Medicare Wonderland


Medicare Wonderland


She is 77 years old, a bit frail, and has a recurrent breast cancer 15 years after lumpectomy and radiation in the same breast. Her only option is a mastectomy. She lives alone and has no family in the area. Most of her friends are snowbirds – they leave Arizona for the summer and return when the weather gets cold up north. She has had a total hip and total knee replacement and isn’t too concerned about the mastectomy, since she recovered reasonably well after those procedures.

The problem is that mastectomy is now considered an outpatient procedure by CMS, the agency that makes the rules for Medicare. That means that in order to admit her to the hospital as an inpatient, I have to document ‘medical necessity’. Being old and frail isn’t considered ‘medical necessity’.

I do her surgery and write orders in the recovery room for Observation Status. This is a loophole that lets me put her in a hospital bed for 23hrs to see if there is a medical reason to require admission. It’s intended for ER patients with things like chest pain of uncertain origin, shortness of breath, fevers, etc. Surgeons have learned that we can use this status to give patients time to recover from anesthesia and regroup before going home. The alternative is to discharge directly from the recovery room within an hour or so of surgery.

I am called almost immediately by a Case Manager wanting to know what my diagnosis is that requires Observation. My stock response is pain control – the patient is receiving intravenous narcotics. It’s a bit of a cheat since they are not awake enough to take pills, but both the hospital and CMS have winked at that for years. Not anymore, apparently. Fortunately, her oxygen saturation is a bit low in the recovery room, giving me another excuse to admit her.

By the next morning, she is taking a diet, her pain is controlled and her oxygen is normal. She is still weak, however, and needs two nurses to get her out of bed. I write to convert her to an inpatient admission, since she clearly can’t go home.

Again the Case Manager calls. Her weakness isn’t considered an admission criterion. I get a little snarky and ask the Case Manager if she is willing to take my patient home and care for her, but that doesn’t really help. Now she’s hostile and tells me I can extend the Observation and get a Physical Therapy evaluation. It’s not what I want, but at least it buys another day. By Friday morning, my patient is still weak, but has managed to walk ‘community distance’ (50ft) with PT and is again ‘ready for discharge’.

I am reluctant to send her home. By objective criteria, she’s ready; but looking at her, I am afraid she’s at risk for falling, she can’t prepare her own meals, and she won’t cooperate with the nurses in learning to manage her drain. None of which buy her an admission. I talk to the Social Worker and we set up a Home Health visit for one drain care visit and a home safety evaluation. She goes home in the early afternoon.

Through this whole process, my hands have been tied by Medicare rules. I can’t do what I consider the right thing and admit the patient for a few days. I can write the orders, but Medicare will refuse payment of the hospital charges. I can lie about her condition, I can falsify or exaggerate her problems, but there are others charting on her record that would reveal the inconsistency and I’d be up on a fraud charge. So I reluctantly send her home.

She lasts 18hrs. Then she falls at home, can’t get up, and pulls her drain out in the process. Fortunately she has one of those Medic Alert pendants and calls an ambulance. I see her in the ER an hour or so later. Other than the drain being out prematurely, she is unhurt. Her wound is fine, she has a small bruise on her knee and her chin, but that’s all. I again write admission orders. Surely she has just demonstrated that she is unsafe to be home alone. I don’t even get to sign the order before the Case Manager is on my back again. Falling without injury isn’t an admission criterion. I can put her in Observation again, but that’s all.

I lose my temper and tell the Case Manager where to put her admission criteria (Hint: the sun doesn’t shine on the place I suggest) and storm out of the ER. Before I get to my car, the hospital’s Medical Officer is paging me. All hospitals have a Medical Officer, a paid lackey who nominally provides a clinical voice to advise the administration on good care and resolve conflict between physicians. In reality, they have sold out and enforce the administration’s line of BS. He first takes me to task for losing my temper with the Case Manager. In this he is right and I promise to apologize to her right away.

Then he starts on a long winded explanation of CMS Medicare rules and admission criteria. I tell him I’m well aware of the documentation needed, but unfortunately, my patient meets none of the criteria. What she really needs is a Skilled Nursing Facility for a few days. But here’s the catch – in order for Medicare to pay any of the cost of a SNF, the patient has to have three continuous days of hospitalization. The Observation days DON’T COUNT! Which is why I have been pushing for admission from day one. The SMO repeats the criteria for admission and then tells me that if I don’t change my admission order I’ll be committing Medicare Fraud. The shouting match that ensues erases any trace of cooperation.

In that, I am at fault. I lost my temper and alienated the SMO and the Case Manager. It wouldn’t have changed anything had I been more polite, but the discussion would have been more pleasant. What my patient needs is irrelevant to the bureaucracy. All I can do is keep finding excuses to keep her in Observation and hope she gets strong enough to be safe at home. In the end, I send her home again with another Home Health referral.

There’s a lesson here for all those who think that a single payer system will solve all of our healthcare problems. Medicare is defacto a single payer system for those over 65. There is no alternative other than paying out of pocket. The rules under which we treat Medicare patient are set by CMS and are often arbitrary and capricious. The emphasis is on cost containment, not clinical effectiveness. This is clear from such stupidity as the three day inpatient rule cited above; from the refusal to pay for screening tests recommended by the American College of Cardiology (due to cost issues); from the SCIP surgical protocol which has been shown in a half dozen studies to be at best irrelevant and yet CMS requires a 98% compliance with it for all surgical patients. The problem is less about who pays as it is about who decides what gets paid for.

But wait, some say, aren’t insurance companies even worse about paying for care? Don’t we hear about that all the time in the media? In fact, insurers are generally much better at covering clinically indicated care than CMS. We hear about the egregious exceptions, about the transplants denied or the experimental but lifesaving therapy that isn’t covered. But Medicare doesn’t cover that stuff either. And in my experience, if there is truly a valid clinical reason for a test or operation, I can talk to the insurance company’s medical advisor and lay out my case to him or her. Most of the time, the service is approved. In CMS, there is no one to talk to, no appeal other than to faceless and nameless bureaucrats who have no responsibility to individual patients, only to their budgets.