Seeing Healthcare Regulatory Theory Turn into Reality

You know, sometimes I wonder if the topics I discuss in these articles are just theoretical concepts, encompassing scenarios that never actually happen. That’s the problem being a regulatory nerd.

Will hospitals adopt my recommendation to be much more liberal with coding discharges “against medical advice” (AMA), as I outlined in a blog I wrote a few weeks ago for CMSA – advising the use of AMA, for example, when an insurance company won’t approve an inpatient rehabilitation facility admission that the medical team is recommending, instead requiring the patient to go to a nursing home, where their therapy needs will not be met, putting them at higher risk of an adverse outcome and readmission? Or will they just continue to use it for patients who insist on departing before their care is completed?

But another theoretical concept I have discussed in the past actually played out in the real world recently.

Mark Sanchez, a former NFL quarterback who is now a football commentator, got into an argument and fight with a truck driver and was stabbed. The details are too bizarre to describe here, but Sanchez apparently started the fight and assaulted the truck driver, who fought back. When police arrived, they took Sanchez into custody, but then released him upon arrival at the hospital for treatment of his injury.

Why? Perhaps so the police department would not be liable for the costs of his medical care. If a patient is in custody, the incarcerating agency is responsible for all the medical costs, not the patient’s insurance. And to make it even more interesting, this rule applies even if the patient is an escapee from custody.

Now, perhaps the police thought that as a public figure he was not a flight risk or a danger to the public and they could find him again to hold him accountable for his alleged crimes after his medical care was completed, but one has to wonder if the financial aspects were more important than the safety aspects.

And remember the other part of this. If the police do not maintain custody of the person at the hospital, you are not permitted to call them when the care is complete so they can come back and arrest the person. That person is free to walk out like any other patient.

Moving on, there is always one person who sees the bright side to an otherwise dismal situation. And that person is Maggie in Tennessee.

Everyone is talking about Aetna’s new policy for approving all inpatient admissions, but only paying some of them at the inpatient rate. Well Maggie, who works at a large academic medical center, pointed out that under this policy, the hospital gets to keep their Indirect Medicare Education money from the Centers for Medicare & Medicaid Services (CMS) for all of these admissions, instead of having to refund it if the admission is denied and only approved as outpatient care. Way to be positive, Maggie!

Finally, I have discussed the Lown Institute before. They are a nonpartisan organization that looks at ensuring that patients get the right care every time and advocating for social responsibility in healthcare. Well, they released a report last week on back surgery, and it is not pretty.

Their data suggests that thousands of unnecessary back surgeries are performed every year. But most interesting is they looked at the U.S. News Honor Roll hospitals, and found that even many of those top hospitals had very high rates of back surgery overuse.

Now, is this data perfect? Absolutely not. But as you know, CMS is also looking at back surgery overuse with their new Transforming Episode Accountability Model (TEAM) bundled payment program, the Wasteful and Inappropriate Service Reduction (WISeR) prior authorization program, and the new prior authorization program for ambulatory surgery centers.

So, you have to wonder: maybe we really do perform too many back surgeries in this country.