Patients shouldering higher healthcare charges and out-of-pocket expenses are paying more attention than ever to the cost of their care.
That may be one reason why some providers are seeing an uptick in the number of patients who ask whether they're being admitted as inpatients or being kept in observation status as outpatients. The distinction can carry significant financial ramifications for Medicare patients.
Soon, a new form may actually offer the chance to strengthen that patient conversation. The Medicare Outpatient Observation Notice (MOON) — which is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) — is intended to help patients better understand observation care and their financial obligations for it under Medicare. The MOON must be implemented by all hospitals and critical access hospitals no later than March 8, 2017.
As providers begin a new disclosure process with Medicare beneficiaries who receive observation services as outpatients for greater than 24 hours, they should look at not only how the MOON might improve the patient/provider relationship, but also how it might impact patient choice. In the face of higher co-insurance, some patients might opt to leave against medical advice (AMA) rather than stay for observation care.
4 tips to improve the MOON conversation
The NOTICE Act requires providers both to give patients the MOON and to talk with them about the difference between outpatient observation care and inpatient status. This dialog offers the opportunity to answer questions, increase patient understanding, and even potentially help clinical outcomes. Consider these four best practices for a stronger patient conversation:
1. Translate what the MOON form really means. A key step toward transparency is ensuring that patients truly understand the difference between inpatient admission and observation care provided as an outpatient service. Let patients know that the distinction isn't arbitrary; they must meet certain criteria to qualify for an inpatient admission. On the MOON form, providers are required to document their description of why the patient is under observation rather than receiving inpatient services. In addition, hospitals should explain to patients how Medicare pays for outpatient services and certain self-administered medications, as well as the impact that outpatient observation services may have on Medicare payments for subsequent skilled nursing facility care.
2. Understand specific Medicare coverages. The type of Medicare coverage patients have may impact how likely they are to accept observation care. As a result, it's important for hospitals to understand the demographics of their patient populations. Of the 53.8 million people covered by Medicare, for example, 4.5 million have only Part A (hospital) insurance — which does not cover an observation stay. On the other hand, the 49.3 million patients who have both Part A and Part B (outpatient) coverage usually have some cost-sharing requirement such as a copay for hospital outpatient and physician services. The 16.2 million patients enrolled in Part C or a Medicare Advantage plan may have different costs and coverages. Analyzing your organization's Medicare patient population can help you understand which patients may be more likely to leave AMA when an observation stay is advised.
3. Serve as a knowledge conduit. A provider's job is to offer patients as much information as possible to make informed decisions about their care, and then to respect those decisions. In situations where observation is recommended, providers can explain the advantages of staying at the hospital — such as the opportunity to monitor certain signs or symptoms that could be missed at home. Conversely, providers can also discuss the option to forego hospital-supplied oral medications (if they are not covered) in favor of taking self-administered oral medications that are brought from home. When patients do chose to leave, keep the provider/patient relationship balanced and positive. A patient callback process or an automated patient follow-up system can help monitor those patients who leave AMA.
4. Document the conversation properly. The MOON must be given to a patient in observation or other outpatient status within 36 hours of admission, so be sure processes are in place for timely execution. Whether a patient agrees to observation or leaves AMA, providers must document that a verbal explanation took place and the patient understood both the care and financial implications. If a patient opts to leave AMA, providers should explain the risk and ensure the patient understands it before gaining the appropriate signature. While an automated patient follow-up system can help monitor their conditions, AMA patients should always be encouraged to return to the ED immediately in case of a change in mind or if their conditions worsen.
As consumerism grows, hospitals and health systems must pay careful attention to the mounting demand for patient choice. Although it may be perceived as yet another paperwork hassle, don't underestimate the potential of the MOON to support patient choice by empowering clearer conversations and greater transparency.
Tom Scaletta is the emergency department chair and patient experience medical director at Edward-Elmhurst Health in Naperville, Illinois.
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