Wednesday, July 30, 2014

Observing observation status

Brad Flansbaum offers this interesting post about the ambiguities and uncertainties inherent in the current Medicare "two-midnight rule."  He refers to a recent white paper prepared by a group of hospitalists:

Months of work have led us to our white paper, entitled, The Observation Status Problem: Impact and Recommendations for Change. The release utilizes a multidimensional data set of significant size and includes a finding synthesis.  It is our hope to use the information we collected to inform Congress, CMS, media, and members on the somewhat chaotic understanding of observation status policy. 

This is well done and thoughtful and could be of assistance to federal policy makers, if they take the time to read and listen.  Look at this portion of the introduction:

The intricacies of observation policy have created a situation where observation care is now commonly being delivered on hospital wards, indistinguishable from inpatient care. The frequency and duration of observation status has also grown significantly in recent years, well beyond its original intent. This is important because observation is not covered by Medicare Part A hospital insurance, and patients under observation are ineligible for skilled nursing facility (SNF) coverage at discharge, which may leave them vulnerable to additional complications.

The results:

--Lack of knowledge and confidence in implementing the two-midnight rule
--Disruptions to hospitalist and hospital workflow
--Decrease in the ability of hospitalists to make independent clinical decisions
--Negative impacts on patients, including access to SNF coverage and highly variable financial liabilities 
--Damage to the physician-patient relationship


Ronald Hirsch, MD said...

It is amazing that supposedly intelligent doctors cannot grasp the simple two midnight rule. It is two questions. Do they require care in a hospital that would endanger their safety if provided at home or in a SNF? If not, send them home. If so, do you think that care will require more or less than two midnights? If not, observation; if so, inpatient. There is no penalty to being wrong; just document what is wrong with the patient, why they need to be in the hospital and what you plan to do for them.
That's the rule. That is all. How hard is that????
Now getting the 3 day rule for SNF is a separate issue and that's all about the money.

Dino William Ramzi said...

Seriously Ronald? You couldn't possibly be a clinician, if you are so unaware of the ambiguities in medical care and so able to put every single human being into such a neat box. Or else you have no experience dealing with government bureaucrats.

The problem with obs rules has always been that the concept is difficult or impossible to operation alive and yet some simpleton thinks that because the rule is simple, it should be simple to follow.

This is like the difference between complex and just complicate... Don't worry, I know. I just lost you.

Anonymous said...

The concept is simple. When I heard the CMS officials who designed the rule explain it I was impressed.

Once one looks in the regulations and subregulations though (medical necessity screening, secondary reviews, penalties - oh yes they exist, etc.) and especially after having experience with contractors that enforce the law, one has no reason to celebrate. How the simple concept translates into law, then how it is interpreted my MAC, then how it is implemented in real life are all opportunities for major mutations that alter and multiply the effect on the practicing physicians and institutions - mutations that are bound to happen as there is no appreciable accountability in the process of implementation on the government's side. (Don't take my stance wrong here, I am not anti-governemnt: many people would even classify me as a socialist)

The idea is simple, and while I do not fully agree with it, I would fully support it had it been implemented as Ronald described it. The problem is not the idea: the problem is the bureaucracy that Dino pointed out. I believe the revolt is not truly against the 2MN rule, this may just have been the last straw that broke the camel's back that suffered under that weight long enough.

Anonymous said...

"Do they require care in a hospital that would endanger their safety if provided at home or in a SNF?" is the correct question, Ronald, but if the patient has had complications of out-patient procedures, resulting in complications, how many doctors want to document that in their reason to admit? In my experience, we have two categories of observation concerns, ER patients with mutliple conditions in addition to the presenting problem, and same day surgery patients with complications who might need more than 2 nights in the hospital. Not as easy to decide as Ronald suggests.