It's a confusing situation for patients and a financially necessary one for hospitals: If a hospital cannot decide whether a patient is appropriate for inpatient admission, the patient can be kept up to 48 hours under "observation" while the hospital administers short-term treatment and tests.
For hospitals, admitting a patient unnecessarily can mean Medicare will not reimburse for the admission; for patients, staying in "observation" status for several days can mean Medicare will not pay for follow-up care without the requisite three days of inpatient care.
The number of patients treated under "observation" status rather than being admitted has climbed from 828,000 in 2006 to 1.13 million in 2009, according to CMS data and a Connecticut Mirror report. At the same time, claims for observation care lasting more than 48 hours tripled to 83,183, according to a report by The Washington Post.
The difference between an inpatient and an outpatient can be small and difficult to measure, Steven Meyerson, medical director for care management at Baptist Hospital of Miami, told The Washington Post. Patients who undergo what they consider a normal inpatient hospital visit — their own bed, an ID tag, treatments and tests — may be surprised to find out they were never admitted, simply observed.
The report said 3,700 U.S. hospitals use a tool created by McKesson Health Services to decide which patients should be admitted. The tool looks at various medical conditions or treatment, though the company will not reveal how the tool decides inpatient status. And just as hospitals may not know how their patients are selected for admission, patients may not know they haven't been selected: Medicare doesn't require a notification.
In a September interview with JC Online, Michele Paddack, operations manager for two observation units at St. Elizabeth East Hospital and St. Elizabeth Central Hospital in Lafayette, Ind., explained the purpose of the units she oversees. "It's really considered an extension of the ER," she said. "Patients frequently would come from the ER … the ER physician would work them up and feel that they don't need to be an inpatient for a lengthy stay, but they are not ready to go home either."
She said many patients kept under observation are those who show symptoms, but not enough for a true diagnosis. Symptoms like nausea, vomiting or abdominal pain let hospitals know a patient needs treatment without giving an exact idea of what's wrong.
John Fontanetta, MD, chairman of the emergency department at Clara Maass Medical Center in Belleville, N.J. and CMO for EDIMS, confirms the use of observation in emergency departments is climbing as the government and insurance companies "tighten down on what they consider appropriate care." He predicts that more and more patients will receive care in observation units, which he says currently treat between 10 and 18 percent of emergency department patients in many hospitals.
Ms. Paddack told JC Online that observation units benefit the patient because they reduce turn-around time and eliminate unnecessary admissions. However, a recent Washington Post editorial by Bruce Yarwood, president and CEO of the American Health Care Association, said the Medicare rule that requires a three-day inpatient stay as a prerequisite for covered post-acute care at a skilled nursing facility can hurt patients who are sick but ineligible for admission.
"To avoid patients being lost in the precarious limbo of observation stays, all days that patients spend in a hospital should be counted for purposes of the three-day hospital stay," he said. Rep. Joe Courtney (D-Conn.) recently introduced legislation that would amend the Medicare law to time in the hospital under "observation" status toward the three-day hospital stay requirement that triggers post-hospital nursing care, according to The Connecticut Mirror.
He said he fears without the legislation, the stay requirement will mean Medicare patients return to the hospital when they find they can't afford post-discharge care.
For hospitals, admitting a patient unnecessarily can mean Medicare will not reimburse for the admission; for patients, staying in "observation" status for several days can mean Medicare will not pay for follow-up care without the requisite three days of inpatient care.
The number of patients treated under "observation" status rather than being admitted has climbed from 828,000 in 2006 to 1.13 million in 2009, according to CMS data and a Connecticut Mirror report. At the same time, claims for observation care lasting more than 48 hours tripled to 83,183, according to a report by The Washington Post.
The difference between an inpatient and an outpatient can be small and difficult to measure, Steven Meyerson, medical director for care management at Baptist Hospital of Miami, told The Washington Post. Patients who undergo what they consider a normal inpatient hospital visit — their own bed, an ID tag, treatments and tests — may be surprised to find out they were never admitted, simply observed.
The report said 3,700 U.S. hospitals use a tool created by McKesson Health Services to decide which patients should be admitted. The tool looks at various medical conditions or treatment, though the company will not reveal how the tool decides inpatient status. And just as hospitals may not know how their patients are selected for admission, patients may not know they haven't been selected: Medicare doesn't require a notification.
In a September interview with JC Online, Michele Paddack, operations manager for two observation units at St. Elizabeth East Hospital and St. Elizabeth Central Hospital in Lafayette, Ind., explained the purpose of the units she oversees. "It's really considered an extension of the ER," she said. "Patients frequently would come from the ER … the ER physician would work them up and feel that they don't need to be an inpatient for a lengthy stay, but they are not ready to go home either."
She said many patients kept under observation are those who show symptoms, but not enough for a true diagnosis. Symptoms like nausea, vomiting or abdominal pain let hospitals know a patient needs treatment without giving an exact idea of what's wrong.
John Fontanetta, MD, chairman of the emergency department at Clara Maass Medical Center in Belleville, N.J. and CMO for EDIMS, confirms the use of observation in emergency departments is climbing as the government and insurance companies "tighten down on what they consider appropriate care." He predicts that more and more patients will receive care in observation units, which he says currently treat between 10 and 18 percent of emergency department patients in many hospitals.
Ms. Paddack told JC Online that observation units benefit the patient because they reduce turn-around time and eliminate unnecessary admissions. However, a recent Washington Post editorial by Bruce Yarwood, president and CEO of the American Health Care Association, said the Medicare rule that requires a three-day inpatient stay as a prerequisite for covered post-acute care at a skilled nursing facility can hurt patients who are sick but ineligible for admission.
"To avoid patients being lost in the precarious limbo of observation stays, all days that patients spend in a hospital should be counted for purposes of the three-day hospital stay," he said. Rep. Joe Courtney (D-Conn.) recently introduced legislation that would amend the Medicare law to time in the hospital under "observation" status toward the three-day hospital stay requirement that triggers post-hospital nursing care, according to The Connecticut Mirror.
He said he fears without the legislation, the stay requirement will mean Medicare patients return to the hospital when they find they can't afford post-discharge care.