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1、 CARINGFORTHEAGES.COM CARING FOR THE AGES 15 F ed up with the uncertainty and confusion surrounding Medicare s rules for when a patient should be admitted to the hospital or classifi ed as under observation status, hospitalist leaders are urging Congress to address one key piece of the issue: the 3-
2、day inpatient hospitalization requirement for coverage of a skilled nursing facility stay. Earlier this year, a small group of lawmakers introduced bills in both the House and Senate to alter the require- ment that Medicare benefi ciaries must be hospital inpatients for at least 3 days in a row to q
3、ualify for Medicare coverage of their stay in a skilled nursing facility (SNF). Under the proposals, time spent in observation status at the hospital, which Medicare considers to be “out- patient” treatment, would be counted toward Medicare s 3-day requirement. Dr. Ron Greeno, chief medical offi cer
4、 at Cogent HMG and chairman of the Society of Hospital Medicine s (SHM) Public Policy Committee, said there are a number of reasons why he s optimis- tic that the bills (H.R. 1179 and S. 569) will move faster than some other health care issues currently before Congress. For starters, the bills have
5、at least some bipartisan support. Another is that the issue is easy to understand and will help seniors, a key voting demographic. “It s very hard for legislators at this point to say that they aren t going to correct this really clear inequity in the system,” Dr. Greeno said. The biggest impact of
6、the current 3-day requirement falls on Medicare patients who are facing either a signifi - cant cost burden or potentially less than ideal care. Patients who don t meet the 3-day inpatient requirement must pay out of pocket for their SNF stay or come up with a less comprehensive plan of care at home
7、. “We try to piecemeal a plan together that may not be entirely safe for them,” said Dr. Ann M. Sheehy, head of the division of hospital medicine at the University of Wisconsin and a member of SHM s Public Policy Committee. “I certainly think that we end up sending patients home that are more likely
8、 to be readmitted.” But the legislation could hit a snag in Congress due to cost. “It will increase the number of patients who qualify to have their SNF care cov- ered by Medicare and so there s a cost,” Dr. Greeno said. “I don t think there would be any resistance to either of these bills if it did
9、n t come with a pretty hefty bill. That s where the push-back will come.” That leaves lawmakers to agree on a way to off set the cost, something that has already stalled progress on other issues with bipartisan support, such as repealing Medicare s Sustainable Growth Rate (SGR) formula. If the 3-day
10、 rule legislation passes this year, it will be a “huge victory” and send the signal that Congress is serious about reforming observation status, said Dr. Sheehy. But it will still leave hospital- ists and other admitting physicians with a set of dysfunctional rules on when to employ observation stat
11、us, she said. The problem, Dr. Sheehy said, is that observation status has expanded dra- matically in recent years as Medicare auditors have returned hundreds of mil- lions of dollars to the Medicare program by deeming many inpatient admissions as inappropriate. Perhaps as a result of the aggressive
12、 auditing by Medicare, the number of Medicare benefi ciaries clas- sifi ed as receiving observation services for more than 48 hours has grown from about 3% in 2006 to about 8% in 2011, according to the Centers for Medicare & Medicaid Services (CMS). “Observation status right now is so dysfunctional
13、because it has expanded greatly under audits to include so many patients that it s almost hard to envision a way that it can become functional again,” Dr. Sheehy said. “It s so far from where it was intended to be that I don t know how it could be fi xed.” In May, CMS proposed to simplify the curren
14、t observation rules by creating a “time-based presumption” of medical necessity for hospital inpatient services based on the patient s length of stay. The plan was fl oated as part of the 2014 Hospital Inpatient Prospective Payment System proposed rule . Under the rule, Medicare s external review co
15、ntractors would presume that inpatient admissions were necessary for patients who require more than one Medicare utilization day (or two “mid- nights” in the hospital). The policy would also assume that hospital stays of less than two midnights should be classifi ed as observation status. Dr. Sheehy
16、 said it s a positive that Medicare wants to move away from the status quo. “But it s hard to know how the rule change might play out,” she added. “Only time will tell if these rules are going to be benefi cial or not.” Dr. Greeno predicted that the issue isn t going to fade away. The Center for Medicare Advocacy, a consumer group, has fi led a class action lawsuit against CMS on behalf of 14 Medicare benefi cia- ries seeking to remove the observation status designation. In Bagnall v. Sebe
