Medicare and Medicaid

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OBSERVATION STATUS — what does it mean?
If a Medicare patient is in the hospital, it is extremely important to find out whether the patient’s status is “inpatient” or “outpatient.”  That status affects how much the patient must pay for hospital services such as drugs, x-rays, etc. and will affect whether Medicare will pay for care in a skilled nursing facility after the hospital stay.

Information about observation status:
“FAQ: Hospital Observation Care Can Be Poorly Understood and Costly for Medicare Beneficiaries”
(Kaiser Health News)

“Find out is you’re an inpatient or an outpatient — it affects what you pay”

“Observation Status: New Final Rules from CMS Do Not Help Medicare Beneficiaries”
(Center for Medicare Advocacy)

“Self Help Packet for Medicare ‘Observation Status'”
(Center for Medicare Advocacy)

“Observation stays don’t count for Medicare coverage, many seniors harshly learn”
(Pittsburgh Tribune-Review)

“Medicare proposes limits on hospital observation stays”
(American Medical News)

“Medicare’s midlife crisis: Catastrophic finances pit doctors against patients”
(Washington Examiner — July 20, 2015)
ACO’s [Accountable Care Organizations put doctors in charge of both the treatment and payment of healthcare.  It puts the doctor and patient in conflict with each other, especially sicker patients.  The more sicker patients, the harder it is to achieve savings.”

“Medicare Plans to Pay Doctors for Counseling on End of Life”
(New York Times — July 8, 2015)
Medicare, the federal program that insures 55 million older and disabled Americans, announced plans on Wednesday to reimburse doctors for conversations with patients about whether and how they would want to be kept alive if they became too sick to speak for themselves.

“To Collect Debts, Nursing Homes Are Seizing Control Over Patients”
(New York Times — January 25, 2015)
…In a random anonymized sample of 700 guardianship cases in Manhattan over a decade, Hunter College researchers found more than 12 percent were brought by nursing homes…[L]awyers and others versed in the guardianship process agree that nursing homes primarily use such petitions as a means of bill collection…. Guardianship transfers a person’s legal rights to make some or all decisions to someone appointed by the court…Legally, it can supplant a power of attorney and a health care proxy.

“Coverage for End-of-Life Talks Gaining Ground”
(New York Times — August 30, 2014)
Five years after it exploded into a political conflagration over “death panels,” the issue of paying doctors to talk to patients about end-of-life care is making a comeback, and such sessions may be covered for the 60 million Americans on medicare as early as next year.

“1 in 5 Elderly U.S. Patients Injured by Medical Care”
(HealthDay — May 27, 2014)
Nearly one in five Medicare patients are victims of medical injuries that often aren’t related to their underlying disease or condition, according to new research.

“From Eugene to Eugenics: Oregon’s new cost-cutting strategy is o deny care to cancer patients”
(Statesman-Journal — November 6, 2013)
Oregon’s new Medicaid guidelines take treatment decisions out of the hands of doctors and patients and put them in the hands of distant state bureaucrats willing to cut costs no matter the human toll.  It’s the practice of cost-centric controls over patient-centric care.
More on Oregon

“Stop a Violation of Health Care Reform In Oregon”
(Huffington Post — September 27, 2013)
In August, Oregon’s Health Evidence Review Commission (HERC) voted to approve Revised Guideline 12, Cancer Care Near the End of Life. As a result, starting October 1, patients on Medicaid will not receive life-saving cancer medications if they have certain HERC-determined symptoms…. Furthermore, the Guideline will take clinical decision making out of the hands of doctors and deprive patients their best chance of fighting cancer.
More on Oregon

“Observation stays don’t count for Medicare coverage, many seniors harshly learn”
(Pittsburgh Tribune-Review — August 24, 2013)
Betty Rickett was surprised by a $15,000 nursing home bill after spending three days in a hospital for a broken ankle in 2009.
What she didn’t know was that time spent in a hospital bed under observation doesn’t count toward the three-day minimum needed for Medicare coverage — and being under observation does not count.

“Medicare proposes limits on hospital observation stays”
(American Medical News — May 13, 2013)
The Centers for Medicare & Medicaid Services proposed a hospital admissions definition change in its annual rule for inpatient payments…Medicare patients face greater cost-sharing responsibilities when they stay for days — and sometimes for weeks — in a hospital under observation status instead of being admitted…. “For patients, reclassification as ‘observation’ rather than admitted can result in unanticipated costs and co-payments,” the AMA stated in an Aug. 31 letter to CMS,

“UMass Memorial Tests Software to Curb Hospital Readmissions”
(Wall Street Journal — December 3, 2012)
Until Oct.1 this year, the Centers for Medicare and Medicaid (CMS) paid hospitals a flat rate when a patient was admitted with a heart attack, heart failure or pneumonia….Now, the Hospital Readmissions Reduction Program, a section of the Patient Protection and Affordable Care Ac, has begun penalizing hospitals if their 30-day readmission rates for patients exceed national averages.

“Study: Hospice Rules May Keep Away Patients”
Kaiser Health News — December 3, 2012)
The study found 61 percent of hospices would not accept patients who wanted chemotherapy, which can be used to help ease their pain in their dying days. Fifty-five percent would not accept patients who could only be fed intravenously, and 40 percent would not accept patients who were receiving blood transfusions.

“Decisions doctors must make to avoid Medicare penalties”
(American Medical News — November 12, 2012)
2013 will be a crucial year for physicians to avoid possible pay reductions under quality reporting and health information technology programs. A physician’s decision not to report Medicare quality measures or participate in paperless prescribing and health record programs in 2013 will be a costly one in the long run.

“If Medicare Tells You ‘No'”
(Wall Street Journal — October 18, 2012)
There are several things Medicare beneficiaries can do to reduce their costs….[O]ne that most beneficiaries don’t pursue  is appealing denied medical claims.  While the appeals process can be complicated and time-consuming, those who press their cases enjoy relatively high success rates.

“Medicare Fines Over Hospitals’ Readmitted Patients”
(Associated Press — October 1, 2012)
As of Monday, Medicare will start fining hospitals that have too many patients being readmitted within 30 days of discharge due to complications. The penalties are part of a broader push under President Barack Obama’s health care law to improve quality while also trying to save taxpayers’ money.

“Obama’s health care plan negatively impacts seniors”
(Centre Daily — State College, PA — September 20, 2012)
President Barack Obama’s Affordable Health Care Act, also known as Obamacare, will seriously impact the health care and health insurance of 40 million American seniors on Medicare.  I am one of them.  Those of us older than 65 represent 13 percent of the population but we consume 36 percent of the $2 trillion of the annual cost of health care.  This is how we are to be dealt with.

“Beyond Obamacare”
(New York Times — September 16, 2012)
We need death panels.  Well, maybe not death panels, exactly, but unless we start allocating health care resources more prudently — rationing by its proper name — the exploding cost of Medicare will swamp the federal budget.

More Concerns About Observation Status: Hospitals Join the Chorus”
(Center for Medicare Advocacy — September 13, 2012)
Hospital case managers and the hospital industry have joined the chorus of those opposed to observations status — a designation that renders a beneficiary ineligible for Medicare-covered skilled nursing facility (SNF) care.

“Medicare: Inpatient or Outpatient”
(AARP — August 24, 2012)
Staying in the hospital without being formally admitted can cost you thousands of dollars. Under the rules, Medicare picks up the whole tab for the first 20 days of skilled nursing for rehab or other care in an approved facility, but only if someone has spent at least three full days in the hospital as an admitted patient. If, instead, a patient has been under observation — for all or part of that time — he or she is responsible for the entire cost of rehab.

“Rationing Health Care More Fairly”
(New York Times — August 21, 2012)
Older adults are understandably anxious about the future financing of Medicare….Putting a value on life, as it were, is controversial. The National Institute in Britain has denied or limited coverage of expensive drugs for ailments like pancreatic cancer, macular degeneration and Alzheimer’s. But in a world of limited budgets, such decisions must be made.

“To Save Money, Save the Health Care Act”
(New York Times — November 3, 2010)
Perhaps most important, the legislation creates an Independent Payment Advisory Board [IPAB], a panel of independent medical experts who will look for more ways to improve Medicare’s cast-effectiveness. Under the law, any policy that the board issues takes effect unless legislation to block it is passed by Congress and signed by the president. This way, inertia works in favor of cost containment rather than against it.