This Is What Really Happens, And Why: Part 2

In the first post of this three post series, I described the shifting of resources between Part A and Part B. It's not cost savings. It's cost shifting. Read on for Part 2 of my series

Medicare Part A: Hospital Insurance

• Hospital Stays
  
• Skilled Nursing Facilities. To qualify for skilled nursing a patient must be hospitalized for three midnights
  
• You pay no premium if you have worked 40 quarters in your lifetime
• Deductibles apply which can be paid for by purchasing a supplemental Medigap policy
  

Medicare Part B: Medical Insurance

• Outpatient Care that includes physician services, nursing care, labs, radiology, blood transfusions, dialysis, outpatient procedures.
  
• You pay a monthly premium dependent on your income. The lowest level is $96/month, rising to about $240/month for couples making over 400K/year.
• Covers 80% of the costs, minus a $135/year deductible, a supplemental policy may be purchased to cover the rest (a Medigap Policy)
  

Medicare Part C: Privately administered Medicare Plans.

• Benefits vary depending on the plan
• May or may not have a premium
  

Medicare Part D: Drug Insurance

• Just over a couple years old, these privately administered plans cover most drugs.
• May or may not have a premium

The Three Midnight Rule

The three midnight rule. This rule says that a Medicare patient, in order to qualify for their skilled nursing stay under Part A benefits, MUST spend three midnights in the hospital. I speak for myself, and probably just about every hospitalist or other specialist that works in the hospital setting, this is one of the most asinine rules ever created. There is nothing magical about three midnights. In fact, I can fix a lot of illness in one or two days.

For example, lets say I admit an 87 year old who lives alone and functions well. They present to the emergency room with profound weakness, and are found to have a UTI which is showing signs of pyelonephritis (extension to the kidneys). They have fever and an elevated infection count. Clinically they have pyelonephritis. I start them on IV antibiotics and 36 hours later they look markedly better. Our physical therapists say granny is very weak and is unsafe to be discharged directly home. By now, they are on oral antibiotics, they are not vomiting. They have no indication to be in the hospital. So what do you do? They can't go home. They must be in the hospital for three midnights to qualify for their skilled benefits. This question is answered thousands of times a day, all across the country. The answer is: You qualify them for continued inpatient hospital stay.

If my 87 year old is documented as unsafe to be discharged home, I cannot discharge them home. It's the same, in my book, as patient dumping. A lawyer would have a field day. You just don't do it. But they also don't qualify for their skilled benefits because they must stay 3 midnights. So what do you do? And no place will take them if they don't qualify for their Medicare benefits, without payment upfront. So what do you do? You find away to qualify them for continued inpatient care. You keep them on IV antibiotics. You keep them on IV fluids. You give them IV pain medications. You put them on telemetry. You qualify them, because it's the right thing to do. You don't send an 87 year old home who can't function.

In essence, the arbitrary rule penalizes great medical care. When you do everything right. When you are so good that you get your medical issues resolved quickly, ahead of the 87 year old's ability to recovery physically and mentally, you are penalized by not allowing the patient to move on to the next level of care. Often times, I'd say as a group, a 100 times a year we admit frail old ladies who fall and have non surgical pelvic fractures or other nonurgent acute medical episode that can be stabilized in 24-48 hours.

These nonsurgical, non urgent issues could be handled in a skilled nursing facility from day one. You can't send them home. They can't afford $1000 a day for rehab, so they come into the hospital to get one shot of IV morphine a day for pain control, to qualify them for their skilled nursing benefits. Do they need pain control? Yes. Do they need to be in the hospital? Yes, because they have no where else to go. To qualify to get their rehab, they must sit in a hospital bed for three midnights. It's a ridiculous exercise that puts patients at risk for hospital acquired infections and DVTs. But we are forced to play the game because the patients have no where else to go.