Blog | Thursday, September 5, 2013

Catch-22 and a whine about observation status


A patient is admitted (appropriately) to the hospital. He should not go back home as he is a danger to himself and his caretaker. Technically, we are told that he does not “meet criteria” for admission status.

Therefore …

Medicare will not allow transfer to a skilled nursing facility. We have to create a medical reason for admission status, so that he can get the nursing home coverage.

Robert Wachter, MD, FACP, in perhaps his best post ever (of course that is just an opinion), explained the madness. Medicare’s Most Maddening Policy … and Why CMS’s Attempts to Improve It May Make it Worse

We simply want to take the best care for our patient and his caretaker. To send him home would violate our moral and ethical obligation. To send him home would violate our principles of professionalism.

So we have to “play games” with CMS. Dr. Wachter writes: “If this mess were only about the question of money for Medicare, hospitals, and auditors, it would be plenty maddening but not miasmal. Unfortunately, patients and their families are unwitting victims, collateral damage. Picture this: your mother is sitting in a hospital bed, with a band on her wrist, an IV in her arm, nasal prongs in her nose, and EKG squiggles skipping across a telemetry monitor. Luckily, she does reasonably well and is discharged to a skilled nursing facility after a three-day stay. OK, your family thinks, at least we know that Medicare will pay for the skilled nursing facility since she’s crossed CMS’s magic three-day threshold to trigger skilled nursing facility coverage.

“Only later do you learn that her hospital stay doesn’t count, because she was on obs the whole time. Or you get a co-pay bill for several thousand dollars because, while inpatient medications are covered under Medicare, “outpatient” medications are not. While she sat in her hospital bed, you see, she was really an outpatient.”

Bob said it so well. Today I am frustrated for our patient and his family. What the (*&(*^ are they thinking?

Excuse me. Obviously they are not thinking; they are just making rules.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.