Letters To The Editor

The impact of rapid response teams (RRTs) on preventing nonintensive care unit (ICU) cardiopulmonary arrests (CPA) and decreasing in‐hospital mortality is a complex issue that goes beyond the structure of RRTs. The success of RRTs depends upon institutional culture, resources, RRT structure, hospital size, and expertise. These are some of the major reasons RRTs have failed to show benefit consistently across the board, because not all institutions are able muster enough resources, reasonable nurse‐to‐patient ratio, advanced ongoing training, and easily accessible onsite intensivists or physicians. An institutional culture where nurses and ancillary staff do not feel intimidated or retaliated on for calling unnecessary RRT codes is extremely important for the success of any RRT program. We have observed at our institution and others where just improvement in culture reduced non‐ICU CPAs, although it also led to a higher number of RRT codes. As a hospitalist leader of RRTs for many years, it sometimes felt as if unwarranted RRT codes were overwhelming already busy hospitalists. However, the real improvement in patient mortality and morbidity reminded us of the importance of creating an open and stress‐free environment for the nurse responsible for initiating RRTs. Davis et al.'s novel RRT program showed improvement in non‐ICU CPAs and in‐hospital mortality.[1] The researchers and their institutions did a great job in improving outcomes, perhaps by devoting enough resources and creating a positive work environment for the nursing staff.

A large observational study conducted in 9 European countries showed that an increase in a nurses' workload by 1 patient increased the likelihood of a hospitalized patient dying within 30 days of admission by 7%. Furthermore, every 10% increase in nurses with a bachelor's degree was associated with a decrease in this likelihood by 7%.[2] Nursing staff can activate RRTs in a timely fashion if they are not overworked or undertrained. Additionally, having an intermediate‐care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in‐hospital mortality.[3] A study by Ghaferi et al. showed that survival after in‐hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse‐to‐patient ratios, and high‐level hospital technology.[4] Therefore, there are many factors that could have had an impact on in‐hospital mortality in this study.[1] It will be interesting to know if there was a difference in the novel RRT's success rates in the primary medical center and smaller sister campus in the study by Davis et al.[1] Activation of RRTs based on the change in vital signs is challenging for the elderly.[5] Therefore, geriatrics‐unit staff need special training for RRTs to be successful.

In the study by Davis et al., the charge nurse on each inpatient unit conducted rounds on at‐risk patients throughout each shift.[1] Additionally, the charge nurse responded to each RRT code and received intensive training. This strategy may have contributed to the benefit shown by the novel RRT strategy. However, most community hospitals are struggling to maintain adequate nurse‐to‐patient ratios due cost constraints, and adding a significant burden to the already busy charge nurse's responsibilities is difficult to sustain for some institutions. Having a highly trained, dedicated, multidisciplinary team is likely to improve outcomes, but more sustainable solutions for smaller community hospitals are needed. As this study has demonstrated, devoting more resources to patients may pay off over time. The public and private payers should also recognize this as a quality‐of‐care indicator and reward hospitals making improvements in this arena.

The impact of rapid response teams (RRTs) on preventing nonintensive care unit (ICU) cardiopulmonary arrests (CPA) and decreasing in‐hospital mortality is a complex issue that goes beyond the structure of RRTs. The success of RRTs depends upon institutional culture, resources, RRT structure, hospital size, and expertise. These are some of the major reasons RRTs have failed to show benefit consistently across the board, because not all institutions are able muster enough resources, reasonable nurse‐to‐patient ratio, advanced ongoing training, and easily accessible onsite intensivists or physicians. An institutional culture where nurses and ancillary staff do not feel intimidated or retaliated on for calling unnecessary RRT codes is extremely important for the success of any RRT program. We have observed at our institution and others where just improvement in culture reduced non‐ICU CPAs, although it also led to a higher number of RRT codes. As a hospitalist leader of RRTs for many years, it sometimes felt as if unwarranted RRT codes were overwhelming already busy hospitalists. However, the real improvement in patient mortality and morbidity reminded us of the importance of creating an open and stress‐free environment for the nurse responsible for initiating RRTs. Davis et al.'s novel RRT program showed improvement in non‐ICU CPAs and in‐hospital mortality.[1] The researchers and their institutions did a great job in improving outcomes, perhaps by devoting enough resources and creating a positive work environment for the nursing staff.

A large observational study conducted in 9 European countries showed that an increase in a nurses' workload by 1 patient increased the likelihood of a hospitalized patient dying within 30 days of admission by 7%. Furthermore, every 10% increase in nurses with a bachelor's degree was associated with a decrease in this likelihood by 7%.[2] Nursing staff can activate RRTs in a timely fashion if they are not overworked or undertrained. Additionally, having an intermediate‐care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in‐hospital mortality.[3] A study by Ghaferi et al. showed that survival after in‐hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse‐to‐patient ratios, and high‐level hospital technology.[4] Therefore, there are many factors that could have had an impact on in‐hospital mortality in this study.[1] It will be interesting to know if there was a difference in the novel RRT's success rates in the primary medical center and smaller sister campus in the study by Davis et al.[1] Activation of RRTs based on the change in vital signs is challenging for the elderly.[5] Therefore, geriatrics‐unit staff need special training for RRTs to be successful.

In the study by Davis et al., the charge nurse on each inpatient unit conducted rounds on at‐risk patients throughout each shift.[1] Additionally, the charge nurse responded to each RRT code and received intensive training. This strategy may have contributed to the benefit shown by the novel RRT strategy. However, most community hospitals are struggling to maintain adequate nurse‐to‐patient ratios due cost constraints, and adding a significant burden to the already busy charge nurse's responsibilities is difficult to sustain for some institutions. Having a highly trained, dedicated, multidisciplinary team is likely to improve outcomes, but more sustainable solutions for smaller community hospitals are needed. As this study has demonstrated, devoting more resources to patients may pay off over time. The public and private payers should also recognize this as a quality‐of‐care indicator and reward hospitals making improvements in this arena.

The impact of rapid response teams (RRTs) on preventing nonintensive care unit (ICU) cardiopulmonary arrests (CPA) and decreasing in‐hospital mortality is a complex issue that goes beyond the structure of RRTs. The success of RRTs depends upon institutional culture, resources, RRT structure, hospital size, and expertise. These are some of the major reasons RRTs have failed to show benefit consistently across the board, because not all institutions are able muster enough resources, reasonable nurse‐to‐patient ratio, advanced ongoing training, and easily accessible onsite intensivists or physicians. An institutional culture where nurses and ancillary staff do not feel intimidated or retaliated on for calling unnecessary RRT codes is extremely important for the success of any RRT program. We have observed at our institution and others where just improvement in culture reduced non‐ICU CPAs, although it also led to a higher number of RRT codes. As a hospitalist leader of RRTs for many years, it sometimes felt as if unwarranted RRT codes were overwhelming already busy hospitalists. However, the real improvement in patient mortality and morbidity reminded us of the importance of creating an open and stress‐free environment for the nurse responsible for initiating RRTs. Davis et al.'s novel RRT program showed improvement in non‐ICU CPAs and in‐hospital mortality.[1] The researchers and their institutions did a great job in improving outcomes, perhaps by devoting enough resources and creating a positive work environment for the nursing staff.

A large observational study conducted in 9 European countries showed that an increase in a nurses' workload by 1 patient increased the likelihood of a hospitalized patient dying within 30 days of admission by 7%. Furthermore, every 10% increase in nurses with a bachelor's degree was associated with a decrease in this likelihood by 7%.[2] Nursing staff can activate RRTs in a timely fashion if they are not overworked or undertrained. Additionally, having an intermediate‐care unit for the patients who do not quite meet the ICU criteria and yet require more intensive care has been shown to decrease in‐hospital mortality.[3] A study by Ghaferi et al. showed that survival after in‐hospital complications following pancreatectomy was high in hospitals with teaching status, those with a size greater than 200 beds and average daily census greater than 50% capacity, increased nurse‐to‐patient ratios, and high‐level hospital technology.[4] Therefore, there are many factors that could have had an impact on in‐hospital mortality in this study.[1] It will be interesting to know if there was a difference in the novel RRT's success rates in the primary medical center and smaller sister campus in the study by Davis et al.[1] Activation of RRTs based on the change in vital signs is challenging for the elderly.[5] Therefore, geriatrics‐unit staff need special training for RRTs to be successful.

In the study by Davis et al., the charge nurse on each inpatient unit conducted rounds on at‐risk patients throughout each shift.[1] Additionally, the charge nurse responded to each RRT code and received intensive training. This strategy may have contributed to the benefit shown by the novel RRT strategy. However, most community hospitals are struggling to maintain adequate nurse‐to‐patient ratios due cost constraints, and adding a significant burden to the already busy charge nurse's responsibilities is difficult to sustain for some institutions. Having a highly trained, dedicated, multidisciplinary team is likely to improve outcomes, but more sustainable solutions for smaller community hospitals are needed. As this study has demonstrated, devoting more resources to patients may pay off over time. The public and private payers should also recognize this as a quality‐of‐care indicator and reward hospitals making improvements in this arena.

We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.

The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.

Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.

The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.

We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.

We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.

The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.

Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.

The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.

We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.

We appreciate very much Dr. Singh's interest and insight regarding our article, A Novel Configuration of a Traditional Rapid Response Team Decreases NonIntensive Care Unit Arrests and Overall Hospital Mortality.[1] Dr. Singh makes several critical points that are worth emphasis and additional commentary.

The importance of cultural change in the success of a rapid response team (RRT) program cannot be emphasized enough. The willingness of frontline staff to access an RRT is based on a belief in the potential benefit to the patient as well as a lack of concern about the repercussions of such an activation, whether these are from the primary physician team or the RRT members themselves. Both of these require institutional commitmentideally from administrative and clinical leadershipas well as routine, direct feedback to providers as to the effectiveness of the program. Both of these have been addressed in our advanced resuscitation training (ART) program, which has replaced traditional life‐support training and consolidates many efforts related to patient safety and preventable death.[2] The ART program represents adaptive training, in which arrest prevention is emphasized for nonintensive care unit staff and the importance of institutional processes such as RRT is emphasized.

Our approach to RRT configuration reflects the resource constraints referenced by Dr. Singh. Although the ideal RRT would include critical‐care nurses located physically outside the intensive care unit to allow regular assessment of at‐risk patients, this would have required expenditures that were not available for the program. In our opinion, a reasonable alternative was to train charge nurses from nonintensive care units as RRT members. The role expectation for these charge nurses included twice‐daily rounds, and their proximity to at‐risk patients facilitated regular reassessments throughout each shift. In addition, the ART program allowed routine training for bedside nurses to emphasize code/RRT issues on an annual basis and underscores the importance of early recognition of patient safety and preventable death. The ART program actually reduced life‐support expenditures and allowed implementation of both our RRT and institutional cardiac arrest resuscitation programs in a cost‐effective manner.

The last point made by Dr. Singh that we wish to address involves the balance between over‐ and under‐utilization of RRT resources. Our RRT‐to‐code ratios are relatively favorable, allowing the program to exist with efficient allocation of resources. This may be due, in part, to the approach to training with regard to recognition of deterioration. Most RRT programs appear to emphasize vital sign thresholds or use of scoring systems for activation, both of which rely upon single sets of vital signs. Instead, we focus on pattern recognition, emphasizing dynamic changes in vital signs and other clinical assessments and de‐emphasizing absolute values. We believe that this helps develop clinical decision‐making skills and improves both sensitivity and specificity with regard to RRT activation. Again, the adaptive nature of the ART program allows annual training to enhance these skills without additional expense to the institution.

We very much appreciate Dr. Singh's comments and urge other institutions to listen to his message carefully. There is no substitute for efforts spent in establishing just culture and creating an institution that supports its staff in addressing patient safety issues, ultimately reducing preventable deaths.

I thank Locke et al. for their article published in the Journal of Hospital Medicine.[1] It summarized well the challenges created by the Recovery Audit Contractor (RAC) program. It is encouraging that the Centers for Medicare & Medicaid Services (CMS) have proposed a different payment method to address the contingency‐fee payment controversy. The new method would require the RACs to be paid after a provider's challenge has passed a second level of a 5‐level appeals process.[2] This, however, has been protested by 1 of the RACs, and a federal appeals court has agreed with the protest.[3] Furthermore, the Office of Medicare Hearings and Appeals (OMHA) is receiving more requests for hearings than the administrative law judges can adjudicate in a timely manner. OMHA is currently projecting a 20‐ to 24‐week delay in entering new requests into their case processing system. The average processing time for appeals decided in fiscal year 2015 was 547.1 days.[4] Financial impacts of the status issue have thus far only affected hospitals and patients, whereas physician reimbursement has been sheltered. This may change if the RACs request to utilize the CMS manual changes announced in Transmittal 541,[5] which allows certain auditors to deny or recoup payment for procedures performed as inpatients that were not medically necessary. Hospitals have increased the cohorts of observation patients on a single unit or implemented different discharge planning processes for inpatients versus observation. However, patient quality outcomes are not available yet on these approaches.

I thank Locke et al. for their article published in the Journal of Hospital Medicine.[1] It summarized well the challenges created by the Recovery Audit Contractor (RAC) program. It is encouraging that the Centers for Medicare & Medicaid Services (CMS) have proposed a different payment method to address the contingency‐fee payment controversy. The new method would require the RACs to be paid after a provider's challenge has passed a second level of a 5‐level appeals process.[2] This, however, has been protested by 1 of the RACs, and a federal appeals court has agreed with the protest.[3] Furthermore, the Office of Medicare Hearings and Appeals (OMHA) is receiving more requests for hearings than the administrative law judges can adjudicate in a timely manner. OMHA is currently projecting a 20‐ to 24‐week delay in entering new requests into their case processing system. The average processing time for appeals decided in fiscal year 2015 was 547.1 days.[4] Financial impacts of the status issue have thus far only affected hospitals and patients, whereas physician reimbursement has been sheltered. This may change if the RACs request to utilize the CMS manual changes announced in Transmittal 541,[5] which allows certain auditors to deny or recoup payment for procedures performed as inpatients that were not medically necessary. Hospitals have increased the cohorts of observation patients on a single unit or implemented different discharge planning processes for inpatients versus observation. However, patient quality outcomes are not available yet on these approaches.

I thank Locke et al. for their article published in the Journal of Hospital Medicine.[1] It summarized well the challenges created by the Recovery Audit Contractor (RAC) program. It is encouraging that the Centers for Medicare & Medicaid Services (CMS) have proposed a different payment method to address the contingency‐fee payment controversy. The new method would require the RACs to be paid after a provider's challenge has passed a second level of a 5‐level appeals process.[2] This, however, has been protested by 1 of the RACs, and a federal appeals court has agreed with the protest.[3] Furthermore, the Office of Medicare Hearings and Appeals (OMHA) is receiving more requests for hearings than the administrative law judges can adjudicate in a timely manner. OMHA is currently projecting a 20‐ to 24‐week delay in entering new requests into their case processing system. The average processing time for appeals decided in fiscal year 2015 was 547.1 days.[4] Financial impacts of the status issue have thus far only affected hospitals and patients, whereas physician reimbursement has been sheltered. This may change if the RACs request to utilize the CMS manual changes announced in Transmittal 541,[5] which allows certain auditors to deny or recoup payment for procedures performed as inpatients that were not medically necessary. Hospitals have increased the cohorts of observation patients on a single unit or implemented different discharge planning processes for inpatients versus observation. However, patient quality outcomes are not available yet on these approaches.

We appreciate Dr. Antonios' comments regarding our article[1] and agree with his view that there is a need for both a recovery auditor and observation reform. The House of Representatives recently unanimously passed the NOTICE Act (H.R. 876), which would require hospitals to provide verbal and written notification to patients hospitalized as observation for more than 24 hours and obtain a signed record that the patient has received this information.[2] Also, the law to repeal the Medicare Sustainable Growth Rate (SGR) (Medicare Access and CHIP Reauthorization Act of 2105, P.L. 114‐10), signed into law by President Obama in April, 2015, included a provision to delay recovery auditor activity for an additional 6 months, through September 30, 2015.[3] Although both of these bills demonstrate that congress is informed about problems with recovery auditors and observation policy, neither beneficiary notification of observation nor a 6‐month auditing delay does anything to reform the fundamental problems with observation and the recovery audit program that have resulted in the appeals backlog described by Dr. Antionios.

While we agree that hospitalized beneficiaries should be notified of their visit status, notification alone of outpatient status with observation services, without any enhanced ability of beneficiaries to appeal this determination, or adequate beneficiary education that status determinations are made by clinicians based on Centers for Medicare and Medicaid Services (CMS) regulations, may result in even more confusion and frustration for beneficiaries and clinicians. We hope that Congress will move forward with improvements in actual observation policy, such as counting observation midnights toward the 3‐midnight stay requirement for skilled nursing facility coverage.[4]

Furthermore, as Dr. Antonios points out, the March 2015 victory in a federal circuit court by CGI Federal, Inc., an RAC contractor, over CMS's new payment terms for recovery audit contracts, which reversed a previous decision and remanded the case to the Court of Federal Claims, will delay CMS' awarding of the new RAC contracts. This makes the actual effect of the 6‐month RAC auditing delay in the SGR bill unclear at this time.[5] We hope that these current legislative efforts are revisited and will be the beginning, and not the end, of legislative and regulatory reform efforts on these important issues.

We appreciate Dr. Antonios' comments regarding our article[1] and agree with his view that there is a need for both a recovery auditor and observation reform. The House of Representatives recently unanimously passed the NOTICE Act (H.R. 876), which would require hospitals to provide verbal and written notification to patients hospitalized as observation for more than 24 hours and obtain a signed record that the patient has received this information.[2] Also, the law to repeal the Medicare Sustainable Growth Rate (SGR) (Medicare Access and CHIP Reauthorization Act of 2105, P.L. 114‐10), signed into law by President Obama in April, 2015, included a provision to delay recovery auditor activity for an additional 6 months, through September 30, 2015.[3] Although both of these bills demonstrate that congress is informed about problems with recovery auditors and observation policy, neither beneficiary notification of observation nor a 6‐month auditing delay does anything to reform the fundamental problems with observation and the recovery audit program that have resulted in the appeals backlog described by Dr. Antionios.

While we agree that hospitalized beneficiaries should be notified of their visit status, notification alone of outpatient status with observation services, without any enhanced ability of beneficiaries to appeal this determination, or adequate beneficiary education that status determinations are made by clinicians based on Centers for Medicare and Medicaid Services (CMS) regulations, may result in even more confusion and frustration for beneficiaries and clinicians. We hope that Congress will move forward with improvements in actual observation policy, such as counting observation midnights toward the 3‐midnight stay requirement for skilled nursing facility coverage.[4]

Furthermore, as Dr. Antonios points out, the March 2015 victory in a federal circuit court by CGI Federal, Inc., an RAC contractor, over CMS's new payment terms for recovery audit contracts, which reversed a previous decision and remanded the case to the Court of Federal Claims, will delay CMS' awarding of the new RAC contracts. This makes the actual effect of the 6‐month RAC auditing delay in the SGR bill unclear at this time.[5] We hope that these current legislative efforts are revisited and will be the beginning, and not the end, of legislative and regulatory reform efforts on these important issues.

We appreciate Dr. Antonios' comments regarding our article[1] and agree with his view that there is a need for both a recovery auditor and observation reform. The House of Representatives recently unanimously passed the NOTICE Act (H.R. 876), which would require hospitals to provide verbal and written notification to patients hospitalized as observation for more than 24 hours and obtain a signed record that the patient has received this information.[2] Also, the law to repeal the Medicare Sustainable Growth Rate (SGR) (Medicare Access and CHIP Reauthorization Act of 2105, P.L. 114‐10), signed into law by President Obama in April, 2015, included a provision to delay recovery auditor activity for an additional 6 months, through September 30, 2015.[3] Although both of these bills demonstrate that congress is informed about problems with recovery auditors and observation policy, neither beneficiary notification of observation nor a 6‐month auditing delay does anything to reform the fundamental problems with observation and the recovery audit program that have resulted in the appeals backlog described by Dr. Antionios.

While we agree that hospitalized beneficiaries should be notified of their visit status, notification alone of outpatient status with observation services, without any enhanced ability of beneficiaries to appeal this determination, or adequate beneficiary education that status determinations are made by clinicians based on Centers for Medicare and Medicaid Services (CMS) regulations, may result in even more confusion and frustration for beneficiaries and clinicians. We hope that Congress will move forward with improvements in actual observation policy, such as counting observation midnights toward the 3‐midnight stay requirement for skilled nursing facility coverage.[4]

Furthermore, as Dr. Antonios points out, the March 2015 victory in a federal circuit court by CGI Federal, Inc., an RAC contractor, over CMS's new payment terms for recovery audit contracts, which reversed a previous decision and remanded the case to the Court of Federal Claims, will delay CMS' awarding of the new RAC contracts. This makes the actual effect of the 6‐month RAC auditing delay in the SGR bill unclear at this time.[5] We hope that these current legislative efforts are revisited and will be the beginning, and not the end, of legislative and regulatory reform efforts on these important issues.