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The controversial "two-midnight rule" governing when Medicare patients are considered inpatients could change how hospitals operate their observation or short-stay units.
The rule technically went into effect on Oct. 1, 2013, but enforcement through postpayment claims audits by Recovery Audit Contractors (RACs) has been delayed until March 31, 2015. Although most audits are on hold, RACs are allowed to perform audits in cases for which there is evidence of systematic gaming, fraud, abuse, or delays in delivering care, under the latest delay of the policy.
In the meantime, hospitalists, who are often in charge of hospital observation units, are figuring out how the new policy will impact who goes to an observation unit and who is admitted as an inpatient.
Under the rule, the decision to admit a Medicare patient as an inpatient depends on two factors: whether the condition meets medical necessity requiring a patient to be in a hospital setting and the expectation that their time in the hospital will surpass two midnights.
Dr. Aziz Ansari, the medical director of the observation unit at Loyola University Medical Center in Chicago, said that, while the observation units vary across hospital systems, most are set up to handle low-acuity patients with high turnover. The challenge with the two-midnight rule is that sicker patients will now be classified as observation status simply because of the duration of their time in the hospital.
"The challenge is whether these patients should come to the observation unit," Dr. Ansari said.
The answer depends on how much acuity the facility’s observation unit can handle, he said.
At Loyola, which has a 19-bed observation unit with dedicated hospitalists and nurses, they can take on a wide range of patients, with a few exceptions. For instance, they don’t take patients who require one-on-one care from the attending physician, patients withdrawing from alcohol, or patients who are under observation prior to a psychiatric admission.
For a specialty unit that only handles chest pain, or a unit that can’t handle high-acuity patients, the sicker, short-stay Medicare patients would need to be kept under observation but placed on an inpatient floor where they could receive more intensive medical care from the attending physician, he said.
Dr. Ansari recommended that, in light of the two-midnight rule, hospital medicine groups set up clinical parameters that can guide clinicians about where to send high-acuity observation patients.
He predicted that, over time, observation units will evolve so that they can accept more of the sicker patients. One important change is to hire more physician assistants or advanced practice nurses so that hospitalists can spend more time with the sickest patients.
Another key element to making the observation model work with sicker patients is having a mechanism in place to move patients out of the observation unit and admitted to the floors once their status changes to inpatient. These patients should be quickly moved to an inpatient floor bed, Dr. Ansari said.
"The boarding of inpatients in the observation unit is not best for patient care, nor is it an efficient use of resources," he said.
On Twitter @maryellenny
The controversial "two-midnight rule" governing when Medicare patients are considered inpatients could change how hospitals operate their observation or short-stay units.
The rule technically went into effect on Oct. 1, 2013, but enforcement through postpayment claims audits by Recovery Audit Contractors (RACs) has been delayed until March 31, 2015. Although most audits are on hold, RACs are allowed to perform audits in cases for which there is evidence of systematic gaming, fraud, abuse, or delays in delivering care, under the latest delay of the policy.
In the meantime, hospitalists, who are often in charge of hospital observation units, are figuring out how the new policy will impact who goes to an observation unit and who is admitted as an inpatient.
Under the rule, the decision to admit a Medicare patient as an inpatient depends on two factors: whether the condition meets medical necessity requiring a patient to be in a hospital setting and the expectation that their time in the hospital will surpass two midnights.
Dr. Aziz Ansari, the medical director of the observation unit at Loyola University Medical Center in Chicago, said that, while the observation units vary across hospital systems, most are set up to handle low-acuity patients with high turnover. The challenge with the two-midnight rule is that sicker patients will now be classified as observation status simply because of the duration of their time in the hospital.
"The challenge is whether these patients should come to the observation unit," Dr. Ansari said.
The answer depends on how much acuity the facility’s observation unit can handle, he said.
At Loyola, which has a 19-bed observation unit with dedicated hospitalists and nurses, they can take on a wide range of patients, with a few exceptions. For instance, they don’t take patients who require one-on-one care from the attending physician, patients withdrawing from alcohol, or patients who are under observation prior to a psychiatric admission.
For a specialty unit that only handles chest pain, or a unit that can’t handle high-acuity patients, the sicker, short-stay Medicare patients would need to be kept under observation but placed on an inpatient floor where they could receive more intensive medical care from the attending physician, he said.
Dr. Ansari recommended that, in light of the two-midnight rule, hospital medicine groups set up clinical parameters that can guide clinicians about where to send high-acuity observation patients.
He predicted that, over time, observation units will evolve so that they can accept more of the sicker patients. One important change is to hire more physician assistants or advanced practice nurses so that hospitalists can spend more time with the sickest patients.
Another key element to making the observation model work with sicker patients is having a mechanism in place to move patients out of the observation unit and admitted to the floors once their status changes to inpatient. These patients should be quickly moved to an inpatient floor bed, Dr. Ansari said.
"The boarding of inpatients in the observation unit is not best for patient care, nor is it an efficient use of resources," he said.
On Twitter @maryellenny
The controversial "two-midnight rule" governing when Medicare patients are considered inpatients could change how hospitals operate their observation or short-stay units.
The rule technically went into effect on Oct. 1, 2013, but enforcement through postpayment claims audits by Recovery Audit Contractors (RACs) has been delayed until March 31, 2015. Although most audits are on hold, RACs are allowed to perform audits in cases for which there is evidence of systematic gaming, fraud, abuse, or delays in delivering care, under the latest delay of the policy.
In the meantime, hospitalists, who are often in charge of hospital observation units, are figuring out how the new policy will impact who goes to an observation unit and who is admitted as an inpatient.
Under the rule, the decision to admit a Medicare patient as an inpatient depends on two factors: whether the condition meets medical necessity requiring a patient to be in a hospital setting and the expectation that their time in the hospital will surpass two midnights.
Dr. Aziz Ansari, the medical director of the observation unit at Loyola University Medical Center in Chicago, said that, while the observation units vary across hospital systems, most are set up to handle low-acuity patients with high turnover. The challenge with the two-midnight rule is that sicker patients will now be classified as observation status simply because of the duration of their time in the hospital.
"The challenge is whether these patients should come to the observation unit," Dr. Ansari said.
The answer depends on how much acuity the facility’s observation unit can handle, he said.
At Loyola, which has a 19-bed observation unit with dedicated hospitalists and nurses, they can take on a wide range of patients, with a few exceptions. For instance, they don’t take patients who require one-on-one care from the attending physician, patients withdrawing from alcohol, or patients who are under observation prior to a psychiatric admission.
For a specialty unit that only handles chest pain, or a unit that can’t handle high-acuity patients, the sicker, short-stay Medicare patients would need to be kept under observation but placed on an inpatient floor where they could receive more intensive medical care from the attending physician, he said.
Dr. Ansari recommended that, in light of the two-midnight rule, hospital medicine groups set up clinical parameters that can guide clinicians about where to send high-acuity observation patients.
He predicted that, over time, observation units will evolve so that they can accept more of the sicker patients. One important change is to hire more physician assistants or advanced practice nurses so that hospitalists can spend more time with the sickest patients.
Another key element to making the observation model work with sicker patients is having a mechanism in place to move patients out of the observation unit and admitted to the floors once their status changes to inpatient. These patients should be quickly moved to an inpatient floor bed, Dr. Ansari said.
"The boarding of inpatients in the observation unit is not best for patient care, nor is it an efficient use of resources," he said.
On Twitter @maryellenny