Blog | Tuesday, May 10, 2016

There's so much more to the whole observation versus inpatient debate


A few weeks ago I wrote a piece about my hero patient, a World War 2 veteran who landed on Normandy beach, and how he had been left in a difficult position by the whole observation versus inpatient situation while he was hospitalized. The original title of the essay was: Inpatient versus Observation: To all elderly patients from the Greatest Generation, so sorry this is the way it is.”

My intention was to draw attention to these types of scenarios and how they cause intense anxiety and concern to our elderly. It's a horrible and unacceptable situation when this happens. While I can't obviously divulge the individual details of the case or make any claim to be an expert on the pyramid of rules and regulations (nor do I ever intend to become an expert on this either), all I can do is write about the essential truths of any given situation as I see them in my capacity as a frontline doctor. I received significant correspondence after writing the article, which I was very appreciative of. It's always good to stimulate debate on important topics that affect so many people. I wanted to address a few of the many questions and opinions I received.

1) Observation stays are not always more expensive for the patient.
This is certainly true, but the designation of observation status does make the patient potentially liable for more out-of-pocket costs, as co-payments and coinsurance for additional services that are not covered by Medicare Part B kick in (typically 20%). Home prescription medications are sometimes not covered either. Medicare Part A, on the other hand, typically covers all inpatient costs after a fixed deductible is met. Whether or not a minority of observation patients end up with higher total out-of-pocket costs is irrelevant to the situation I highlighted. Nor should any respectable system allow uncertainty, “surprise bills,” or be a constant merry-go-round of moved goalposts, negotiating, and bargaining over final costs. This PBS article draws attention to the confusion that can arise by what's covered and what's not inpatient versus observation.

For whatever intrinsic checkbox reasons and history, my patient and his family had reason to believe based on their previous experiences and individual circumstances that they would be left with a higher bill for an observation stay. That was their reality, and a terrible situation for our vulnerable elderly to be left in as they are lying unwell in a hospital bed. Instead of focusing on getting and feeling better, they are concerned about the implications of this artificial distinction we've created and what the consequences are for them. Even if only one patient in our country is going through this and stuck in the system, especially a World War 2 hero, this is one too many.

2) Patients have a right to know whether they are inpatient or observation
Of course they do, and at least everywhere I've worked, are always given that information (usually by case management). In the particular story that I was highlighting, I didn't have the heart to tell the patient and his elderly wife immediately, since I didn't want to cause increased anxiety at a moment when he was acutely unwell and already not feeling good (especially when I wasn't 100% sure myself and needed to clarify). My job as a physician is to address clinical issues first, and always will be. After analysis of the case and making sure we were right, sure enough they were told a couple of hours later. We as physicians make that determination, but are guided by tick boxes and often told that “criteria for inpatient are not met”—even when we know a longer hospitalization is likely. In other words, physicians' hands are tied. I know I speak for the vast majority of physicians when I say that we find the whole process annoying and unnecessarily complicated, something we didn't go to medical school for.

3) Determining observation versus inpatient is costly for other reasons
There are many other financial factors at play, outside the scope of this article. In a nutshell, hospitals can take a big financial hit if this determination isn't made correctly (for reasons even including whether that patient is readmitted). Another huge financial consideration is whether the patient requires a rehabilitation or skilled nursing facility stay post-discharge. That really can be a financial disaster for anyone in observation status.

The story of that World War 2 veteran was just one of hundreds, if not thousands, of such situations that I've dealt with over the years. Ditto I'm sure for physicians all over the United States who on a daily basis face these difficult cases.

At the end of the day, we have created a monster of our own making, and this distinction causes a huge amount of stress, anxiety and wasted resources (in fact, it's actually spawned a whole new costly industry!). This applies to physicians, case managers, hospital executives—but most importantly to our long suffering patients. That's the bigger picture of why we need change. If you ever hear anyone ferociously defending the system or giving the impression that all is well, be sure to double-check their bio and make sure their job title doesn't depend on keeping the status quo intact!

The issue has finally been getting more public and political attention over the last couple of years, as congressmen and women up and down the country are hearing about this from their angry constituents. But rather than debate it and make rules to work around it, why not go back to basics and ask why we even need this distinction in the first place? As I said in my initial article, if you're sick enough to be in hospital, that should be the end of the story, whether it's for 1 day or 4 days. Same bed, same room, same medical equipment, same attention to detail and caring staff.

What we should really do is abolish this whole circus and start afresh. After all, if the ultimate aim was to control health care costs, surely there are better and more effective ways to do this?

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.