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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
My wife and I took a walk Saturday. There was a flock of turkeys in the park. Glad to know that if I had gotten into a rumble with them (Thanksgiving is coming) there would be a code for that.
I think you have had a combination of luck, people appropriately allocating services, and also a certain lack of underlying knowledge of what is going on in the background. For retirees, $415 is a significant amount. I’m glad you haven’t had to pay anything else other than a secondary insurance to pay for the items MediCare will not pay (which is a fair amount).
Your ankle specialist may be the best in the city. He may also be altering his opinion on your case based on what his repayment is going to be. You received a boot. That is much, much cheaper than having surgery, having a CT or MRI to further diagnose your concern, or investigating. It made you happy.
Another satisfied customer at minimal cost! All it cost them was a boot! At most, that will be charged to Medicare for a contracted rate of around $300-500. They’ll pay it happily. I hope you have no further foot problems and I knock on wood-type object.
Medicare is like many HMOs: the rules are obscure, it is meant to demoralize and reduce cost. If you got lucky and had a good person navigating the system, they can find ways to make it work for you. My HMO has been okay thus far because my doctor is liberal with her referrals and isn’t trying to be such a gate-keeper. But that good-will only lasts as long as there is no crack down.
Just try to stay aware. I hope you have continued good luck.
I actually want no more, nor less, than I need. If you think my Doctor makes more on a boot than on surgery…well that doesn’t quite jive with me. But I can tell you for absolute certainty, I would rather not have surgery. So I pray the boot will suffice and would much rather try that first. Again, my best wishes for your mother.
Ah, but I didn’t say you needed surgery or not. I said that it wasn’t being investigated. Also, starting with a boot appeases managed care (which keeps the doctor in repayment). I don’t advocate overusing medical resources, but I also know that many times doctors are paid based on the services they prevent as well as the services they are denied.
I hope the boot works for you too, since it is the easiest and cheapest option.
Thank you. I know we all appreciate it.
TRN, Panda Hugs for you and your Mom! And <splutter, growl> Arrrgggh for that beastly hospital/staff/system. Have been in Medicare since ’99. Have been to the hospital twice since (last to diagnose something we ultimately managed successfully at home almost five years ago.)
As with all government systems, you become part of the system. The mission of the system is not important. It’s the life of the system that is. Medicine is going the way of education. More and more money for less and less.
Hmm. I’m slowly coming to the conclusion that the proper way to deal with government is to lie. A terrible moral, but increasingly necessary? Maybe so.
I deal with it everyday as an orthopaedic surgeon. It’s sad, harsh and government based.
I hand patients and their families the office numbers of our House rep and Senators so they can hear the complaints. But, hey, single payer is going to be great.
Yep. My mom’s fractures were non-displaced, so they just sent her home with best wishes. True, there’s only so much you can do. But one of the things that can be done is to help with activities of daily living.