Primum Non Nocere

Observation vs Inpatient Care of the Hospitalized Patient

There have been several instances within the past several months in my small practice, where I needed to admit an elderly person after a fall at home because the person in each case was unable to care for themselves within the home environment, nor were there any family members that were able to provide the necessary care that they needed.  To illustrate the point, in one such case, a 90 year-old female fell at home and broke her pelvis.  She was in severe pain and basically couldn't move.  There was no way her 90 year-old husband could help her to the bathroom or get her in or out of bed.

Under Medicare regulations, you have to admit a patient either as an "Inpatient" or as an "Observation" patient.  If the patient meets certain criteria to qualify as an "Inpatient", after a minimum stay in the hospital of 72 hours, she can then be transferred to a skilled nursing facility (SNF) and receive Medicare coverage for their treatment in the SNF.  If the patient "doesn't meet criteria" to be an "inpatient", then the person has to be considered as an "observation" patient.  If this occurs, then the person is no longer eligible to be transferred to a skilled nursing rehabilitation facility and have it paid for by Medicare.  They can still go to the SNF, but Medicare won't cover it, and the patient or the family will have to pay out of pocket, at the rate of $6-8000 per month, which most people can't afford.

In the case of my elderly, frail lady with the pelvic fracture, I was told by the hospital utilization reviewer and by the associated physician reviewer that my 90 year-old patient who couldn't walk and was laying there in bed unable to move, that she did not qualify for "inpatient" care and therefore would not be eligible to go to a skilled rehab facility under Medicare coverage.  She would have to go home after discharge and fend for herself with her husband's "help".  In my mind, this would have been totally and completely unsafe.  Surely she would soon be back after another fall with perhaps even a worse injury, not to mention the severe pain that she would have to endure without getting the benefit of skilled care.

After multiple phone calls to the utilization reviewer and the physician reviewer, they insisted that I must change her status from inpatient to observation and that she would have to go directly home after her three-day stay.  This put the onus on me to discharge the patient to a level of care that would be totally inappropriate for this patient in my mind.  Not only would this have been a difficult medico-legal position for me to be in, but, even worse, it would place my patient in a potentially harmful and risky situation.  Ultimately, I called the Vice President of Medical Affairs and finally got him to agree with me that she truly needed inpatient care.

Without my advocacy, this patient would have definitely received inferior care and the results could have been devastating.

I can't imagine that these complicated Medicare regulations save money.  In fact they almost certainly increase the risk of a recurrent hospitalization.  They are harmful to patients.  And they put the physician in a difficult medico-legal situation.  If I had discharged her to home under the pressure of Medicare reviewers following Medicare rules, and if she had fallen and sustained a life-threatening or life-ending injury, I would be liable for that injury, even though I protested the whole process.

In other cases, the minimum requirement that inpatients must stay in the hospital for at least 72 hours is also a waste of Medicare money.  There are many patients who meet the criteria for inpatient coverage but then can be treated in the hospital effectively in a matter of 1-2 days, but they have to stay the third day in order to qualify for coverage at a rehab facility, even though they could have been safely discharged to that facility earlier.

These rules don't allow for any physician judgement.  Why did I go through 11 more years of higher education if I can't now be trusted to make these kinds of decisions?  Not only that, but we get squeezed in the middle by Medicare and other insurance companies, hospital policies that don't work or don't make sense, evidence-based medical guidelines (which are meant to be guidelines, not laws) societal considerations, need for cost containment, legal requirements and by malpractice risk - all of which push us in opposing directions.  I relish any education or enlightenment by these entities, but don't take away my judgement in the care of my individual patient, and then force me to cause harm to my patient - ultimately making me responsible for the harmful effects of that action.

Frustrating though it is,  I was able to make a difference for my 90 year-old patient, by persistence in standing up for what was right for her proper and appropriate care.  Some doctors wouldn't have had the time or the energy to do this.  Our patients are relying on us to help get through this quagmire of a health care system with so many complicated rules and regulations that serve no real purpose and in many ways are harmful.  

It is becoming increasingly taxing on primary care physicians to be now also the vigilant soldiers and protectors for our patients in addition to being their doctors, their care coordinators, their safety advisors, their lifelong healthcare companions, their paper handlers, their chief letter-writers, their psychologists, their confidants, their teachers and their friends.  I don't mind protecting them from disease.  But we shouldn't have to protect them from our government or from our health-care system or from their hospitals or other providers.  The rules of those organizations should be made to be helpful to our patients, not harmful.  Primum non nocere should apply to everyone that has to do with patient care, not just doctors.

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