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Medicare Only Covers Some Medications During A Hospital Stay

One of the worst parts of my job over the years has been to tell patients I was going to bring them into the hospital as an observation status because they did not have any criteria for full inpatient status.  There is a huge difference in how CMS pays for hospital care (excluding critical access hospitals) between inpatient versus observation.

Observation is considered outpatient.  Medicare will pay for observation hospital services for up to 48 hours to allow physicians a chance to observe the patient and determine if they need to have an inpatient hospital admission.  Observation was never intended to be used as a holding pit  to help social workers arrange for a nursing home transfer during normal business working hours because it can’t be arranged, on either end, at 10 pm on a Friday night.
What used to be a moral family obligation to care for loved ones too weak to care for themselves has now been relinquished to the role of hospitals and hospitalists.  And we all pay for it.  Families have abandoned their loved ones for good.  It’s really quite sad.  Bringing patients into the hospital for the purpose of arranging a nursing home transfer is, in my opinion, a form of Medicare fraud, since these patients have no intention of being fully admitted.

But it’s paid for and will always be paid for, except when they come back for their 30 day heart failure readmission.  Then it’s just free nursing home care in the hospital.  More than likely, when this payment model kicks in, a program to divert the social admit will be implemented as a matter of necessity.

One obstacle to patient satisfaction, which by the way is going to determine Medicare payment rates in just a few short years, is patients getting bills from the hospital that weren’t covered by their primary and MediGap policies.
Unfortunately for patients admitted under observation status, many routine home medications that are administered to the patient during their hospital stay will not be covered under Medicare part A (in patient services), or Medicare Part B (outpatient services).  That means the patient will often get a bill for hospital administered home medications with exorbitant mark ups.

I can’t count the number of times I’ve been yelled at by families upset because the hospitalist had mom in under observation last month and they got a $1,000 bill for a bunch of her medications she would normally take at home.

I was able to hunt down a nice February 2011 summary of which medications Medicare will pay for during an outpatient observation hospital stay.  Here’s the first few paragraphs.  Go read the rest at the link so you can tell your patients the truth about what is and what isn’t covered when the daughter drops dad off  at 9 pm on a Thursday so she can leave town for the weekend (it happens more than you think).

Medicare Part B (Medical Insurance) generally covers care you get in a hospital outpatient setting, like an emergency department, observation unit, surgery center, or pain clinic. Part B only covers certain drugs in these settings, like drugs given through an IV (intravenous infusion). Sometimes people with Medicare need “self-administered drugs” while in hospital outpatient settings. “Self-administered drugs” are drugs you would normally take on your own. Part B generally doesn’t pay for self-administered drugs unless they are required for the hospital outpatient services you’re getting. If you get self-administered drugs that aren’t covered by Medicare Part B while in a hospital outpatient setting, the hospital may bill you for the drug. However, if you are enrolled in a Medicare drug plan (Part D), these drugs may be covered.

So Medicare Part D might be an out, however, don’t count in it.  Go read the rest of the link to see why.  More than likely, the patient will get stuck with a bill for $200 worth of Tylenol.

For years, I was constantly confronted by patients upset that they couldn’t take their own home medications while in the hospital because of hospital policy.  And I would tell them up front that the hospital did not allow them to bring in their own medications as a matter of hospital policy.  Safety was the reason given as medications coming on campus were difficult to verify across accurate identification, dose, storage and expiration.  For safety purposes many hospitals don’t allow patients to bring in their own medications.  That leaves patients in a bind. This is a catch 22 for patients from a cost perspective.  It’s a catch 22 for hospitals from a safety perspective. What were the choices the patient then faced?

  • Refuse to take their own home meds trying to be administered by the hospital at hospital based charges
  • Doctors refuse to order patients’ home meds because they know the financial hardship this will cause
  • Patients’ loved ones sneak in the medications behind everyone’s backs as a way of bypassing the hospital’s policies.

For years I have taken on little battles as a patient advocate to help get them the right to take their own home medications and not fall victim to massive uncovered pharmacy bills.  I’m curious to know what other hospitals are doing in this situation to minimize the financial burden patients experience with “self administered” home medications during an observation hospital stay.

*This blog post was originally published at The Happy Hospitalist*

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One Response to “Medicare Only Covers Some Medications During A Hospital Stay”

  1. Doctorsh says:

    Maybe it’s time Medicare stopped paying altogether, other than for catastrophic. Before I get flamed, hear me out.
    As people now believe in the entitlement of Medicare, they want and demand more and more, and end up putting what should be their responsibilities on our system. This is as much the politicians and regulators fault who put this system in place as it is the families who use the system this way.
    We need to put the onus back on the individual while still providing for a government safety net, while also reestablishing a deeper charitable safety net. If the govt would fix their costs, by providing an health savings account for lower income, combined with a catastrophic policy the govt purchases from a private insurer, the costs would be more fixed, and the individual would have some more skin in the game, as any leftover hsa funds remain in the individuals account.
    When Medicare stops being the payer, the entire icd system would go away, and docs and hospitals would be free to terminate the third party chains, and innovate not only care, but costs as well, as true competition would occur.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.


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