How To Defer, Delay and/or Eliminate
The Need For Nursing Home Care:
(How Current Medicare Reimbursement
Law Makes Such Now Very Difficult)
MEDICARE: A Brief History of Relevant Amendments
In 1983, Medicare completely changed the way hospitals are paid (reimbursed) for providing acute care to any Medicare Beneficiary.
In short, that year, hospitals stopped receiving “per diem” reimbursement: put another way, since 1965, hospitals were essentially reimbursed when treating a Medicare Beneficiary, this by simply billing Medicare for the number of days during which a given patient was “in-patient and receiving acute care services”. Since the Medicare Program’s inception, hospitals (literally) sent a hard copy billing to Medicare, eventually, through an Insurance Company (Intermediary): and this insurance company, acting as an agent for Medicare, simply paid the local hospital an agreed upon amount (hence, the term, per diem payment) for each day of care delivered to a Medicare in-patient.
THEN: Came the era of new drugs, pharmaceuticals, and much more sophisticated diagnostic machinery, e.g., think of all of today’s tomographic imagining machinery, including CT-Scans, MRI’s as well as PET-SCANS !! These, all, were very expensive to purchase, and expensive to run, to operate inside of hospitals. Hence the spending for Medicare began to burgeon, and finally came to a ‘breaking point’: in terms of federal, Medicare costs.
ENTER A NEW FUNDING FORMULA: Referred to by its acronym, called Medicare DRG’s. In plain English, this stands for Medicare Diagnostic Related Groupings. AGAIN: Medicare passed this law, made this change for virtually all hospital stays, in 1983. There was at least one exception to this universal rule !!
Avoiding Nursing Home Placement/p.2
The MOST significant exception to all patient hospital stays being billed out to Medicare per a “DRG”, came in the arena of Acute Care Rehabilitation. For acute care patients, each of whom is absolutely unique in the level of care they require to “recover”, e.g., the intensity of care for one patient differs radically to the next. This makes it (really) impossible to bill Medicare for such care and treatment, i.e., in-patient Acute Care Rehabilitation: PM&R. (Physical Medicine and Rehabilitation). Right now, get acquainted with the acronym for such care: it is real simple: “PM&R”. Then came the ugly problems, i.e., after this new acute care funding formula for HOSPITAL In-Patient ‘Rehab’ stays!!
First, however, know this also: as most of you in fact may be familiar with: in order not to drop such needy patients in the middle of the road, so to speak, federal Medicare LAW now provides for two other LEVELS OF CARE: (1) Home Health Care PM&R, as well as (2) Very limited days in a so-called Rehab Nursing Home Skilled Care (100 days, if you are lucky: as in Las Vegas lucky), ALL such patients in need of PM&R, must FIRST be admitted (in-patient) to an Acute Care Hospital for THREE (3) DAYS: then, only then, Medicare Nursing Home “rehab” is, theoretically, possible: but again, per the order of an Attending Physician, or PM&R Medical Specialist, i.e., an MD. (or D.O.). While the acute care patient is medically stable for discharge, she is often NOT ready to ambulate, walk on her own, or even with what is called MAXIMUM ASSISTANCE (with two persons assisting her, one under each arm). As she begins to receive rehab treatment, e.g., the Endurance Training, required, this under a kind of “eventual” physician supervision, and delivered at a Skilled Nursing Home by a Physical Therapist: often with the help of aides, and/or nurses, the kind that are often serving up to 100 folk….meaning, NOT AVAILABLE. Some basics: You can understand better, per this: $2000/ day, Hospital Rehabilitation.
Avoiding Nursing Home Placement/p.3
THUS: PLEASE INDULGE ME AS I CUT TO THE CHASE:
Today, most frail, elderly acute care patients who are (remember) per hospital $$$$’s, always going to be shoved out of the acute care hospital door: thus never getting the kind of PM&R (rehab) they require, at the level they require !! Nursing homes are paid a fraction of the money amount which HOSPITALS claim, bill and most often GET !!! Why? Because Congress revisited the one, most needed kind of care, where the DRG System simply does not work, in the lion’s share of cases, i.e., when a very frail elder or disabled person, is “prematurely discharged” from the very acute care/hospital setting, which may have done a beautiful surgery. It is ludicrous to think that once out of any kind of hospital rehab, a patient will be served just as well with “sub-acute care”. It often comes down to the dollars: $2000 per day, vs. a few hundred, once out of the ACUTE CARE setting. (See any problems?) Answer: The most obvious need for continued “rehab” is that following an Open Reduction (surgically opening the skin, real surgery) and having a Replacement Hip fitted to the patient, beautifully.
But under today’s Medicare Acute Care Hospital system, the next in line to care for such a frail person, very, very often never gets the right order at Discharge, for the right TYPE of rehab care, this from the Attending Hospital Surgeon, just one example, one problem at the point of Hospital Discharge. REMEMBER: Only a physician can order up rehab, at any level, but most critically, when the frail elder is going out of the Acute Care (Hospital) door.
And always remember this: The hospital (even now for patients needing rehab care) will be eager to get the patient, even post-surgical patients, out the door as soon as possible. Why? AGAIN: Even rehab hospital care under the “DRG SYSTEM”, means that the hospital will be paid the same amount of money for a patient’s stay !!!
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THUS: Whether for eight (8) hours, eight (8) days or even, i.e., VERSUS: eighteen (18) days. Thus, simply put, as family, as an advocate for the most frail, you must always be looking at the possibility of a premature, EARLY, (too early) discharge from Acute Care !!!!
And you can appeal such premature HOSPITAL discharges:
NEXT ISSUE: Next Time: ….we continue our look at PM&R care: essential care to returning FREEDOM, independence, and all that can lead to a return individuals to a more normal life, especially for the most frail …..THUS AVOIDING ANY RETURN TO A NURSING HOME SETTING, EVER !!!!
Albert Buford, Esq.
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