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| Catherine Fitzgerald, the author's mother, spent four nights in a
hospital after falling in her home. But Medicare refused to pay for her
rehab care, saying she had only been an inpatient for one night.
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A few months ago, I wrote a check for $12,000 but couldn't figure out exactly why.
The payment was to secure a place for my mother at
Sligo Creek Center, in Takoma Park, Md. It's a nursing home and rehab center owned by Genesis Healthcare.
My mother was about to be discharged from
Holy Cross Hospital, in nearby Silver Spring, after a fall. Medicare wouldn't pay for her rehabilitation care.
So before the Sligo Creek Center would let her through the door, I had to prepay for a month — $12,000 — or nearly $400 a night.
Now,
my mother had paid into Medicare her entire working life, and since she
retired, the Social Security Administration has automatically deducted
$130 for her basic Medicare premium from her $1,650 monthly check. On
top of that, she pays about $300 a month for a prescription drug plan
and supplemental "Medigap" insurance
.
But because of
dueling rules and laws that have been well-known to Medicare officials
and members of Congress for years, none of that covered my elderly
mother when she needed care.
This is a story of how money, outdated laws and federal
budget rules can interfere with patient care and leave elderly patients
vulnerable.
The fall
I found my
mother lying on the floor of her apartment one evening in early January.
I had stopped by because she didn't return my calls. It was Wednesday,
and she had fallen sometime in the previous 24 hours.
She was
awake, but confused. Her lips were chapped, her skin was too pink, and
her thick white curls were a mess on her head. I needed help getting her
up and into bed. When my husband and I couldn't do it, we called the
local fire department.
There were no obvious injuries and she
was speaking coherently, so I spent the night with her and tried to care
for her the next day, thinking she just needed rest and food. But it
soon became clear she needed medical help.
She couldn't walk, couldn't even move her left leg. Her confusion was getting worse. Her doctor recommended I take her to the
emergency room at Holy Cross Hospital in Silver Spring.
An
ER doctor there examined her, saw that she couldn't move her leg,
couldn't really even hold her body upright and had trouble with her
memory. He said he would admit her to the hospital's observation unit to
figure out what was going on. He mentioned she might need rehab care to
get up and walking again.
The word observation triggered an alarm deep in my brain. I had read that
patients on observation status sometimes weren't eligible for rehab care, and I told the doctor that I was concerned.
He said he and the hospital "do all they can to be sure their patients' care is covered." I was reassured.
My
mother spent four nights at Holy Cross. She was on IV antibiotics for
an infection. She got nine X-rays, two MRIs, scans of her carotid
arteries and lungs, and a CT scan. Hospital staffers drew blood no less
than six times because they were concerned she might have had a mild
heart attack or stroke that had caused her to fall.
Administrative maze
On
the day they decided to release her, a social worker named Jay called
to say the doctors were recommending she go to an inpatient rehab center
— and then he said Medicare wouldn't pay for it.
My mother was
caught in an administrative wonderland where she slept at a hospital
for four nights, but the paperwork said she was an inpatient only one of
those nights. Medicare's
rules, dating
back to the 1960s, require people to spend three nights in a hospital
before the federal program will pay for inpatient rehabilitative care.
It would cost upward of $12,000 a month, Jay told me.
I
sped to the hospital in a rage. I demanded to know why they were
releasing her when she still couldn't walk. Further, I wanted to know,
why were they calling her an "outpatient" when she was sleeping in their
bed, under their blankets, wearing their hospital gown and being cared
for by their staff.
Here were some of the things a parade of social workers and nurses told me that day.
- The doctor couldn't admit her as an inpatient because she didn't have a qualifying diagnosis.
- Her status was changed from observation to inpatient on the third day because Medicare requires that.
- They could not change her status to inpatient for the entire stay because they didn't want to be audited.
- She
couldn't go to acute rehabilitation, which Medicare pays for, because
there was no evidence she had had a stroke or heart attack.
They didn't say much about her medical care. It was all about the rules.
For
the record, my mother has no money. She lives on Social Security. She
has no car, no house, no savings. My siblings and I help pay her bills.
And now they were saying she had to leave the hospital. But she obviously couldn't go home.
Holy
Cross kept her one more night — at no charge — while we figured out
where she could go. They said she could apply for Medicaid, and a social
worker handed me a
17-page application.
I picked a handful of rehab centers from a list, after a quick search
of reviews on my iPhone. One was full, one rejected her because she was
listed as "Medicaid pending," and finally, Genesis Healthcare said they
would take her — on the condition that I come by with a $12,000 check
that day.
So I did.
Rules, rules, rules
So now I was out $12,000 — borrowed from a home equity line of credit — and I wanted to know why.
And here's what I learned.
Medicare, in its
zillions of
pages of
guidelines and
regulations,
has two competing rules. The first says patients must spend three
nights as a hospital inpatient to qualify for inpatient rehabilitation
or skilled nursing care once they're discharged. The second encourages
hospitals to keep patients on observation status or risk being audited.
The
reason? Medicare pays more for short inpatient stays than short
outpatient stays. But once a patient has been at the hospital for a
number of days, that calculus flips, and outpatients end up costing
more. So in its effort to control costs, Medicare forces hospitals to
justify their decisions about inpatient and outpatient status.
"It
was always kind of assumed that when you go to the hospital, people
know what hospital care is," says Judy Stein, executive director of the
nonprofit
Center for Medicare Advocacy. "Hospital admission is when you're admitted to the hospital."
Her group is leading a class-action
lawsuit
against the Department of Health and Human Services, seeking to give
patients the right to appeal their status as observation patients.
Stein
says the use of observation status has grown dramatically in the past
decade, in part because Medicare has become far more aggressive in going
after hospitals the agency said were inappropriately — and expensively —
admitting patients who didn't need hospital care.
A
study in the journal
Health Affairs
found that the number of Medicare patients who spent three or more days
in a hospital under observation rose 88 percent from 2007 to 2009. That
increase came just after Congress authorized Medicare to use
contractors to audit hospitals for overcharges. But the trend in
observation care has continued.
A report by the HHS inspector general found that in fiscal year 2014, more than
633,000 Medicare beneficiaries
spent three or more days in the hospital but were considered
outpatients, an increase of 8 percent over the previous year. A separate
report found that in 2012, about
24,000 patients went to skilled nursing homes or rehab centers and had to pay their own way.
New Unit
Holy Cross built a dedicated observation unit around 2011, according to
Yancy Phillips, the hospital's chief quality officer, who spoke to me at length about the use of observation status.
That
was where my mother spent those four nights. She had her own room, with
glass doors that were covered by a curtain. The nurses station was
right outside her door. It looks like a cross between a traditional
patient floor and the emergency room. Doctors came around at least once a
day.
Phillips says that Holy Cross has no financial motive to
classify patients like my mother one way or another because Maryland law
requires the same payment for the same services. It's the only state
with such rules.
But the hospital still has to follow Medicare's rules when it comes to inpatient and observation care.
"There's
really no financial advantage to us except if we get the status wrong,"
he said. "Medicare has come back to us and said, 'No, no, no, this
should not have been an inpatient.' "
When that happens, Medicare pays nothing at all.
To avoid losing money, Holy Cross, like many other hospitals, uses "decision support" software — in this case a package called
InterQual,
sold by McKesson — that guides doctors or case managers in making the
call on whether a person should be admitted or kept on "observation."
The
programs are designed to ensure that hospitals don't get dinged by
Medicare for overcharging or providing inappropriate services.
Phillips
says doctors use their own judgment about whether a patient should be
admitted. But he also acknowledges that InterQual is embedded in the
electronic health record software used at Holy Cross. It was likely this
program that concluded that my mother didn't meet Medicare's criteria
for inpatient care.
The thing about all this is that this problem is well-known to everybody involved.
But lawmakers and Medicare haven't taken action to fix it.
A bipartisan group of lawmakers, led by Sen.
Sherrod Brown, D-Ohio, and Rep.
Joe Courtney, D-Conn., have
proposed bills multiple times that would simply require Medicare to count all the time patients spend in a hospital toward its requirements for nursing care.
The
House version attracted 162 co-sponsors from both parties, but neither
bill has gotten a hearing on Capitol Hill or been close to a vote.
Jonathan Blum, the former Medicare director at CMS, suggests another fix: Get rid of the three-night requirement altogether.
"It's
really an artifact," he said. "It was put in place as a budgetary
control and it was designed when the average length of a hospital stay
was seven, eight or nine days."
Everyone I talked with agrees
that the root of the problem is money. There has been no formal analysis
from the Congressional Budget Office, but most people believe that
eliminating the three-night requirement would end up costing the
government more money.
"These are insurance rules. They're
policies. They can be changed," says Phillips of Holy Cross Hospital.
"But it would have enormous financial implications for the country. And
we may have an appetite for tax cuts, but I don't see that we have an
appetite for something that would increase Medicare costs."
It's
not clear that it would cost more, however. Two pilot programs from the
late 1970s showed mixed results from eliminating the three-night rule,
with Medicare costs rising in Massachusetts, but falling in Oregon,
according to an
article in
JAMA, the
Journal of the American Medical Association.
That article concluded, however, that the rule may be preventing patients from getting appropriate care.
And that would have been the case with my mother, who couldn't have written a $12,000 check to secure a rehab bed for herself.
Two
weeks into her therapy at the Sligo Center, my mother fell again. This
time, she broke her hip and needed hip replacement surgery. Because she
didn't stay the whole month getting rehab care, I got a refund of about
$6,000.
Under Medicare's rules, that surgery meant she was
automatically eligible for post-surgical rehab care. So after she was
released from the hospital, she went to a new center — no deposit
required.
Full Article & Source:
How Medicare's Conflicting Hospitalization Rules Cost Me Thousands Of Dollars
