By Al Norman
Three years ago, I wrote a letter to Congress about a woman I will call Mrs. Green, a 94-year-old resident of the Berkshires, who lived with her daughter.
In 2010, Mrs. Green suffered a fall, and was taken to the Berkshire Medical Center’s emergency room where she was treated and sent home. After two more days of pain, her daughter took her to a general practitioner, who briefly examined her and then sent her to the hospital for “evaluation of weakness and frequent falls.”
Mrs. Green was in the hospital for six days, after which she was sent to a nursing home, where she stayed for several weeks of rehabilitation. She was then discharged back to her daughter’s home. That’s the good news.
However, because Mrs. Green was never admitted as an in-patient to the hospital, but was classified as being on “observation status” for her entire six-day hospital stay, Medicare rejected coverage for the nursing home stay. And Mrs. Green received a $10,000 bill from the nursing home that she had to pay.
“Observation” is the term Medicare uses to describe the outpatient status of a patient who is in a hospital — but not as an inpatient. On page 31 of the Medicare & You 2013 manual, it says clearly that Medicare will only cover skilled nursing home care and rehabilitation services “after a three day minimum medically necessary inpatient hospital stay for a related illness or injury.”
Mrs. Green never heard of this rule, and even if she did, she had no idea that after six nights in a hospital she had never officially been admitted as an inpatient.
Recently, Gov. Deval Patrick asked the federal government to give Massachusetts a waiver from this three-day prior hospital stay rule. “A waiver has the potential to reduce costs to the federal government,” the administration wrote. “If a patient has a diagnosis that requires on-going care in a skilled nursing facility, requiring that patient to continue to be cared for in an inpatient acute hospital setting, it is not efficient from a cost perspective. Care provided in a hospital is more expensive than care provided in a skilled nursing facility.” It is not certain yet if the federal government will grant this waiver.
Rep. Joe Courtney, D-Conn, has filed a bill in the House called the “Improving Access to Medicare Coverage Act of 2013. This legislation, H.R. 1179, has 88 House sponsors, including Massachusetts Democrats Joe Kennedy, Jim McGovern, John Tierney, Niki Tsongas and Bill Keating.
On the U.S. Senate side, the same bill filed by Sen. Sherrod Brown, D-Ohio, attracted 17 sponsors, but no one from the Massachusetts delegation has signed on.
Rep. Courtney’s bill says “an individual who is in a period of observation status in a hospital that exceeds 24 hours shall be deemed to have been an inpatient during such period of observation status and the individuals leaving the hospital after such period of status shall be treated as a discharge from the hospital.”
The federal government says it is working on changes to the current three-day rule. Whether the Obama administration changes the rules on its own, gives Massachusetts a waiver from the rule, or whether Congress changes the rule — one way or another the three-day rule that trapped Mrs. Green should never happen to another senior again — anywhere.
Anyone who needs nursing home care should not have to first spend three days in a hospital. Such bureaucratic rules make no sense, and only hurt innocent people like Mrs. Green. Once this rule is overturned, we can then focus on why Medicare does not cover custodial care in a nursing home — another illogical injustice.
Al Norman is the executive director of Mass Home Care. He can be reached at email@example.com, or 413-772-6289.