Good afternoon. This is Alan Pitt with Healthcare PittStop. Today I have Dr. Marc Lato, former VP of Medical Management at St Joseph’s Hospital, with us. I thought Marc could help us understand hospital admissions and some of the confusing times that we all face either as patients or family members. Today healthcare is often less about drugs and procedures and more about the rules, regulations and social factors that influence healthcare. So Marc, welcome. I’m glad to have you.
ML: Great to be here.
AP: Marc, you’ve had a fairly varied career in health care. You were a family physician for a long while.
AP: That’s quite a practice. Then you worked on the payer side. And most recently, most recently you were the Vice President of Medical Management, supporting case management here at St. Joseph’s Hospital in Phoenix. This is a poorly understood area, so I thought today we could talk about what it means to have an admission from the hospital perspective and perhaps get some advice for families when they have a loved one who has been admitted to the hospital. My generation is something of a sandwich generation; we’re taking care of our children and we have older fparents with illnesses that we have to care for. I was hoping you could walk me through a typical hospital admission, say for the new onset of chest pain.
ML: That’s a fairly straightforward one. Usually that patient would be placed in observation status, which means that most of this work could be done theoretically in an outpatient type setting although we’re watching that patient in the hospital. The patient would be ruled out for acute coronary syndrome or for a heart attack—the blood work and serial EKGs—and if that occurred he or she might get a stress test, a nuclear imaging test. If they looked fine, then that patient could go home sometimes as quickly as 12 or 24 hours after they’ve been admitted.
AP: You mentioned that all of this could have been done as an outpatient. That seems kind of extreme for somebody with new onset chest pain, but is that where we’re at in healthcare today?
ML: Well, it’s categorized as outpatient procedures; those blood tests and other tests can be done as an outpatient. However, the patient needs to be observed or monitored before we commit to what’s called an inpatient admission. It used to be called 23-hour observation. Now it can go as long as 48, sometimes even longer, but we might observe the patient in that “status” for that time.
That is more of a payment status than it is anything else. The care is the same; the observation is the same; the patient may be in a telemetry unit where he or she is monitored. But it’s just going by the payers, such as Medicare, CMS or others. That’s how it’s viewed and it’s paid at a lower level of care.
AP: You have to pay back to the hospital, you mean.
ML: The hospital receives a lower level of payment.
AP: I would imagine the hospital is not incentivized to have patients on observation status, but they’re probably required based on what’s being done to the patient.
ML: The hospital participates in Medicare and what’s called the “conditions of participation.” So by virtue of those conditions, to be licensed or certified by the federal government, you have to agree to those conditions of participation, and one of them is the appropriate status for the appropriate patient.
AP: There’s something called the “MOON” letter that patients are given and that I heard about on the national news a few months ago. It sounds like an innocuous term and stands for the Medicare Outpatient Observation Notice. When a patient is offered this letter what’s the point? What does it mean for the patient when they sign off on that letter?
ML: Well, it’s in order to notify the patient and his or her family of what that observation status is, which means that you may remain in this status for 24 to 48 hours. Some of your medications may not be paid for. And you may have a deductible if you don’t have any co-insurance, or if you don’t have a supplement. Then you may be responsible for as much as 20 percent of the bill or 20 percent of what Medicare or the payer deems the bill is.
AP: I can’t imagine. I mean, you’re caught up in all the emotion of a new medical problem and all of a sudden you get this letter. Most patients probably don’t realize that signing the letter means that later down the road they may be responsible for more of the costs.
ML: Well, they’re responsible for the cost whether they sign the letter or not. And it’s part of the rules that we operate under.
AP: Now, as part of this patient’s journey, let’s just say that the patient who comes into the hospital is found to not be able to go back to their own home or apartment or wherever they live. You’ve mentioned to me there’s this 3-day rule for traditional Medicare patients. Can you tell me a little bit more about that?
ML: Traditional Medicare is also known as Medicare [Private] Fee-For-Service (PFFS), in contradistinction to a Medicare Advantage or a Medicare HMO plan. And for the majority of patients—although fewer and fewer of them in Arizona have this—this is a rule put in place as far back as the 80s. It said that a patient must be in an inpatient status for at least three days—three midnights—in order to qualify for a skilled nursing facility or nursing home stay. I believe the original thought was they didn’t want to warehouse Medicare patients—theoretically older patients—in a nursing facility just as a means of “getting rid of them.” Now medicine’s changed a lot over the last 30 years, and the ramifications are much different.
AP: Yes, there are the increasing acuity levels. I know in my career they’ve increased dramatically in terms of what we used to treat on the floor or in the ICU. Now we treat super sick patients on the floor. It’s much different.
ML: As a matter of fact, yes, the nursing home used to be a place that grandma did or did not want to go to. Now many of them [nursing homes] can maintain the acuity or the significant severity of patients that would previously have been housed in a community hospital. So yes, the acuity along the whole health care continuum in the ICUs, in the hospital, and now in the SNF (Skilled Nursing Facility) has changed dramatically.
AP: You did tell me that there’s a glimmer of hope that the Affordable Care Act—these next gen ACOs—offers an opportunity to do away with this 3-day rule.
ML: That’s correct. As a matter of fact the Medicare HMOs or Medicare Advantage plans have always been able to—not circumvent—but are not required to have that rule because they’re all capitated. If they deem that the patient is better served at a lower level of care—that is, in a skilled nursing facility—-then the patient can go there directly from the emergency room; they can go from a 1 or 2 or 3-day stay regardless of whether they’re inpatient or outpatient or observation. The next gen ACOs now have the ability to do the same thing.
AP: So in some ways it allows us as physicians to get back to doing what we want to do, which is make the right decision for the right patient at the right time and not follow these strict rules, or at least not follow them in the same way that is outlined by Medicare.
ML: Right. And in the right place.
AP: So we’ve talked about two kinds of “gotchas” that patients might have. One is these MOON letters and another is these nursing home placements. I can’t imagine that either is top of mind when you or a loved one’s admitted to the hospital, that you’re going to have to deal with these issues. Can you offer any advice to families—3 or 4 recommendations for patients to avoid getting delayed bills or ending up in a nursing home they don’t necessarily want to be in?
ML: Sure. So if you come in emergently to simply the closest facility, make sure that that facility is on your plan, or if it’s not, make sure that health plan or payer has provisions to allow you to go to any facility in the case of an emergency. The same thing with the conditions of care for you. Also have a single point of contact. Some times there’s a whole family and everyone is interested. It’s hard enough to coordinate the care of the doctors and the nurses and everything, but I think if there’s one person who is either going to be there or has a phone number that can be the point of contact, that’s something that I would recommend.
And then, finally, think about early on what the disposition you would like for your loved one is. Clearly you want him or her to get better, and that depends on what the condition is. If it’s a stroke, then you’d want them to go to a rehabilitation facility. If it’s a bad infection, they don’t keep you in the hospital for 7 or 10 days for IV and antibiotics; they may require you to go to a skilled nursing facility. If it’s a once-a-day medication, you could have that done at home where the family is taught how to be a caregiver with the help of a home health nurse who would come to the house initially and every few days.
AP: In previous discussions, both Dr. Spetzler and my mom, who is a patient herself, said something to the effect that the patient needs to be the captain of their own ship. I guess what you’re saying is that the patient or their family member should expect to take more of an active role as a partner in trying to help that patient get better.
ML: As you said, if you’re coming into the hospital, you may or may not have all your faculties about you. That doesn’t mean you’re disoriented, but you’re sick, you’re in pain, you’re uncomfortable, you just want to get well. And someone else who is not in that position can possibly better help you make those decisions or at least interpret them for you.
AP: As you know, I’m something of a technophile. I think people expect me to bring them a new app on a weekly basis. I know technology won’t solve everything, but do you see any opportunities to improve care and communication between providers or between providers and patients? Things that you’ve noticed on your day-to-day?
ML: There are a few things. In Arizona we’ve had a health information exchange—it’s now called Health Current—which has been endorsed by most hospitals and most insurers who participate in it. So there will be a broader and much more robust interchange of health information between hospitals and insurance agencies that hospitals and doctors and others can get hold of to make it easier.
The second would be what I would call a personal health record, which I thought of as you talked about being the captain of your own ship or your own advocate. There are many of these around that you could copy, but know what you have and develop that little health record. It could be as simple as a one-pager that you keep with you in your shirt pocket or on your iPad.
And finally, many office practices and even hospitals are going to secure portals where you can get the information yourself and interact electronically with your clinician. Even if that is an unsatisfactory communication, there are alternatives such as a phone call or things like that. But at least it expedites those transactions.
AP: That’s really good advice. I know that I’ve had patients who come to me without any information and I have to start from scratch, which really delays their care. Even if people had a list of places they’ve been in, a list of their drugs somewhere handy, that would be pretty awesome. I do think it really is on us as the healthcare industry to come up with some better solutions, such as the personal health record and better portals because that can be a bit clunky of late.
AP: I’d like to shift topics now. I know that currently repeal of the ACA is a hot topic. From your perspective, having been in health care a long time, do you think the ACA is a good thing, a bad thing? What problem was it really addressing? Why was the ACA brought forward in the first place?
ML: I think the ACA was a good thing. Prior to the ACA there were as many as 50 million in our population who were uninsured. Now they’ve ratcheted that down to about 30 million, but there are still a lot of uninsured. It provided insurance for those people who couldn’t get it or wouldn’t get it because it was so expensive, because they had a preexisting condition and were un-insurable, or because they simply didn’t make enough money—they worked but they made too much money to be in Medicaid and too little money to actually afford a regular health plan.
Part of the problem with the ACA is there were things called “risk corridors” that were put in that helped sustain the insurers with a downside loss or an upside gain. That went out, I think, in the summer of 2013 or 2014 in one of the budget reconciliations, so consequently they were all flying free and they were supported to some extent in the first year or two of the exchange but not subsequently. That is why you heard that about five states—Arizona being one of them—had a substantial fleeing of the insurers; very few insurers remained and the cost of the remaining insurance for those people on the exchange was higher.
But remember, I think it’s like 6 percent of our population. The vast majority of people either get insurance through the government like Medicaid, Medicare or the V.A. or through their work, as many of us do. Nonetheless, this served a significant part of the population. Those are the people from whom you’re hearing now with the concern that the plan that they apparently didn’t like now they like because it was better than what they had, which was nothing.
AP: I know there was a significant change for patients with mental health issues in the new law. They reached something called “parity.” I know if I go down to our emergency room, there are folks with a lot of issues—mental health issues as well as health care issues. Can you speak to that from your perspective?
ML: I think a few years ago—it might have been part of the ACA or even slightly before—laws were passed that said that if people had a behavioral health diagnosis such as major depression or schizophrenia or bipolar disease, to mention just a few, that they couldn’t be discriminated against; that their insurance had to cover the cost and care of those diseases as well as diabetes or high blood pressure or anything else. Now I don’t know that it’s allowed inpatient hospitalization for those conditions because I think the trend within behavioral health has been to treat many of these people as outpatient as soon as they can. But at least it would provide for clinicians to see them and for drugs to be provided to them.
AP: It has always struck me as odd that mental health issues are treated separately from cardiac or lung or other organ systems. I think it reflects some of our mentality of curing patients rather than caring for patients.
ML: Apparently there’s a lot of bias within our country and our community—we’ve seen it rear its ugly head in a lot of different ways—and mental health has been the poster child for being looked down upon rather than being looked at as a disease. Fortunately some famous sports figures and celebrities who have gone public with their fight against these diseases have helped to humanize it a bit, but I still think we have a way to go.
AP: What do you expect moving forward? Do you think the Republican plan is the answer? Do you think we’re going to a single payer system? Something else entirely?
ML: I hope the Republican plan is not the answer because I think in their haste to try to undo Obamacare or the Affordable Care Act, they’ve thrown the baby out with the bathwater. I think there are ways to reform the system and to make better the Affordable Care Act that will both save money and continue to provide insurance for this group of people, as well as for those who couldn’t get it before.
My glass is always half full and I’m optimistic. We recently discussed an article in the Journal of the American Medical Association, JAMA—I believe it was the April 11 issue—where some researchers talked about universal care without single payer coverage, and they used Germany, Switzerland and Singapore as examples where multiple payers can exist in a system. But it required a mandate or an ability to amortize that risk over the entire population so that the less sick could help subsidize the sicker. If you have things like these risk pools that have been bandied about, they rarely work because all you have is people that are at very high risk and are going to use those pools. There isn’t anybody who’s not going to use those pools unless they unfortunately expire much quicker than expected.
AP: Marc, I appreciate your time. I know I’ve seen many folks get admitted and it’s just a bewildering culture that gets thrust on them in the hospital. I’m hopeful that your experiences and recommendations can be of help to others. Thank you very much.
ML: Thanks a lot. I appreciate the opportunity to talk with you.