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Affordable Care Act Concerns: An Opinion to Consider

Effective October 1, 2012, our hospitals, under the Affordable Care Act, face financial penalties for those Medicare patients who return for a second admission within 30 days. The justification under the ACA is that they are holding the hospital to a better quality of care. Skilled Home Care agencies have dealt with these types of penalties for years in the form of a PEP (partial Episodic Payment). A PEP basically penalizes an agency when a patient returns to service during their original 60 day certification period. So, for many years, home care has strived to do all they can to help patients manage their disease processes, wounds, and infections. However, nationwide, approximately 25% of patients are re-hospitalized, and their medical caregivers are penalized. The ACA and its mandates do not take into account that many of the re-hospitalized are patients that have chronic illnesses, such as Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Dementia, and complications of Diabetes. These chronic diseases have no cures and by their nature often exacerbate even in those patients who are compliant.

While the medical community has come together to create a multitude of transitional care and in home monitoring programs, there will always be those patients who must return to the hospital for care. This brings us to observation. Most hospitals now have an alert system in place that notifies them at registration that a patient has had an admission within 30 days. With that notification, many hospitals are now using observation as an alternative to admission. In the past, many who came to the hospital through the emergency department were kept in observation for 23 hours while testing and medical observation determined the patients need to be admitted. In most cases, at the 24th hour, the patient was admitted or discharged home with instructions regarding the hospital’s findings.

Now facing the penalties of the ACA observation has taken on a whole new meaning. We are seeing patients kept on medical units under observation up to two weeks, with the norm seeming to be around three to five days. What you as a patient must understand is that observation is not an impatient stay. Therefore, your Medicare that covers your inpatient stay does not apply. You are basically, for insurance purposes, an outpatient with all your deductibles and copays applicable. We know that at least one major provider in our region is informing patients that they are in out-patient status under observation and that fees may be chared to them. They are providing the patient with a pamphlet that provides some explanation and having the patient sign a statement of understanding.

But does the patient really understand the potential financial ramification of being in observation? We have found that most do not. For example, consider a case where Medicare requires a 72 hour inpatient stay before they will pick up the cost of rehabilitation in a facility. If the patient has been in observation, that 72 hour requirement has not been met. Patients are receiving bills for their rehab that are mounting to thousands of dollars. Additionally, skilled home care agencies are being billed by hospitals for patients that receive therapy services while observation. This is supported by Medicare refusing to pay based on the one provider rule. If a patient is under the care of home care, that agency is the provider, and any other therapy services are that agency’s financial responsibility.

While many Medicare patients are worried about “losing” their Medicare benefits, they are not aware of what they have already lost. The future is very uncertain, and patients cannot afford the out of pocket costs of observation. Nor can small non-hospital affiliated home care agencies afford these costs. Many smaller hospitals across the country are being forced to close their doors, many physicians are no longer accepting new patients, and many home care agencies face closure. Patient choice will no longer be an option. The Affordable Care Act is not the answer many have thought it would be. No one has a maginc want to cure the chronically ill, and while we all strive to help patients manage these illnesses, we all know that penalizing the patient and their medical caregivers is not an acceptable answer for the chronically ill.

Editorial comments are the opinions of the author. Editorial article provided by Personal Touch Home Care in Pittsburgh, PA.

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