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Stuff Medicare Says
I recently had a terrible experience with my mom being an “Observation” patient in the local CHW hospital, St. Joseph’s of Orange (Yes, it was so bad, I’m naming names. I hope it comes up in a Google search). Observation means that unlike real patients, you are effectively still an ER patient, simply with a floor bed to relieve the room in the Emergency Department. Observation also limits your rights under Medicare.
That’s right. If you’re over 65, Observation status is basically a way that the hospital gives you only slightly more care than you’d have at home while charging you hospital fees.
My mom’s experience included: not being placed on the floor until 3am (not uncommon) and being discharged without even being seen by the attending Dr. Johnson Chiu at 9am (for those of you doing the math, that’s 6 hours later).
Let us begin with a problem. Let’s say that you are a patient with baseline neuromuscular symptoms. You can walk, but slowly and with a cane. Some days you do not walk well. Pain is a part of your life, but you generally get by. You can get through the day, most days, without too much trouble. You can get to the bathroom and back to your chair. Some days, you even feel adventurous and do some cooking or shopping.
Let’s say that one day, your puppy (being trained to be a service dog) runs up to you and knocks you off balance. Surprised, you fall on your side on the concrete outside. You were so surprised, you didn’t even try to catch yourself. Good for you! You do not have any hand or wrist injuries! Bad for you… you also are on the concrete and can’t move. After a few stunned moments, you call for help. Luckily, family is home and they manage to pull you up into a chair. You cannot even hold yourself up. After anguished time and a 911 call, you get to the hospital.
Home free, right? No. Not even close. Now you get x-rays. You think that with your history of osteoporosis and neck and back fractures, you’ll get x-rays everywhere; hips, back and neck? No. You get a limited X-ray of the hip you landed on. The x-ray shows nothing. They give you an oral pain medication (Norco, if you’re wondering). 45 minutes later, the aide pulls you out of bed to stand up and walk to the bathroom. Sitting causes you to wince. Having had back fractures, rib fractures and cancer, you have a high tolerance for pain and general inconvenience. You get pulled to your feet and you begin to crumple. Your left leg buckles almost instantly as the pain overwhelms you. You get pushed back into bed. The nurse gets the report that it was “too painful” to walk. Instead of investigating why, they assume the real problem is pain. The X-ray was clear, so clearly, it’s just pain. You get some Dilaudid (hydromorphone, 0.5mg IV) in a new IV they started just for you. 30 minutes later (peak drug functioning time), they repeat the experiment with similar results. Despite you saying that you can’t stand, you can’t move, your leg is giving out and your daughter standing by and confirming, they try time and again. Eventually, the doctor stops by to say that they’ve decided to do a CT of the pelvis, you know, just to check. It shouldn’t be so hard to stand unless something is broken.
When the CT comes back positive for not one, but two non-displaced fractures, you feel vindicated. You are not a wuss! Pain is real! There is actually something wrong that can be proven! The ER doctor confirms that you are going to be admitted and leaves you to the admitting physician.
You are admitted, brought to a room (much, much later) and try to get some well-earned rest.
This is when the real fun begins. You see your nurse in the morning and discover that you are admitted as “observation”. This means that you are not a real inpatient and will not receiving real inpatient services. The hospital will only get paid for 24 hours, at most, per CMS (Center for Medicare Services) guidelines. A few hours later, you talk to your nurse and find out that Dr. Chiu already discharged you. Wait…who is this doctor? You met someone else in the ER who was supposed to be your hospitalist….what happened to that doctor? Oh, he’s just the admitting, not the attending. Dr Chiu already looked at your chart and put in the discharge paperwork. He’ll come by at some point, but then you’ll be discharged. Hours pass, then the doctor glances you over and says that pain is no reason to stay. He saw that the nurse charted that she got you up to the commode. That means you are not bed-bound and can go home. Your daughter asks about your neck, back, your osteoporosis. Did anything get investigated? Did anything get examined anything further than the CT? No, the doctor says, he’ll order a couple of x-rays, but then she’ll go home.
Hours pass… the X-rays happen…finally there are results. At 8:30pm, you are given your discharge paperwork. Effectively, it says that non-displaced fractures are painful, but there is nothing to be done. Go home, take your meds, and tough through it.
You shrug.
This is what the Case Manager said earlier.
You need a commode because you can’t walk? You need a wheelchair? You need a shower bench? Oh, well, Medicare doesn’t cover that. You need someone to take care of you?
Well. You are observation. You’re not really admitted. Medicare will not pay for someone like home care. Toileting and daily activities of care aren’t covered under Medicare, particularly in this case. If you want to pay privately, you can, but really, you might as well ask your family to take some time off to care for you 24/7.
The Case Manager hands you this:
This is insane! You can barely be transferred to a commode… but they won’t give you one because you already own a toilet?! This is madness!
At 9pm, your husband drives to the local 24 hour pharmacy to get you a commode. It isn’t like you will be able to get to it on your own, but there’s no other choice. You have a walker that someone once gave you, surely that doesn’t count… oh, but it does. You have one, therefore, Medicare will not pay for other options. You get a rental wheelchair, because that is what is covered by your secondary insurance.
You go home in pain, exhausted, and defeated. Worse, you have to pee and you know you can’t get up on your own.
This is the world of Medicare.
This is before services are limited due to an influx of patients.
Remember this. This is government run healthcare. This is what we provide people with fractures that limit mobility.
…we also then don’t give them narcotics because, you know, opiate crisis. But that’s a tale for another time.
Just remember. My mom is one of many. There are people who are refused services every single day. They are told that they must quit their jobs or hire help simply because the right code wasn’t put in or the hospital didn’t feel like properly admitting the patient. People are restricted in their services because it benefits the hospital and it benefits Medicare that patients have their benefits limited.
You may one day need someone to advocate for you. Please remember this and have someone there to ask for the tests, to remind the doctors and to insist that care is taken.
Nowadays, care is just another word in MediCare.
Published in Healthcare
What a powerful post, Right Nurse. I hope a lot of Ricochet looks it over; it affects readers’ family members, even if not themselves anytime soon.
I reached 65 this year and as I can cheerfully attest, almost everyone reading this will, too, so unless you’re in the comfortable-as-all-hell class, you’re likely to deal with this to some degree in later life, or closely know someone who will.
I wasn’t done with this comment, but I will say this: it’s genuinely terrifying.
This is how people lose their life savings. We have this happen at my hospital as well, though we try to admit people under ICD-10 codes that will get them care and services. Alcohol addiction isn’t a big enough problem to require admission. A pelvic fracture takes 4-6 weeks to heal…but it isn’t an inpatient type injury. Not only is it not inpatient, it requires care (particularly if you are limited like my mom) and the care is not provided. You can buy 24 hour caregivers, but you’d have to do that for 4-6 weeks and it gets really expensive really, really fast.
God help you if you have a diagnosis like my mom where the answer is simply “time”. Medicare will only cover rehab and Skilled Nursing if you are officially Admitted for 3 days time. We have patients languish for 3 days for no other reason than to qualify! This is all abject madness. We have to lose money to qualify for services that increase functionality and reduce long-term costs.
The government is penny wise, pound foolish.
Amen.
Gary at 65? Sure is.
Your guv’mint tax dahllars at werk.
Oh this is the hospital CM’s paper that they made to explain why things are rejected. Isn’t it glorious?
Yep. I remember when I got my walker having to sign a form to say that I would not/could not receive another one paid for by insurance for at least five years. Is this really a big insurance fraud scam, getting multiple walkers or walkers and commodes? (That is a rhetorical question. I do not even want to know the truth.)
My mom’s wasn’t even paid for by insurance. It was given by a friend. We were still told that it didn’t matter how we got it. The important thing was that we had it at all. We no longer qualified for a commode because she already had a walker (that had been free).
It’s awesome.
Commodes and walkers are no longer dispensed simultaneously because gubmint.
It would be nice to know which rocket scientist at HHS made that call.
And when.
Now that I have had a bit of intimate experience with government services, I realize that the solution people inevitably come up with is simple: lie.
Don’t tell them that you have a walker. Don’t tell them you have a bathroom. Don’t tell them that you have family who could help out. Be as lonely, impoverished, hapless and dysfunctional as you can get away with being.
This is what those who are dependent on the government do—at least the clever, dishonest ones. Children growing up in welfare-dependent homes learn to do it from the start. Eventually, when the Revolution comes and the Resisters and Antifa and/or White Nationalists have their way, we’ll all become good little liars and con-artists as our brethren in Eastern Europe were before us.
I’m sorry about your Mom, RN. I’m glad she had you. No one should be in the hospital without an energetic advocate.
Is there a reference readily available to the public where one could look up codes to see whether “the right code” has been used? This has led to much wasted time and money in my experience, and I am sure it has in many others’.
I just went through this with a neighbor. She and her husband, who passed away about a year ago were close friends of my parents. They both were from Munich and survived the Allied bombings of Munich during WWII. She fell and broke her collarbone. She was transported to the hospital, received x-rays that confirmed the broken collarbone. An orthopedic surgeon was not going to be available to see her until the following day so a decision was made to send her home in a taxi. As they were dressing her for the cab ride she passed out from the pain. So they finally admitted her for an overnight stay.
I suppose what Allied bombs couldn’t accomplish Medicare may well accomplish.
Prayers and best wishes for you and your mom.
One of the many reasons I won’t last in the profession. Red tape. Rules. Indifference.
Just wait til you see the bill. 12-15K. The hospital made good money I bet.
Hope she gets better quickly.
My neighbor’s father, a physician who had been a gynecologist and then qualified as an orthopedic surgeon, retired from medical practice when he was diagnosed with MS. He was placed in care within the British National Health scheme. Had his wife not visited every single day and been his constant advocate, his life would have been much shorter, and much more horrible. My neighbor told me one story that proved to be a great consolation, however: when she was visiting her mother (now in care herself following a stroke), she met a young man whom she did not know at a bus stop in London. “Are you by any chance Mr. M’s daughter?” he asked her. “You look so much like him.” He went on to explain that he had been her father’s nurse for several years, “He was such a sweet man; I loved taking care of him.” he went on, and told her that he had been with her father when he died. It was one of the few human touches in the whole sorry history of her father’s illness.
One of the things that infuriates me about electronic medical records and complicated “codes” is that people are rapidly being reduced to non-entities, just “diagnoses” and insurance coverage problems. No wonder there is such advocacy for euthanasia! My old nursing instructors made damned sure we students never, ever, referred to patients as “the pneumonia in room 51” or the “colostomy in room 62.” Now I can imagine someone giving a start-of-shift report with “the 316.8 in room 32 will need to go to x-ray at 9:00.”
A good Case Manager ignores the inconvenient facts. Unfortunately, we had a mediocre case manager. Lying is convenient and downright useful, particularly in healthcare. If you need drugs, exaggerate your pain. If you need a surgery, exaggerate how badly it impacts your life.
It is sad that it has come to this because, ultimately, it means that healthcare providers have to assume that everyone is lying.
Ah, well as Kate was saying, it’s all a game of manipulation. ICD-10 has 68,000 codes. That’s 68,000 specific diagnoses including “struck by a turkey”. Some codes support the services needed. Some do not. It’s simply a matter of getting people to use the right words.
My mom has MS. She refuses to have it put down in her chart because the treatment for MS is worse than the treatment for CIDP. She’s been receiving life-changing drug therapy that she will not have if MS is the diagnosis. So, the doctors conveniently just forget to put it in the actual charting as a diagnosis.
I guess there’s no guidebook, but the ultimate guide is round UP. Whatever it is, get them to diagnose up. Tell them everything wrong. Make sure it is documented as complex rather than simple and you might actually get the appropriate resource allocation.
The irony here is that even though we are taught that in nursing school, we revert to using room numbers instantly.
Because of HIPAA. If you dare mention the patient’s name in the open along with any information, you are in violation. What are nurses expected to do? Chart in the hallways, chart in patient rooms. We have phones to be called about every patient. How do you talk about one while allowing for privacy in front of the other? Room numbers. Vagueness.
Say one thing, do another.
Yup, the law that forbids anyone to know anything about your health except the government and any insurance company.
How dare you! It’s protection, privacy and access… it reduced paperwork….right?
I took my lovely bride to the ER this past winter. She has had 9 strokes so far in her life. She was running a very high fever and was becoming delirious. I had no idea what was going on so I took her to the ER. Blood tests in the ER revealed (wait for it) an infection. After 48 hours in the hospital, lots of IV anti-infection drugs, multiple blood tests, and virtually no sleep, she was told to go home. Her observation time was over. We asked what had infected her. They didn’t know. What kind of infection was it? They didn’t know. They had NO idea what was causing the infection. The attending MD gave her a prescription for some kind of anti-infection drug. When we got it filled, it was for two (2, count ’em, 2) pills. One for tonight one for in the morning.
I took her home and did my best to make her feel comfortable. I now know how they dealt with illness in the 1800’s. I had to do it in 2017.
But don’t you see. Everyone else is getting the same lousy care and that is what is most important. Its only fair for you to suffer, because everyone else is suffering.
I would very much like to hear about that. If you are not comfortable here, please share in PM. That needs good management.
If they found it in the blood, that means that she is septic. If she is septic, they should have had an infectious disease MD follow her case. They should have cultured the buggies and then adjusted antibiotics accordingly in order to reduce resistance/allergic potential.
I hate how litigious our society is getting, but as the old hospital saying goes, “Nothing will change until someone dies or someone sues.”
That’s crazy. They had her on a 5 day course for sepsis? That’s nuts. Even with high dose and broad spectrum. If she kept running a fever… that’s just nuts. It’s malpractice.
Do no harm.
I see nothing but harm there.
Well, it is the most “fair” option. I would appreciate if those people extended fairness to our ruling class. I would thoroughly enjoy watching Congress try to navigate the stupidity they have created.
Please allow me to second Kate’s pity for your Mom and yourself @rightnurse. As far as lying is concerned, it sounds as though your Mom might as well go to a bar and get good and drunk…she could then go back to the hospital and say she was an alcoholic. Very sad.
I have thought about other pathways back to inpatient status. Luckily, she is now taking her pain medications as ordered and is doing slightly better (more mobile). The problem is now that the medication will back her up and she already had part of her colon removed.
Layers upon layers. This entire experience was so bad, I have few words for it. We didn’t receive services, we didn’t have things explained. We didn’t spend more than 5 minutes with the doctor. We didn’t receive adequate discharge education. If I weren’t a nurse, my mom would have no idea how high her risk for DVT is or how high her risk for bladder/bowel problems.
This is why at age 67 I work full time–just to keep the employer provided insurance, as I dread the thought of going on Medicare. Under Medicare, everything that is not permitted is forbidden.
Medicaid is worse. The term is short for “Medical Apartheid”.
All of this reminds me of Mel Brook’s “Men in Tights” movie, the scene in which Robin’s men are handing out booty to the peasants, silver platters, goblets, one apiece, as if these would do the peasants any good. But, as each peasant steps forward and receives his or her piece of booty, one of Robin’s men hauls off and hits the peasant in the face as hard as he can. Robin wanders by and asks if the fist in the face is necessary and is duly informed, oh, yes, yes, Robin, the peasants except it.
That’s the government way.
Which raises the question: Why isn’t Medicare optional? The mandate under Obamacare is odious, so is not the forced requirement for Medicare just as odious. No one has a choice. Medicare should be optional. As should Social Security. That’s how one knows there is not a single actual Conservative in Washington, or int he entire country for that matter; we are all Progressives now.
I’m on Medicare A,B and Blue Cross/Blue Shield Plan F supplemental. My cost is $415 per month. So far in three years I have paid nothing else. This year I have had cataract removal w/ lense replacement on both eyes and I just got back from the ankle specialist (best in the city) wearing a boot to help reduce strain on my achilles tendon. I’m knocking on my wooden head saying thank God, but I still have not paid anything beyond my premiums and have not been rejected from any services. Before I started Medicare I owned a small business with 17 employees. I provided, at the end, 65% of employee premium ( years ago I paid 100%). There were deductibles and a max out of pocket of about $4000. My personal premium total was $750 per month. That was four years ago. I can only imagine what it would be today. So for now all I can say is Medicare is superb. I know how strange that sounds.