JustCare

Tag: Inpatient care

  • One in four people with Medicare harmed in hospital

    One in four people with Medicare harmed in hospital

    A new HHS Office of the Inspector General (OIG) study finds that one in four people with Medicare were harmed in hospital in 2018. As a result, they experienced worse health outcomes. The study further finds that 43 percent of the time, the harm was likely avoidable.

    One in 16 hospitalized patients with Medicare needed more treatment as a result of the harm they experienced. These treatments add hundreds of millions of dollars to Medicare spending. Patients also often face increased costs.

    The Department of Health and Human Services (HHS) claims that patient safety is one of its top priorities. The OIG believes that heightened understanding of the types of harm patients experience in hospital will help HHS reduce harm to patients.

    More than one in eight hospitalized patients experienced harm (13 percent) temporarily. Another 12 percent experienced harm that led to longer hospital stays, permanent harm and/or died.

    Patients received different types of poor or substandard care in hospital, according to the OIG. Prescription drugs were responsible for most patient harm (43 percent). Patient care was responsible for harm about a quarter of the time (23 percent). Medical interventions were responsible for harm more than one fifth of the time (22 percent). Slightly more than one in ten patients (11 percent) acquired an infection in hospital.

    Since the COVID-19 pandemic, anecdotally it appears that a higher proportion of people with Medicare have been harmed in hospital.

    Here’s more from Just Care:

  • For help in the hospital, contact a patient advocate

    For help in the hospital, contact a patient advocate

    Tara Parker-Pope writes for the New York Times about how she was able to help her family members receiving hospital inpatient care. As you likely know, it can be extremely difficult and stressful to try to help a loved one who is hospitalized. What you might not know is that patient advocates are available to come to the rescue.

    Patient advocates serve as quarterbacks when you’re trying to get non-medical problems solved in the hospital. In Parker-Pope’s case, she wanted her dad, who was hospitalized for pneumonia, to be able to spend time with her step-mom, who was dying of Covid and also hospitalized. The patient advocate managed to get them into the same hospital room.

    Patient advocates can help with treatment plans and visitation issues. They can help arrange for a loved one to stay with a patient overnight, a virtual Zoom visit, or a visit from a pet. They also can sometimes follow up with the medical care team to understand and explain to family members what is going on and the status of a loved one’s hospital care.

    If there’s anything you need that is not billing-related or treatment-related, ask to speak to a patient advocate. Patient advocates are employed by the hospital, so there are limits to what they will do for you. There are also advocates you can hire, who are independent, but they tend to cost quite a bit.

    How do you find the patient advocate at the hospital? Ask your patient’s nurse. Or, ask the hospital operator to direct you to the advocate. Sometimes, the advocate is a hospital social worker.

    Here’s more from Just Care:

  • More hospitalized Medicare patients will qualify for nursing home care

    More hospitalized Medicare patients will qualify for nursing home care

    For many years now, Medicare has not always covered nursing home care for patients post-hospitalization. Hospitals that treated patients as outpatient–even when the patients stayed overnight–had no right to Medicare coverage of their nursing home or rehab care upon discharge. Susan Jaffe reports for Kaiser Health News that this might finally be changing, in some cases.

    More than ten years after a class-action suit was brought challenging Medicare nursing home coverage policies, a federal appeals court in Connecticut has ruled that patients should be able to challenge a Medicare coverage denial of their nursing home care if they were admitted to the hospital as an inpatient and the hospital switched their status to outpatient or observation, which is covered under Part B of Medicare. Complicated? Yep.

    For reasons that are surely financial, hospitals sometimes admit patients as inpatients, which is covered under Medicare Part A, and then switch them to outpatient or observation status. What’s most insane is that a hospital can change a patient’s status even when the patient has stayed overnight for three nights and even after the patient has been discharged. The decision is completely unrelated to the care the patient received in hospital.

    From the patients’ perspective, so long as they have Medicare Parts A and Part B and supplemental coverage, there is generally no difference how Medicare pays for their hospital care. But, if patients need rehab or nursing home care post hospitalization, there’s a big difference. Medicare generally only covers nursing home and rehab care for people who have been hospitalized as inpatients for at least three days.

    Patients who receive outpatient care in hospital never qualify for skilled nursing or rehab coverage. It doesn’t matter if they received exactly the same care as an outpatient as they would have as an inpatient.

    Consequently, tens of thousands patients who would have qualified for Medicare nursing home care had their hospital treated them as inpatients are denied Medicare nursing home or rehab coverage. If they need to be in a nursing home or rehab facility after discharge, they have to pay the full cost out of pocket.

    If you are admitted to hospital, you want to speak with your doctor and make sure that the hospital admits you as an inpatient. Hospitals did not have to disclose this information until recently, when a federal law was enacted in 2017. Since then, they must give you written notice, but, until this latest ruling, you weren’t able to appeal the hospital’s decision to treat you as an outpatient.

    The government has not said whether it will appeal this latest ruling. For now, patients who are admitted to the hospital as inpatients have the right to appeal a hospital decision to switch them to outpatient status. And, the tens of thousands of patients who have had to pay for their nursing home care because their hospitals switched their status can file a claim seeking reimbursement. For more information, visit the Center for Medicare Advocacy site.

    Here’s more from Just Care:

  • Medicare mental health care cost and access issues

    Medicare mental health care cost and access issues

    As a nation, the US has done a terrible job of meeting people’s mental health care needs. Both public and private health insurance cover mental health care, but they pay so little for mental health services that it is often hard to find mental health providers who accept insurance.  CNBC reports on mental health care cost and accessibility issues.

    Almost 20 percent of Americans have a mental health condition. And, spending on mental health care, including therapy, prescription drugs and inpatient care, is up 52 percent in the last 11 years. But, it’s hard to find mental health providers who take insurance.

    Nine in ten physicians providing physical health care take insurance. Fewer than six in ten psychiatrists, 56 percent, take insurance. More than five times as many people are forced to pay out of pocket for the full cost of their mental health care than for their physical health care.

    Mental health care tends to cost people a lot more than physical health care. People with depression typically spend $10,836 each year. People with diabetes on insulin spend less than half that, $4,800 a year.

    It’s also hard to find mental health care providers in many areas of the country. More than one-third of Americans live in areas where they are scarce.

    Between high costs and the difficulty of finding mental health providers, more than half of people who need treatment do not get the treatment they need. And, Black Americans have twice as much difficulty getting mental health care than white Americans.

    The US needs to do a far better job of ensuring people access to mental health care for their personal needs as well as for the economic health of the nation. Mental health conditions take a toll on workplace productivity. People miss work or cannot perform at their best level. Reduced productivity is estimated to cost an additional $44 billion a year.

    The 2008 Mental Health Parity and Addiction Equity Act improved access to mental health care. It requires insurers to cover access to mental health care on an equal level with physical health care. Put differently, insurers are not allowed to discriminate against people with mental health conditions. But, there are plenty of ways insurers can get around the law.

    There are a few ways that people who can’t see a psychiatrist can still get help. For one, their primary care doctors have the opportunity to identify and address their mental health care needs. That’s another reason why having a primary care doctor is so important. Also, at least for now, if you have Medicare or most private health insurance, you could see whether using telehealth services, which are easier to access and cost less, can help.

    Medicare coverage of mental health services has improved some, but it is still in need of significant improvement. There is coinsurance parity for outpatient mental health visits. It also now covers depression screenings through the annual wellness visit.

    But, more generally, Medicare offers poor coverage for mental health treatments and substance abuse counseling. And, at most, Medicare covers 190 days of inpatient mental health care services in a lifetime. Moreover, fewer than one in four psychiatrists accept Medicare’s rates.

    In addition, Medicare does not cover care delivered by mental health counselors. And, people in Medicare Advantage plan have particularly poor access to mental health providers.

    Right now, if you need mental health services, NAMI, the National Alliance on Mental Illness, has a free helpline at 1-800-950-6264. And, you can find other lower-cost places to go for treatment through the Substance Abuse and Mental Health Services Administration. If neither of these resources provide you with the information you need, try the National Association of Free & Charitable Clinics or the Open Path Psychotherapy Collective.

    Here’s more from Just Care:

  • Should you get inpatient or outpatient care? It matters

    Should you get inpatient or outpatient care? It matters

    In December 2020, the Trump administration changed payment policy for hundreds of procedures that Medicare had previously covered on an inpatient basis only. To save money, over the next three years, Medicare will begin covering these procedures on an outpatient basis, where appropriate. What does that mean for people with Medicare?

    This payment policy change should reduce Medicare spending, as the government pays less for outpatient services than for inpatient services. How the change in coverage will affect people with Medicare is not yet clear. It can be beneficial to receive care for many surgeries on an outpatient basis. Sometimes, however, inpatient care is preferable.

    Here’s the catch: Hospitals can keep you overnight for several nights and still treat you as an outpatient. If you have Medicare supplemental coverage, it might not matter. You should have few if any out-of-pocket costs for your care. But, if you don’t have supplemental coverage, you could be liable for as much as 20 percent of the cost of your care and, depending upon where you live and the physician billing you, another 15 percent on top of that.

    If you are planning to go to the hospital for a procedure and to stay overnight, it’s smart to speak to your doctor about your potential needs after you are discharged from the hospital. In particular, will you need home care, nursing home care or rehab services after your discharge?

    You will only be eligible for coverage of rehab or nursing services if you are in the hospital three nights and treated as an inpatient. If you will need rehab or nursing services post discharge, you should  confirm with your doctor that the hospital treats you as an inpatient. If you will need home care, Medicare comes home care for people meeting the eligibility criteria without a prior hospitalization requirement, but it could be harder to get an agency to take you as a patient if you have not been a hospital inpatient.

    Keep in mind that if the hospital treats you as an outpatient, you will not qualify for covered rehab or nursing services should you need them.

    The change in Medicare payment policy stems from technological advances that allow many more procedures to be done on an outpatient basis and significantly higher Medicare  payments to hospitals for inpatient care relative to outpatient care for the same procedure. That makes no sense. Of course, moving to a new policy should be done in a way that does not hurt patients, either by depriving them of coverage for needed care or shifting more costs onto them.

    Here’s more from Just Care:

  • Medicare covers physical, speech and occupational therapy

    Medicare covers physical, speech and occupational therapy

    Whether it’s because of an illness or an injury, or simply to improve balance, at some point in our lives, many of us will need therapy to regain or maintain our ability to function. Medicare covers physical, speech and occupational therapy in a variety of settings. Talk to the doctor about whether therapy would benefit you or someone you love.

    Medicare offers several outpatient therapy options. You can receive outpatient therapy services at a Comprehensive Outpatient Rehabilitation Facility, hospital, public health agency or from a private therapist, so long as the provider is Medicare-certified and you qualify for coverage. You can also receive outpatient therapy services from a Medicare-certified home health agency, so long as you qualify for the Medicare home health benefit.

    For Medicare to cover outpatient therapy, you must meet the eligibility criteria:

    • Therapy must be a safe and effective treatment for you.
    • A therapist must deliver the services or direct the delivery of the services.
    • Your doctor must certify you need the therapy to regain or maintain your ability to function and set up a plan of care for you in advance of your receiving services. And, if you need ongoing therapy, your doctor must review it and recertify your need.

    Medicare now covers as much outpatient physical, speech and occupational therapy as people need.

    Traditional Medicare pays 80 percent of the cost of these covered services. Supplemental coverage, such as Medicare supplemental insurance or “Medigap,” retiree coverage or Medicaid,  should pay the rest.

    Medicare also offers several inpatient therapy options. It covers physical, speech and occupational therapy in a nursing home as well as in a rehabilitation hospital. Coverage is limited. If you want inpatient care in a nursing home, you will need to have been hospitalized as an inpatient for at least three days in the 30 days prior to admission. You must receive care in a Medicare-certified skilled nursing facility. (Note: You can spend three nights at a hospital and the hospital may still deem it an outpatient stay.)

    If you simply need rehabilitation services–be it nursing, therapy, social worker help or psychological services–Medicare will cover care in a rehabilitation hospital under its hospital benefit.

    Medicare also covers cardiac rehabilitation care.  Click here to read more about this coverage.

    Here’s more from Just Care:

  • Hospital care at home

    Hospital care at home

    More hospitals are training their emergency room staff in geriatric care and building geriatric ERs. At the same time, hospitals are increasingly finding ways to provide the kind of inpatient care available in hospital at patients’ homes after an emergency. Essentially, they are bringing the hospital to people’s homes, with support from the Centers for Medicare and Medicaid Services and private foundations.

    The “hospital at home” model relies heavily on technology that once was only available in hospital. Today, testing technology can be transported to people’s homes. In addition, body sensors can track people’s vital signs and transmit their data to doctors at the hospital. And video technology allows patients to have ongoing visual communication with hospital staff from the comfort of their homes.  

    Avoiding a hospital stay can improve people’s health outcomes. The risk of infection from antibiotic-resistant bacteria in hospital can be high. It is also risky to be in a facility filled with sick people who may be contagious. The likelihood of delirium for older patients in hospital is also very high, as they are out of their normal surroundings. My 95-year old father, a former physician, who is otherwise of sound mind, spent one night in a hospital ER and told me the following morning that he could not understand why staff had made him chief of pediatrics.

    Michelle Andrews reports for Kaiser Health News, that Brigham and Women’s Faulkner hospital has established a hospital at home program for patients in stable condition. As an alternative to inpatient care, the hospital transports patients home, where a doctor and nurse are waiting for them. They check the patients’ IVs and affix sensors to the patients’ body. They can tell whether patients sleep well or are up in the middle of the night. And, they can tell when patients no longer need medical oversight.

    The Johns Hopkins Schools of Medicine and Public Health have also developed a hospital at home model for qualified patients with particular conditions to check into their own bed for their hospital care. In this hospital at home model,  patients with certain types of pneumonia, congestive heart failure, chronic obstructive pulmonary disease and cellulitis, who would otherwise have to be hospitalized for treatment may never go to the emergency room. Doctors and nurses provide both diagnostic tests and treatment therapies to patients at home. It is intended to address the risks of treating acutely ill older adults in hospital, where they all too often experience adverse events, such as hospital-acquired infections, as a result of compromised immune systems.

    People in Australia, England and Canada have been benefiting from hospital at home programs for quite some time. But, in the US, insurers apparently have not come up with a model to pay for the services or a new definition of what it means for a patient to be “hospitalized.” 

    One small study found far lower costs for patients who participate in a hospital at home program than patients who are admitted to hospital, with no negative outcomes and similar patient satisfaction. Another study found that hospital readmission rates for hospital at home patients were about half as high as for hospital inpatients. Hospital at home care also makes it easier for family caregivers, who do not need to travel to the hospital to be with the people they love. But, insurers appear to be unwilling to innovate on this front. Right now, the hospital at home program is supported by foundation grants and the federal government.

    Here’s more from Just Care:

  • What to know about Medicare inpatient hospital care

    What to know about Medicare inpatient hospital care

    Medicare Part A covers medically reasonable and necessary inpatient hospital care and discharge planning. Be sure to speak to your doctor to ensure you are formally admitted as an inpatient, since hospitals often classify people with Medicare as outpatients. And, plan ahead, if possible. Be sure to bring along a buddy, a friend or family member who can be your advocate while you are in hospital.

    Too often, the hospital treats Medicare patients as outpatients, even if they stay overnight for a few days. Patients are generally unaware of the difference since Medicare Part B covers outpatient hospital care. But, getting outpatient observation care may leave patients with huge health care bills without their knowledge.

    People who will need inpatient nursing or rehab care after they leave the hospital particularly want to be sure they are admitted as inpatients. Unless you are admitted as a hospital inpatient for at least three days in the 30 days prior to admission to a skilled nursing facility or rehabilitation facility, Medicare will not cover your care in these facilities.

    What does Part A cover?  If you are enrolled in traditional Medicare, Medicare Part A covers the full cost of a semi-private room and meals, nursing care, medications and medical supplies for 60 days, after you or your supplemental insurance pays the deductible ($1,340 in 2018). Please note that Medicare Part A does not cover a private nurse, a private room, or any non-medical supplies or services, such as telephones or televisions in your room. Medicare Part B covers your medical services. 

    Beginning on day 61 up until day 90, if you do not have supplemental insurance–Medigap, retiree coverage or Medicaid–you must pay daily coinsurance ($335 in 2018).

    If you are enrolled in a Medicare Advantage plan, check with your plan about your out-of-pocket costs. Each plan differs.

    Here’s a list of what you should bring to the hospital. And, to make sure you get the care you need, here’s a list of the seven things you should do before going to the hospital.

    Once you are ready to leave the hospital, you are entitled to a hospital discharge plan, laying out where you are going–e.g., home, a nursing facility or a rehabilitation facility–along with the care you will need, who will provide your care, and a list of your medications. If you are returning home, make sure the hospital arranges for home health care, if you will need it, as well as any other services you may need.

    The hospital should also let you know which services Medicare covers and which services you will be responsible for paying for once you leave the hospital. Finally, you or your caregiver should be given hospital staff contact information if issues arise after you leave. Click on this Just Care post for a list of the seven things you should be sure to do before leaving the hospital.

    Here’s more from Just Care:

  • Observation care: What you need to know

    Observation care: What you need to know

    For the last couple of decades, instead of admitting all Medicare patients who stay overnight as inpatients, hospitals have been providing some patients with “observation” care and treating them as outpatients. Patients are generally unaware of the difference. But, getting observation care leave Medicare patients with huge health care bills without their knowledge.

    A new federal law, which takes effect at the end of 2016, will require hospitals to notify patients if they are not admitting them but rather providing them only with observation care. The NOTICE Act or the Notice of Observation Treatment and Implication for Care Eligibility requires that hospitals let patients know within 24 hours that they are receiving observation care, explain the reasons for this care, and advise them of the possible financial consequences.

    You should talk to your doctor if you or someone you love is going to the hospital overnight to make sure the doctor ensures you are admitted for inpatient care and, if not, why not; you should also plan ahead for the visit by following these seven simple steps.

    Hospital patients who are not admitted as inpatients can end up paying a lot more for their care.  Medicare’s hospital benefit, which only kicks in for inpatients, is more generous than Medicare’s medical insurance coverage, which applies to people getting observation care. Among other things, inpatients have their drugs fully covered. Moreover, Medicare patients needing rehabilitation care or skilled nursing care only qualify for coverage if they have been inpatients for at least three days in the thirty days prior to admission.

    Observation care is a classification hospitals use for patients they claim are not sick enough to be admitted and not well enough to be sent home. But, hospital incentives are such that they may take a more liberal view of what constitutes observation care than appropriate. For example, they may want to make it seem that their hospital readmission rates are low to improve their quality ratings and payments from Medicare.

    There’s compelling evidence that hospitals may be manipulating the observation care classification for their benefit. It’s otherwise hard to explain how the percentage of patients receiving observation care in 2013 is so much greater than in 2006.

    Several states, including New York, Connecticut, Maryland, Virginia and Pennsylvania, already have passed laws according similar rights to patients receiving observation care as the NOTICE Act.

    For more reading on this topic, see this article in Health Affairs.