Plenty of Healthcare News to Cover as Summer Heats Up

Plenty of Healthcare News to Cover as Summer Heats Up

There has been lots of healthcare news in the past two weeks. First, I hope all of you read my RACmonitor e-news article from July 6 about the right observation rate. If you didn’t, here’s a preview: I did it. No, I did not find the right observation rate, since one does not exist. But what I did do was ascertain the national average observation rate for traditional Medicare patients. And that rate is: 12.18 percent. But you are forbidden to ever quote that number unless you read my article and understand all the nuances and caveats that go along with it. For instance, it does not include critical access hospitals (CAHs), and I arbitrarily limited it to hospitals with over 50 beds. Now remember, 12.18 percent is not the “right” rate for your facility. The right rate for your hospital is whatever rate you have when every patient is placed in the right status. I must note, though, that what really shocked me about the data was the number of hospitals, many of them quite large, that had no Medicare observation stays at all. Either the database I was using is terribly flawed, or some hospitals are just making up their own rules.

Next, I am sure many of you have seen articles talking about the epidemic of medical errors and the many patients who suffer harm while hospitalized. These claims, of course, are often inaccurate. These fearmongers take small studies and extrapolate them to every patient in every hospital in the U.S. It’s terribly inappropriate statistical manipulation, but it sells books and inflates the egos of these so-called experts. Well, last week the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) seems to have jumped on the bandwagon by publishing their toolkit for identifying patient harm.

It’s really concerning.

Let me give you some examples: if a hospitalized patient becomes constipated or develops diarrhea, it may be considered patient harm. if a patient receives chemotherapy and requires IV fluids or anti-nausea medication, it may be considered patient harm. Should we not treat the cancer since they might get nauseous? We absolutely must do our best to take excellent care of patients, and of course be forthcoming when errors occur, but this effort by the OIG is going to do actual harm by taking caregivers away from the bedside to fill out more forms and collect more data that surely will be misused, to everyone’s detriment.

You may have also heard that the Food and Drug Administration (FDA) gave full approval to a new medication for Alzheimer’s disease, Leqembi, and as a result, Medicare will cover it. But there are important caveats. First, this medication can cause brain bleeds, and that’s never a good thing. And the incidence of this is higher in patients with a specific gene mutation.

The problem is that Medicare does not appear to cover the applicable gene test. Will patients be willing to pay out of pocket? Will doctors be willing to order the medication if patients don’t get the genetic test done first? If the test is not done and the patient has an adverse event, will the OIG consider this preventable patient harm? In addition, a PET scan is needed to confirm the presence of amyloid in in the brain, and the requirements for coverage are onerous. So many questions still to be answered.

Finally, in the past, I have criticized the Quality Improvement Organizations (QIOs) for the patient advocacy stories they publish. But two weeks ago, Livanta published one that evoked a different reaction. Let me quote the pertinent section: “My dad had a total knee replacement recently and spent a few nights in the hospital for his initial recovery. When the hospital told us he was being discharged, Dad and I were concerned because we had no idea what to expect for his recovery. Was he going to have physical therapy? How intensive would it be? Would I need to take off work to be there with him all day? We had so many questions, but no one told us anything! We were just given a paper with a discharge date of the next day and some information about Dad’s rights as a Medicare beneficiary.”

My reaction? Exasperation. First, where do hospitals keep patients several nights after a knee replacement? Did this happen in 1990? The standard of care is surgery, then discharge the same day or the next day for most patients, unless there were extenuating circumstances. Second, was there really no discussion with the patient or family prior to surgery about the post-hospital plans, conducted by either the surgeon or the case management team? Did the surgeon really simply schedule the surgery without any consideration of post-hospital needs? Then this patient was in the hospital for a few days. Did case management not visit the patient during any of those post-op days to discuss post-hospital care, now that the patient’s physical capabilities and therapy needs were known? Did the physical therapist not assess the patient and then discuss the case with the case manager? Did someone really just drop off the second copy of the Important Message from Medicare (IMM) and not discuss any discharge plans?

If this story is true, and I sure hope it was totally fabricated or embellished, then we have so much more work to do to truly provide patient-centered care.

We must do better.

Programming Note: Listen to Dr. Ronald Hirsch when he makes his Monday Rounds during Monitor Mondays with Chuck Buck.

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Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, and the National Association of Healthcare Revenue Integrity, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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