Three weeks ago, while I was in Oklahoma City, I received a text message from my sister-in-law informing me that my wife Leslie had badly injured her hand while attempting to prepare herself a fruit smoothie using an infernal contraption known as a Kitchen Ninja (I’m not even going to link to this product; suffice it to say that its one of these infomercial products you don’t need, with rotating blades meant for food, not fingers). After bleeding all over our kitchen, she was transported to the emergency room, where 30 stitches spanning four fingers later, she was in better condition.
Because my wife and I dance on the edges of the health care system in our respective occupations, we have the intellectual ability of defining what constitutes an emergency. I use the item above as an introduction to a radical idea that would solve the problems of hospitals and CMS, while at the same time possibly putting the recovery audit contractors out of business.
Yesterday, the American Hospital Association announced that they have filed a lawsuit against the Department of Health and Human Services for “refusing to pay hospitals for hundreds of millions of dollars’ worth of care provided to patients”. The AHA was joined in their suit by Missouri Baptist Southern Hospital in Missouri, Munson Medical Center and Trinity Health Corporation in Michigan and Lancaster General Hospital in Pennsylvania.
The suit is based on the rather frequent habit of the RAC contractors coming back up to three years later and making a determination that medically necessary inpatient care should have been provided in an outpatient setting and voiding all payment for services. Many of these services have been overturned deep into the Medicare appeals process, with CMS stating that not only should the services be covered and paid under Medicare Part B, but that the services were reasonable and medically necessary.
For purposes of self-amusement, let’s go back to the very beginning. Let’s say, you’re sitting in your living room, you’re eating chips and bargain salsa, throwing back a bottle of Yoo-Hoo and watching a rerun of your favorite reality television show, which revolves around someone investigating mysterious noises in a haunted lighthouse that could be either a long-dead sea captain or possibly a gastric accident. Suddenly, you begin to feel pain in your chest. You chalk it up to the salsa at first, but you try to sleep through it later in the evening and it doesn’t go away. You summon someone who cares and they take you to the emergency room.
You wait in the emergency room. The automatic doors open up next to your chair every once in a while, adding a burst of unrequested cold air onto your symptomology. You read an article in an old issue of People about some teen-aged pop star (at first you can’t tell if the subject of the article is a boy or a girl) while continuing to feel discomfort. You are finally escorted to a bed, where in the words of Arlo Guthrie, you are “injected, inspected, detected, infected, neglected and selected”. The ER physician may call in a consultant, or may make a decision to place you in “observation”.
It is at this point that the public definition of common sense and Medicare reimbursement part ways. The patient sees him or herself as being “in the hospital”, but Medicare ties the payment to the hospital for treating you “in the hospital” with some kind of twisted metric concerning where in the hospital you are being treated. To put it simply, “You can only be paid at an inpatient rate if you cross this line”. From the perspective of the patient, the line exists outside, just before the automatic doors.
There is another branch of this argument that begins with the question “How do you define the word ‘emergency’?” being posed to random people, which yields interesting answers in the setting of a typical emergency room. For my wife Leslie, the “I am bleeding all over the kitchen” rule of thumb dictated that she go to the emergency room. Short of that or an unresponsive body on the floor, it’s off to either an over-the-counter medication or Urgent Care.
The problem appears to lie with CMS’ payment methods. Hospitals are finding ways to provide cost-effective care to patients who do not rise to the definition of “emergency”, yet continue to show up in the ER. In the end, the land beyond the ER is defined by everyone except CMS as “in the hospital”. Facilities have encountered continuing heartache at the hands of auditors based on CMS’ twisted definitions and lack of clear guidance. This confusion has now risen to the level of a federal lawsuit, when perhaps the better option is to simplify CMS’ definition of “in the hospital” to align it with common sense.
As for your chest pain, it turns out that you had a bad reaction to the guar gum in the Yoo-Hoo. You really ought to stop drinking that stuff.