When this person speaks, they all listen

Michael Ellenbogen

https://thehill.com/blogs/congress-blog/politics/583572-how-to-improve-care-for-people-living-with-dementia?rl=1

 

Jo C.

Won't hold my breath.

Many people are not aware that for Medicare, hospitals are paid on a DRG basis; that stands for Diagnosis Related Group.  What this means, is that the hospital gets paid for the ADMITTING DIAGNOSIS - for  the principle diagnosis - what it was that has brought the patient to the hospital. This is done at the time of admission, and not what happens afterward.  No additional payment for labs, x-ray, meds, PT, OT, Respiratory Therapy, etc.  ALL care in toto is included under that admitting diagnosis DRG and it is not high payment. 

So . . . . someone comes in with a pneumonia, the patient's admitting diagnosis is pneumonia and is coded for the type of pneumonia, the hospital will get paid for that DRG diagnosis.  BUT . . . . a couple of days later the patient has a heart attack and ends up in ICU and stays in ICU for say, five days or so; then when sufficiently stable, the patient goes to a step-down unit and stays until stable to move forward; all of this adds to the hospital's costs for treating that patient.  No increase in payment; all is  same - pneumonia - the principle diagnosis at the time of admission which sets the DRG in place.

SO . . . . under the DRG system, IF the patient does not require much care, and especially if the patient can be discharged as early as possible, the hospital makes a profit.   However; if the patient requires a lot of care and/or the length of stay is long, then the hospital loses money. (There is a cutoff point for "outliers," where reimbursement is higher, but that rarely happens and is only in tremendously severe/lengthy cases that are far beyond what one usually sees and outliers are definitely not at all common.)

The hospital has Case Managers or Discharge Planners who are licensed nurses.  It is their job to follow the patients reviewing their records, make plans for the discharge and discharging as early as possible keeping the bed days (length of stay) down.  Their job is to make plans for discharge; but believe me, as an Administrator of Patient Care Management at multiple medical centers, their job is to get that patient out as quickly as possible . . . whoooosh!   Sicker and quicker seems to have become the method for too many settings.

Medicare looking at this decided to say; "Hm-m-m; okay sent out sicker and quicker, so we will penalize the hospitals for having early inpatient readmissions as that is more costly for Medicare - these are patients that bounced back into the hospital because they were discharged too early.  Well . . . . not that many are seen as "too early," and Medicare in their infinite wisdom now permits patients to be admitted as "Outpatient" status even if in the hospital for multiple days.  This has permitted the hospitals to not be penalized for inpatient readmissions because they are "outpatients" and not "in," but sadly, it also means that many hospitals will strive to have patients be "Outpatients" when they really should be "in"as there is no penalty for readmission.  Care is usually the same; just the reimbursement is different. The patient can be admitted as an inpatient, but the hospital can push the doctor to permit them to change the patient status to outpatient and it often works.  The Business Office is then supposed to deliver a change of status letter to the patient; however, this is often misunderstood, or the patient is not competent and the letter goes awry.  It happens.

Used to be that a medical outpatient was 24 hours only; then it got to 24 - 48 hours. But we have seen patients in for a week and a half or so still on an outpatient status.  This leaves the patient at high risk financially and for not qualifying for Skilled Care . . . . When an outpatient, one  is NOT covered as they are when an inpatient.  So all care that would be outpatient such as radiology, meds, PT, labs, etc. are present, but the Part A inpatient bed day costs are not covered which is the inpatient part. 

This leaves the patient at significant financial risk for each day in the hospital; and it also means that the patient if he or she needs to go to Skilled Care such as for skilled rehab, the patient will NOT be able to be covered by Medicare. Why?  Because Medicare will cover Skilled  Care ONLY if the patient has been in the acute hospital as an inpatient for three 24 hour days. 

There have been patients who have been sent to Skilled Care and there were slip ups made; the patient did not have those three inpatient days at the acute hospital because they were coded as outpatients.  This was somehow not realized. This means that the patient is now financially responsible for all care at the facility that was providing the Skilled Care. We have had this happen with some of the Members families here on AlzConnected.   Horrible.

There is no benefit for the hospital to push for having more tests, etc. done when payment is on a DRG; they lose money.  It is NOT fee for service in the med centers.

This is no small matter and patients are often short changed and at risk because of it.  It bothers me a lot as I have seen so much in my professional career.  There has to be a better way; but hey - Medicare is mainly for the vast majority an elderly person's coverage; or a disabled person's coverage.  Is this the big voting bloc that can shake the earth bringing about changes?  No.

As for Medicare Advantage . . . that is more or less an HMO model; and I have also been involved with some of these as well as free standing HMOs.  These are cost driven and will push the walls fiercely to have bed days and diagnostics kept as low as low as low as can be; sometimes with some, even when inappropriate.  Especially heaven help you if sophisticated expensive diagnostics are needed.  I have seen these refused to the patient's detriment.  With the Advantage programs, these are run by multiple medical groups that contract wtth  large insurance companies.  Insurance can be an umbrella company called, " Better Wonderful Well Insurance."  That is the umbrella; a big company (and there are many of them) . . . BUT the acutality is, that many multiple different medical groups contract with Better Wonderful Well and they have significant financial incentive for their overall profits as they are paid so many dollars each month or year for each patient enrolled with them.  Many of them also dispense annual bonuses to the doctors whose patient's bed days have been low; whose care costs are low because they have not ordered a lot, discharged inpatients quickly, etc. That keeps the profit center up.   I have seen some of these checks.  What I saw were five to six figures depending on the doctors and this included their contracted specialists who also got bonuses .  So . . . get the patient out early, do not order much and we will reward you.  I am a firm believer that such bonuses should be forbidden by law.

In such a setting; a company or medical group is paid so many set dollars per member life per certain period.  If the group conserves and saves, they have profit.  However; if the costs to provide care go over the amount for the dollars per life, then they lose or profit is very low.  It is to the benefit for such insurance companies and medical groups to have younger members and healther members. However; with Medicare we are looking mostly at ages 65 and older so utilization oversight is huge and many of them have utilization nurses following the patients in Skilled Care and that can limit the amount of time there too.

Sadly, I have even seen patients who needed durable medical equipment at home have differences.  So disappointing when the same physician orders needed equipment when a patient has private insurance, but when it is through their managed care group, equipment is denied though the patient is in a very similar cirumstance.  NOTE:  It is important to know that I am definitely not saying all physicians conduct themselves in such a manner; that is not so. Definitely not.  It is just so much of that does happen.  It is also true that doctors come under much pressure secondary to such dynamics. 

Certainly, DRG reimbursement shortened the length of stay and has brought costs way, way, way down.  However; like everything, there are results which have been dismaying.  We have no control over any of this; it is as others dictate and decide.  Most of our legislators making or approving of laws are well covered for the costs of their healthcare and by their status alone will never have to face what the rest of the people do.  Too bad.  If the shoe were on the other foot . . . .

jfkoc

Thankfully there are organizations out there fighting for people with dementia.

Thanks Michael

[Deleted User]

The user and all related content has been deleted.

Iris L.

I pay over $300 per month for private supplemental insurance so that I can choose my own doctors.  Even though I had only a very few medical visits these past two years due to Covid avoidance.  My doctors are on different plans, if I were to sign up for one plan, I would lose my other doctors. 

There is much about the regular rules that the public don't know.  I can't keep up.  Thanks for this detailed explanation, Jo C.

Iris

Iris L.

I read the article and I wonder what dementia-related care payment is asked for?  It sounds like the writers father was left alone in the hospital--she knew he could not articulate his needs.  Families need to become more pro-active, I think.

I have an analogy.  Yesterday I took my cat to the vet.  The vet did not dmsay much but ordered a lot of laboratory tests.  The second vet told me more about my cat and answered my questions even though she was not the one who examined my cat.  What does this have to do with dementia care?  

Perhaps the  meaning is for patient-centered care (cat-centered) versus diagnosis-centered (laboratory-centered) care.  Now I get it.  Meaning, I think I understand the meaning of the article now.

I have always urged patients to find a doctor who is interested in your case.  All doctors nowadays are thoroughly trained in laboratory values.  But that does not mean they have a good bedside manner or know how to advise a patient in management of illness or health.

Every year there are changes in health care.  But our demographic does not seem to be ordering the changes.  I don't have any answers.

Iris

Mint

I have to go on Medicare a year from yesterday.  Was already leaning toward original Medicare, think from what you guys are saying that is the better choice.   What you are paying Iris is about what I was thinking my Medicare cost would be with good full coverage.  Thank you for verifying that.  That is what I’m paying right now but have a $7500 deductible that I meet first except for preventive care.  So seems I will be a little better off in the deductible area, maybe.

Michael Ellenbogen

Jo C. you bring out some good points and I have herd this before from my wife. Can I share this with Nora as she may not e aware of all of this? I get it systems are broken and that is why we need to wok together to make sure they know all sides.

UnusedScreenName

Jo C.,

Has hospital DRG billing changed that much in the 20+ years since I was in practice?  I suppose it probably has.  When I was a resident and an attending physician, hospitals were reimbursed by DRG, but there could be multiple DRGs, even if some developed during the hospitalization.  It would have to be shown that the later DRG(s) were not related to the admitting one(s), but still.  The Medical Records department was constantly on us physicians to document in our discharge summaries as many diagnoses as could legitimately be applied to our patients.

I hear you about the gradual lengthening of "observation" status of less than 24 hours to outpatient status for 48 or more hours, the "sicker and quicker" discharges, penalties for readmissions, and the difficulty getting patients readmitted for real instead of in an "observation" bed to try to avoid those penalties.

Regarding HMOs, I have had Kaiser myself for many years and used to push my father to get HMO coverage based on my experience with Kaiser as an "everything under one roof" provider with good communication between departments and an excellent web site that tied everything together.  But I discovered, as I was tring to manage his care remotely about 5 years ago, just how horrible "HMO" care could be when it is nothing more than a network of providers being paid by capitation (he did not have Kaiser, but a Blue Cross/Blue Shield HMO).  Dad always said he wanted Original Medicare, and I finally understood why.  After one year with that horrible plan and pitiful excuse for a primary care doctor, he's been back on Original Medicare with a Medicare Supplement Plan N ever since.

Since he moved out here with me two years ago, I've been able to find him excellent medical providers, and since I'm retired (though not by plan), I have the time to invest in ensuring he gets good care.

Regarding the example patient in the article linked, it's a shame that you have to have years of experience with the system to learn the "tricks" to decrease the incidence of things like your loved one being unceremoniously dumped into a wheelchair for hours awaiting your arrival to pick them up.  Medicare patients are supposed to receive 24 advance notice of their discharge, and if you contest the discharge in writing (there is a form, one can ask the nursing staff or discharge planner for it), you can gain an extra day while the case review is pending, even if it is ultimately denied. (Beyond that, if you stay despite a Medicare denial, you have to pay for the extra days out of pocket.)

I used this tactic when my father first came out across the country to live at an independent living facility near me, 10 months after my mother died. He went down in flames with multiple ER visits for confusion and was hospitalized within 3 weeks, hypotensive (due to an accumulation of unremoved nitroglycerine patches over a 3-day period) and agitated and paranoid and wanting to die.  He was in the hospital for 3 days and had lost and was en route to recovering the ability to walk or control his bladder, but as of his proposed discharge date I would not have been able to manage him at home.  By my stalling his discharge by one more day, he improved enough that I was. [Happy ending to that chapter of his life: he did great after moving in with my husband and me and stayed with us for 7 months, bought a recumbent tricycle that he used to ride all over the county, and began 6 successful years of living in different independent living facilities near different offspring around the country.  He finally moved in with us again 2 years ago, where he will stay until I can't manage it any more and he needs to be placed in a care facility.]

Rebeccah