So are you an inpatient or an outpatient?

The hospital and Medicare get to decide. Not your doctor who is actually treating you.

I found this pretty appalling. Medicare patients can be in the hospital for DAYS and be called and an outpatient because they are only being 'observed'. They get the same care as everyone else. But then they get a big fat bill if they were an outpatient.

Their doctor can even admit them and make them an inpatient but then the hospital can change it back to outpatient. Hospitals like this because they get reimbursed more that way.

"Medicare originally intended observation care as a way to give doctors time to evaluate whether a patient should be admitted to the hospital or is stable enough to go home, usually within 24 to 48 hours. But hospitals are increasingly keeping patients in observation status longer: 8 percent of Medicare recipients had observation stays longer than 48 hours in 2011, up from 3 percent in 2006.
Apparently the government can tell by looking at a rule book to figure out how sick you are, not but diagnosing you and reading your chart. Or, God forbid, even talking to you.

That increase may partly be a response to aggressive reviews of hospital billing practices in recent years. Medicare contractors have demanded refunds from hospitals that admit patients the government believes should have been treated as observation patients or outpatients. Medicare pays hospitals less for those patients."

And also hospitals are now rated on their readmission rates. If you aren't admitted the first time, you are not readmitted later on.

"Toby Edelman, senior policy attorney at the Center for Medicare Advocacy in Washington, D.C., said she believes hospitals also could be trying to avoid readmission penalties, which are assessed if too many patients are readmitted within 30 days. Harold Engler, for example, went home after five days, grew sicker, and then returned for another five-day observation stay. If he had been an inpatient, he would have counted as a readmission within 30 days."

Hospitals claim they are working on it because they computer tells them what to do. The computer even knows more than the government:

"Dr. James Hart, who heads a Beth Israel Deaconess committee that makes sure the hospital follows Medicare rules, said he could not comment on Engler’s case. But he said the hospital uses a sophisticated computer program that tries to match patients with the correct Medicare designation based on their illness and the intensity of hospital services required. “We are very focused on getting the level of care accurate,’’ he said."

Medicare knows this is a problem and even has created a brochure on this telling patients the difference. But if you are sick in bed, do you really care about semantics? No.

"Case managers generally inform patients of their status, especially if they require skilled nursing care, he said. But that doesn’t mean patients digest the information, at a time when they have so much to focus on. “Part of the challenge from a patient perspective is there really is an information overload,’’ Hart said."


You just want to feel better and go home where you can be in your own bed eating real food instead of the crappy hospital food they serve.

I knew Medicare had its issues but I didn't think it was out to impoverish seniors. I thought it was supposed to be the other way around. Clearly some changes need to be made here.

Update: 8/30/13 - One of the former heads of Medicare wants the rule on observation to be abolished.

Good bye 2012, Hello 2013 health care-wise

So if you read CNN, which I do. I find it much easier than watching CNN - either HLN screaming about new 'factoids' and miracles, or regular CNN going on and on and on about something boring and political that will put me to sleep before I learn anything. I prefer my news in the low brow way - tell it like it is and keep it short. This is why I like CNN online - because I can skip through articles instead of listening to people S L O W L Y reading them. I don't have a lot of time in my life to waste on the news. I have better things to do - like have fun.

I have digressed. CNN put out their list of the top health news stories of 2012 - which I found to be exceptionally lame as several of them focus on individual people. Here's the list:

1. Supreme Court upheld the Affordable Care Act.
2. Woman from Georgia and her case of flesh eating bacteria
3. Meningitis from steroid injections that killed 39
4. The Record West Nile Virus outbreak
5. Robin Roberts bone marrow transplant
6. Hantavirus at Yosemite
7. Jesse Jackson and bi-polar disorders
8. Spike in autism cases
9. Kathy Bates double mastectomy
10. Hepatitis C from the traveling hospital worker

 I personally think numbers 2, 5, 7, and 9 are not significant as they are mostly about individuals and do not represent any breakthroughs. Nothing against the individuals but they do not reflect any real news.

But here is the list for 2013 of things to look out for:

1. Medicaid expansion
2. Medicaid provider payments will go up so more providers will take medicaid patients
3. Health insurance exchanges
4. Medicaid taxes are going up for those making over $250,000
5. Medicare reform
6. Insurance transparency - health insurance policies will need to be understandable
7. Health care spending will be a big issue

Maybe this is what I get for reading CNN but I would prefer to see stories about health care advances and research. Maybe I need to do more research. But I do like the changes for the coming year with healthcare.

When medical standards change and they don't tell the patients

Back when I had thyroid cancer in 1981, I was followed by an endocrinologist for more than a decade. Then my endo retired and I switched to a general internal medicine doctor for a primary care doctor. Some where during that time, standards for follow up to thyroid cancer patients changed. Ultrasounds become the standard for following up on potential residual tissue or recurrence and were ordered by endocrinologist. I just went along my merry way with out an endocrinologist not knowing that I should have one.

In 2008 I went to the Thyroid Cancer Survivor's Conference in Boston and found out that I had clearly missed something and should have an endo. Then I started seeing an endo twice a year for blood work and regular ultrasounds and am back on the program.

I had felt somewhere I should have been told that the standards are changed and endocrinologists follow thyroid cancer patients for life. There is no real way patients have for learning about changing standards in care over time. We assume our doctors will tell us.

My previous primary care never was a good communicator and I have switched from her to a new doctor. She really was a communication failure and I rarely saw her, mostly her nurse practitioner, which is why she is no longer my PCP. If this change happened sometime after the early 1990s she should have told me at some point.

I have now learned to be more proactive about asking about changes in treatment. I think my new primary care also does a better job of telling me about changes in standards so I feel more comfortable about it. And I can always hop on to Dr. Google and see what he tells me so I can ask about them.

Law, religion, and medical care

This story saddened me. A 16 year old girl who was 13 weeks pregnant died from complications from leukemia in the Dominican Republic. The Dominican Republic constitution forbids abortion which I believe is within their rights to decide as a country. This is probably due to the main religion of the country - Catholicism. Her doctors were concerned that chemotherapy would induce an abortion. It took 20 days to reach the decision that she could receive chemotherapy. At that point she miscarried, had a cardiac arrest and could not be revived.

While I am certainly not going to get into a discussion on the Catholic church's opinion of abortion or the Dominican Republic's Constitution, nor discuss the subject of teen pregnancy, I do feel that the purpose of the Hippocratic Oath was to do no harm. To me this means taking care of the patient first. Where was the sense of urgency in making this decision to let her receive chemotherapy? Why wasn't the concern for the life of the mother taken into consideration?

It is just very sad that politics and religion interfere needlessly with medical care in this day and age.

Tiered health insurance options

We have heard about the options in tiered health insurance. This is where the insurer negotiates rates with different medical facilities and then charges the patient differently based on where they go. That generic drugs are cheaper than brand name ones, etc. are another side of this.

I have always thought this was a good idea. I think patients have a tendency to either go for medical care to wherever their doctors send them or where they have always gone. Patients are human beings who are essentially lazy and take the path of least resistance. But what if the insurance company started charging them more for where they have always gone? I never thought about that part.

Yesterday as I was rushing to go to work on a rainy Monday, I went back first for my hair brush and second to see if I left the stove on (otherwise I would have had a bad hair day and driven myself crazy all day thinking I was burning down the house with the cat in it), I was also listening to the radio. They had a commercial on for some big health insurance plan where the CEO or some big-wig was on talking about the how's and why's of tiered health care.

I know I go to a relatively 'expensive' hospital but it is the closest one without going into the traffic filled city of Boston. Then the horrifying thought occurred to me - what if they started charging me more to go where my 30+ years of medical records reside? 'Surely they can't mean me' are the blinders we live by when these changes are announced. If this happens, I will have to become a rebel and protest this.

I understand the principle behind this steer patients to the less expensive medical facilities. This may also get them to use the smaller community facilities instead of the fancy (expensive) ones but there also should be some logic applied to this formula. Somewhere in the equation should be the consideration for the patient who doesn't want to go geographically far away for treatment when it good treatment is located near by. (This integration intentioned busing applied to medical care - send the patients to far away places because they want to keep things 'even'.)  It sounds good in theory but isn't with the patient's best interests in mind. Hmmm.... must be the insurance companies in charge again.