payoff and who gets it???
32
I wish Paula had given us some of the "why" info on this. I found a piece in AARP.org on "Medicare: Inpatient or Observation" which stated "many experts suggest that hospitals are placing more and more patients under observation to protect themselves against new policies that penalize hospitals for unnecessary admissions and frequent readmissions of the same patient." And "hospitals are placed in an untenable position. On the one hand, they risk penalties if they admit patients for short stays. Yet they anger patients who are put under observation." Information about the class action lawsuit (class action is on Trump's kill-it-off list!) on this practice and a Medicare 'listening session' is included. See: http://www.aarp.org/health/medicare-insurance/info-08-2012/medicare-inpa...
17
I completely agree with you. This is more than a Clerical Error in the Medicare T&C's and why have Politicians not immediately repaired such an error the moment it reared its ugly head?
Either the Hospitals or the Insurers are making or saving a Buck keeping this "loopy hole" in the Medicare Book.
It just doesn't smell right.
Either the Hospitals or the Insurers are making or saving a Buck keeping this "loopy hole" in the Medicare Book.
It just doesn't smell right.
7
I am 69 so I'm a baby boomer. After my husband died over 2 years ago I feel I have been sent to "old people world." I am shocked that people my age refuse to use a computer and act like sheep. Is this really the generation that said,"don't trust anyone over 30?" They act clueless and that is why things like this happen.
As far as nursing homes, a recent article about rape of Alzheimer's patients and unreported abuse in nursing homes appeared on CNN. Where was the Times? Too busy reporting on other groups.
We must take charge of our lives as we age and help one another. I have known about this under observation scam for a long time because I read.
As far as nursing homes, a recent article about rape of Alzheimer's patients and unreported abuse in nursing homes appeared on CNN. Where was the Times? Too busy reporting on other groups.
We must take charge of our lives as we age and help one another. I have known about this under observation scam for a long time because I read.
48
I agree. Well said. As long as I still had my wits about me, the first thing I would ask if being held in an ER would be "what is my status?" and if I were told I "was under observation," the first question I would ask would be "then can I please go home and be observed there?" With alll the electronic doodads we have, and reports of remote medical care, why are people even in the ER to begin with?
8
Good god woman. "Too busy reporting on other groups???!!!!" The NYT can not possibly report in great depth on every single issue. I am happy to read that CNN took the lead on this other important story, just as I have been happy to read that the Wash Post and LA Times have been covering other important stories.
Yes, we all need to take charge of our lives as we age, read widely and help each other.
Yes, we all need to take charge of our lives as we age, read widely and help each other.
4
to ellienyc: You wrote, "As long as I still had my wits about me, the first thing I would ask if being held in an ER would be "what is my status?"
And there's the rub. When you're that ill, can you really count on having your wits about you, asking pertinent questions about your insurance status, consolidating what you hear with your memory of things you've read in the past, and making perfect decisions?
And there's the rub. When you're that ill, can you really count on having your wits about you, asking pertinent questions about your insurance status, consolidating what you hear with your memory of things you've read in the past, and making perfect decisions?
10
Predatory health care system, predatory insurance cartel, predatory capitalism, predatory government. Have I missed anything? At least the Establishment Democrats have our backs!! No, wait . . . .
35
How does a hospital decide whether a patient will be admitted or just be under observation?
Is the decision based only on maximizing profit, or are there medical criteria involved? And if there are, couldn't they be challenged after the fact?
Is the decision based only on maximizing profit, or are there medical criteria involved? And if there are, couldn't they be challenged after the fact?
13
Exactly my question. Why wouldn't hospitals admit patients as inpatients? Are the Medicare reimbursements greater for observation-status patients?
My mother was in the hospital for seven days which I assumed was inpatient status. While I was her health-care proxy and she had documented mild dementia, the hospital had her sign the observation status disclosure document. I found out on her 6th day from the medical social worker and pitched a royal fit.
The hospital suspended the billing while they investigated the lapse in their process. They did submit the claim to Medicare, but never billed my mother. I assume they knew they were on shaky ground regarding the lack of disclosure to a health care proxy of a demented patient.
My mother was in the hospital for seven days which I assumed was inpatient status. While I was her health-care proxy and she had documented mild dementia, the hospital had her sign the observation status disclosure document. I found out on her 6th day from the medical social worker and pitched a royal fit.
The hospital suspended the billing while they investigated the lapse in their process. They did submit the claim to Medicare, but never billed my mother. I assume they knew they were on shaky ground regarding the lack of disclosure to a health care proxy of a demented patient.
24
Good for you! Your mom's lucky to have you speak on her behalf. Shame on the staff for having someone with dementia sign paperwork.
12
I had a bank insist on that. You'd me amazed how often that happens.
1
It sounds like she could have used therapy while she was in the hospital itself. It sounds like she was never encouraged/allowed to leave the bed for 39 days and that it was the treatment itself that led to her loss of strength and ability to walk.
Shouldn't that be something that should be addressed as well?
Shouldn't that be something that should be addressed as well?
42
Yes, it certainly should be addressed -- any well trained doctor knows how quickly muscle mass can deteriorate when bed-ridden and any halfway decent hospital should be providing daily visits from therapists, encouraging people to get out of bed, etc.
7
Yes, and I perceive this whole thing as a racket. Never mind the billing and the status. Old people with Medicare who dare venture into an ER are almost certain to be kept there, often told that leaving would be against medical advice, or simply told they may not leave. If they can't sleep and are given drugs, problems with gait may land them in rehab where, as you noticed, forced bed rest too often leads to muscle atrophy and new disability upon return home. The statistics are dire and the problem is well-known. Too many studies to cite, so here's a link to a Google search results page.
https://tinyurl.com/bedrest-atrophy
This very newspaper reported on this institutionalized elder abuse.
"So even when doctors fix whatever problem brought older people to the hospital, prolonged immobility often sends them to rehabilitation (i.e., a nursing home) for weeks or sometimes for good. The less their mobility, Dr. Brown has determined, the greater the decline in patients’ ability to perform “activities of daily living,” like bathing or dressing. Less active patients were also much more likely to be discharged to institutions."
https://newoldage.blogs.nytimes.com/2013/05/30/trapped-in-the-hospital-b...
https://tinyurl.com/bedrest-atrophy
This very newspaper reported on this institutionalized elder abuse.
"So even when doctors fix whatever problem brought older people to the hospital, prolonged immobility often sends them to rehabilitation (i.e., a nursing home) for weeks or sometimes for good. The less their mobility, Dr. Brown has determined, the greater the decline in patients’ ability to perform “activities of daily living,” like bathing or dressing. Less active patients were also much more likely to be discharged to institutions."
https://newoldage.blogs.nytimes.com/2013/05/30/trapped-in-the-hospital-b...
2
Let me first say that I agree with the previous comment from Terry. "how in the world did a hospital justify a 39 day stay as outpatient?" Secondly it is not just in the last year that hospitals have had to inform patients when they are in OBS status. That has been going on for years. Hospitals unfortunately now have to focus on the bottom line which is the almighty dollar just like any other business. I know because I am a Case Manager in a hospital and it is my job to inform the patient and/or family of OBS status. We as Case Managers have to practically do backward flips to make certain that patients are in the right status and it is not entirely or simply about 2 midnights either. it is a nightmare. The doctors do not like this system. I don't know how Medicare gets away with doing this to the patients or to us Case Managers. I understand saving money but this is once again a nightmare for patients, the families and us the medical staff. Looking forward to retirement.
63
IMHO -- if I'm in a hospital bed, being fed hospital food, AND selecting my food off their menu, then I'm INPATIENT esp if I stay overnight
27
Unfortunately, not your decision and also not even your doctor's decision. As a hospital doctor who has seen this played out over and over, I have long advocated for less "cushy" and less hospital-like accommodations for observation status patients for two reasons: they clearly know their status and they don't want to stay longer than they have to. You'd be surprised how many people prefer the hospital to home in some cases. I envision, recliner-type chairs that lay back for a nap and patient's food brought in from home, or food available for purchase. We've got to start thinking way outside the box in American healthcare.
9
amkfk: But for people who don't want to put up with these endless observation stays in ERs and ER hallways, why can't they just send the people home where they can be checked up by computer or phone? We keep hearing about all the fantastic technology for linking patients with faraway doctors; so how come that can't be used for patients and nearby doctors?
2
Unfortunately, neither your opinion or common sense matters in these issues.
8
How is it this article makes no mention of CMS quality measures or penalties for re-admissions? These almost certainly explain why Ms. Niemi was sent to observation purgatory...and ended up with the bill for it.
The hospital treating Ms. Niemi almost certainly avoided re-admitting her because doing so would put a dent in their quality measures and might result in Medicare reimbursement penalties. (CMS has specifically scrutinized cardiac re-admissions as a quality measure since 2012.)
If so, the hospital effectively gamed CMS...at Ms. Niemi's expense. And, ironically, Ms. Niemi and her co-plaintiffs now may end up suing CMS.
In our for-profit system, patients like Ms. Niemi too often end up being circulated through the care jungle according to the logic of billing and reimbursement rather than the logic of care.
The hospital treating Ms. Niemi almost certainly avoided re-admitting her because doing so would put a dent in their quality measures and might result in Medicare reimbursement penalties. (CMS has specifically scrutinized cardiac re-admissions as a quality measure since 2012.)
If so, the hospital effectively gamed CMS...at Ms. Niemi's expense. And, ironically, Ms. Niemi and her co-plaintiffs now may end up suing CMS.
In our for-profit system, patients like Ms. Niemi too often end up being circulated through the care jungle according to the logic of billing and reimbursement rather than the logic of care.
91
What about Ms. Niemi's inability to walk? Can she win a lawsuit on that basis?
How in the world did the hospital justify a 39 day-stay as an outpatient? The woman wasn't going home for meals. She was in a hospital bed. Hospital staff were checking on her vital signs and administering medications. It's incomprehensible that the hospital kept her so long without admitting her.
127
This is exactly why we need the plaintiff bar (lawyers who take cases on behalf of wronged people) and class action suits. Republicans have been trying to eliminate class action suits and tie the hands of the plaintiff bar for years. When people can not get to court, whether because bound by arbitration clauses they really had no choice but to agree to, or other restrictions, these are exactly the type of abuses that occur, because there are no consequences for unethical behavior.
17
This is Medicare's statement explaining Observation vs Admission :
https://www.medicare.gov/Pubs/pdf/11435.pdf
Still confusing. But the designation of whether for observation or admission is the doctor's order. You must ask to be admitted if you are going to stay overnight and have tests done while you are in the hospital. Might have to confront your doctor. Under observation, claims may be paid at different rate and you might have more copayment. And, even if you stay 3 nights "under observation" you won't qualify for SNF. (39 days observation is absolutely wrong)
I was admitted through ER, went directly to Operating Room for surgery and went home the next afternoon. In the ER I asked if I was being admitted or observed and, even though I needed surgery, I was told I was being observed.
Nonsense. I protested. Doctor ordered admission.
Patients must know what is going on and understand the difference and ask this important question - Am I being admitted or observed?
https://www.medicare.gov/Pubs/pdf/11435.pdf
Still confusing. But the designation of whether for observation or admission is the doctor's order. You must ask to be admitted if you are going to stay overnight and have tests done while you are in the hospital. Might have to confront your doctor. Under observation, claims may be paid at different rate and you might have more copayment. And, even if you stay 3 nights "under observation" you won't qualify for SNF. (39 days observation is absolutely wrong)
I was admitted through ER, went directly to Operating Room for surgery and went home the next afternoon. In the ER I asked if I was being admitted or observed and, even though I needed surgery, I was told I was being observed.
Nonsense. I protested. Doctor ordered admission.
Patients must know what is going on and understand the difference and ask this important question - Am I being admitted or observed?
60
Amy unfortunately sometimes (most times) it is not up to the Admitting Physician. There is criteria out there which has to be used to determine inpatient vs OBS and the Physician's decision can be overrode. Not saying I like it, just saying that's the way it is. Been doing this work about 20 years now.
13
Unfortunately not completely accurate. I have worked in hospitals where, despite orders "Admit as Inpatient" the Utilization Review Gods changed the status. The whole thing is much murkier and convoluted than anyone would believe.
35
Hospital doctor here. I can place an admit to inpatient order on every single patient I admit all day long, but I am rapidly "over-ruled" by the powers that be if the patient's clinical presentation and required treatment does not meet "inpatient" criteria. I can appeal and try to talk or write my way into inpatient status, but the criteria are a moving target and at the end of the day, I cannot make up clinical data or order inappropriate tests to make a patient look sicker. That would be fraud.
So, you can demand all you want from your doctor - but it is truly not up to them. For a couple years there, they said it was and that it was up to the attending physician, but in my recent experience in the last couple years that is no longer the case.
So, you can demand all you want from your doctor - but it is truly not up to them. For a couple years there, they said it was and that it was up to the attending physician, but in my recent experience in the last couple years that is no longer the case.
112
I received a hospital bill yesterday for what I thought was a hospital admission covered by my Medicare Part A only. I am a retired R.N. and the last time i checked a hospital admission was moving from the E.R. into a bed in the main hospital. Just as it would be good to be informed whether the doctors visiting you in the hospital are on your health plan,it also would be good to know what your status is on admission. It begins to feel scammish.
127
Hospitals don't hesitate to wheel a patient down to radiology. The patient never sees the radiologist, just a technician, then the radiologist's billing company sends an incomprehensible statement, seldom covered by the patient's insurance plan. Poor patient thought radiology falls under hospitalization. Nope!
The technician takes the x-ray and the guy in India reads the x-ray, a cushy deal for the radiologist who does what besides ski in in the Alps and hoist the mainsail on his yacht?
The technician takes the x-ray and the guy in India reads the x-ray, a cushy deal for the radiologist who does what besides ski in in the Alps and hoist the mainsail on his yacht?
1
I always advise friends, on hearing that a parent is now in the hospital, to go immediately to the nurses' station and inquire if the patient is "admitted" or "under observation" and always have to explain that just because mom is getting tests and meds does not mean she is admitted. Three midnight stays are required to get Medicare to pay for rehab, should that be necessary. At the continuum of care where I worked in SE Wisconsin, we created an "observation suite," where, for a patient who is not stable enough to return to home alone, they could receive rehab services in the assisted living area for half cost, out of pocket, for those who did not meet the criteria for Medicare coverage. Still not very affordable to a lot of people, but better than going home and trying to fend for one's self.
There should be education available on admittance for every family to understand the difference between observation and admission. It is yet another game played to manage costs at the expense of caring for the patient.
There should be education available on admittance for every family to understand the difference between observation and admission. It is yet another game played to manage costs at the expense of caring for the patient.
77
There is education- a required form called the Medicare Outpatient Observation Notice. I bet this patient got one.
18
Yes, it is one of many, many forms a patient must sign when they aren't feeling well. I don't imagine many sick elderly people truly understand what they are signing.
44
If somebody gives me a form I don't understand, I just say "I don't understand that" and/or refuse to sign it (or, in some cases, if I do understand it, I add limitations, like circumstances under which Iwill refuse to pay bill -- like if somebody brings in a provider that doesn't take Medicare without my consent).
In one case, where as an outpatient at NYU Langone, I said I would like someone to explain their new 5 or 6 page form to me, they said "never mind, nobody understands it" and there was no requirement to sign.
In one case, where as an outpatient at NYU Langone, I said I would like someone to explain their new 5 or 6 page form to me, they said "never mind, nobody understands it" and there was no requirement to sign.
5
This is misleading information. The operative word in the headline is “some.” The number of or percent of total Medicare beneficiaries that would be negatively affected if “illegally” observed vs. admitted is relatively small in number and miniscule as a percent.
1. When observed (and therefore under Part B), typically the beneficiary’s out of pocket responsibility is less than if he or she had been admitted and subject to the Part A deductible.
2. Even that is irrelevant because 98% of us on Medicare feel the need to have some secondary, tertiary or more mostly private insurance. That secondary, tertiary or more mostly private insurance would pay the hospital any deductible/co-pay associated with either A admission or B observation
3. Further only a small percent of people on Medicare leaving a hospital after either admission or observation need a skilled nursing facility (SNF). So now we’re talking about a small % of a small % being affected by the situation described (but this lady – who clearly was not a retired healthcare insurance agent -- should get an attorney and sue the doctors who kept her in acute care for 39 days – but I’m guessing there’s more to that story). Even then, a third of us on Medicare use public Part C health plans to supplement our Parts A and B and in general face none of the crazy SNF rules mentioned in the article.
Sorry but all much ado about nothing (again, unless the author wants to point how bad Medicare would be if applied to “all).
1. When observed (and therefore under Part B), typically the beneficiary’s out of pocket responsibility is less than if he or she had been admitted and subject to the Part A deductible.
2. Even that is irrelevant because 98% of us on Medicare feel the need to have some secondary, tertiary or more mostly private insurance. That secondary, tertiary or more mostly private insurance would pay the hospital any deductible/co-pay associated with either A admission or B observation
3. Further only a small percent of people on Medicare leaving a hospital after either admission or observation need a skilled nursing facility (SNF). So now we’re talking about a small % of a small % being affected by the situation described (but this lady – who clearly was not a retired healthcare insurance agent -- should get an attorney and sue the doctors who kept her in acute care for 39 days – but I’m guessing there’s more to that story). Even then, a third of us on Medicare use public Part C health plans to supplement our Parts A and B and in general face none of the crazy SNF rules mentioned in the article.
Sorry but all much ado about nothing (again, unless the author wants to point how bad Medicare would be if applied to “all).
6
"should get an attorney and sue the doctors who kept her in acute care for 39 day"
I work in this area (Medicare reimbursement), and I've never heard of a 39-day observation stay before. The overwhelming majority of observation cases I see are where someone is kept overnight, or possibly for a second day. I'd be extremely curious for more details about why the hospital felt it was appropriate to keep her in observation status for such a long time.
The article also fails to mention some of the problems with Part A inpatient admissions-- e.g., that many hospitals improperly (or even fraudulently) admit Medicare beneficiaries as inpatients to get a higher level of reimbursement where observation-level care would really be more appropriate. (Essentially billing for a level of care that they didn't provide, and that wasn't medically necessary). This adds up to millions of taxpayer dollars. If the pendulum is swinging more in the other direction now, that may be a very good thing for the long-term solvency of the Medicare program.
I work in this area (Medicare reimbursement), and I've never heard of a 39-day observation stay before. The overwhelming majority of observation cases I see are where someone is kept overnight, or possibly for a second day. I'd be extremely curious for more details about why the hospital felt it was appropriate to keep her in observation status for such a long time.
The article also fails to mention some of the problems with Part A inpatient admissions-- e.g., that many hospitals improperly (or even fraudulently) admit Medicare beneficiaries as inpatients to get a higher level of reimbursement where observation-level care would really be more appropriate. (Essentially billing for a level of care that they didn't provide, and that wasn't medically necessary). This adds up to millions of taxpayer dollars. If the pendulum is swinging more in the other direction now, that may be a very good thing for the long-term solvency of the Medicare program.
20
I think the answer is obvious: $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
15
Good diagnosis. I concur. But what's the treatment? severe curtailing of corruptive practices and wrist-slaps equal to the damage, and then - single payer.
4
... drawn broad bipartisan support in both the Houseand Senate
Endorsed by American Medical Association and AARP.
So far, though, the legislation has gone nowhere.
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I clipped the above four paragraphs from the article.
Am I the only one who thinks we didn't get the whole story?!