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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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