Discharge Planning Advisor

Proposed Medicare discharge rule faces criticism

It targets inpatient discharges but has roots in post-acute world

A new rule being proposed by the Centers for Medicare & Medicaid Services (CMS) — and drawing criticism from case managers who have reviewed it — would require hospitals to alert all Medicare patients 24 hours before discharge that their costs probably won't be covered if they stay longer, and that they have until noon the next day to request a review of the discharge decision.

That step would be in addition to the existing "Important Message From Medicare" — advising patients of their rights — that hospitals must give patients upon admission to the hospital.

"I believe this is adding more bureaucracy to an already complicated and confusing discharge process for a population, generally over age 65, who need our assistance and guidance," says Barbara S. Leach, RNC, MS, CNA, ACM, director of case management, Sacramento/Yolo, with the Sutter Health Sacramento Sierra Region.

"The average hospital stay is already targeted to be four days or less," she adds, "and to provide [extra] paperwork in advance of the discharge will only add tasks to an already overworked system."

Even in scenarios where there is a plan of care in place, she notes, there are many factors that could disrupt the plan, including changes in the patient's condition and the availability of services at the next level of care.

Proponents of the proposed rule, published April 5 in the Federal Register, contend that the "Important Message" is not a timely notice, says Ellen Pryga, director of public policy development for the American Hospital Association (AHA), which has several concerns about the proposal. "They're saying [the "Important Message"] isn't close enough to discharge, even though the average length of stay for Medicare patients is six days."

The two-step process being proposed also would replace two existing forms — the hospital inpatient notice of noncoverage (HINN) for regular Medicare patients and the Notice of Discharge and Medicare Appeal Rights (NODMAR) for those with Medicare Advantage plans — with a new form that must be completed if a patient indicates any disagreement with his or her discharge plan.

"The HINN requires all the details about why the patient would no longer be covered and why the patient no longer needs inpatient care," Pryga says. "It also includes more details on the appeal process."

The proposal is not a new idea, she notes, but got its impetus from a final rule (68 FR 16,652) published April 4, 2003, in the Federal Register that requires post-acute providers to conduct a two-step notice process in connection with the termination of Medicare coverage to an enrollee in a Medicare Advantage (then Medicare Choice) plan.

Among the problems AHA has with the inpatient proposal, she adds, are that in most instances the notice of discharge would add 24 hours to a patient's hospital stay.

"By requiring that it be rendered after the discharge decision is made and yet 24 hours before discharge," Pryga says, "you end up in many cases keeping people another day, and with diagnosis-related groups [DRGs], hospitals don't get paid for that."

Hospital employees would be required to have Medicare beneficiaries sign a copy of the notice of discharge, a largely generic document that would leave space for the patient's name and date of discharge, and attest that they have received it and understand it, she says. "The entire thing is a recitation of how the person has the right to protest the discharge and stay in the hospital free while [the issue] is adjudicated."

"If the patient isn't able to comprehend the notice," she adds, "then that has to be done with whoever the person's representative is, and whether or not their representative is even available to get the form and acknowledge receipt is problematic."

Pryga says she also is concerned about the way the notice is written. "It will create the impression that it is likely that the patient will be sent home too soon and should automatically be asking the quality improvement organization [QIO] to review the decision."

"It doesn't speak to medical necessity," she adds, "but is all about noncoverage, and 'you will be charged if you stay.' I think patients will be asking for many more requests for review that really aren't founded."

Perhaps the most troubling thing about the proposed rule, Pryga says, is that its proponents "don't really understand who makes the discharge decisions. The hospital doesn't. It's the physician. Trying to pretend that isn't the case isn't helpful."

"The physician doesn't generally make the decision to discharge until all the clinical markers are met," Pryga continues, "which is usually the morning of discharge or late the evening before — but that still wouldn't meet the requirement."

There are situations where the proposed process simply cannot work, she says, such as a one-day admission or an admission in which the patient is scheduled to be discharged on a certain day but then develops a fever overnight.

"We're also trying to figure out how to make it work on off-hours and on weekends," Pryga notes, "because discharge planners are usually on duty Monday through Friday, on a 9-to-5 schedule."

The CMS description indicates that if the patient stay is expected to be only two or three days, the new notice may be given upon admission, Leach points out. "However, the rules clearly say [notice is given] 'where the physician concurs with the discharge decision.'"

"Concurrence with the discharge decision is not defined," she adds. "I don't know if it is a discharge order saying, 'Discharge Mrs. Smith tomorrow after her antibiotic,' or if it is a note in the progress section saying, 'Plan to discharge tomorrow,' or if it is a hallway conversation with the nurse, patient, or family."

"I don't know how the 'physician can concur with the discharge' on admission of the planned two- or three-day stay," Leach says. "There are rules around how the hospital can process this new notice without physician concurrence, but that is with the review of the QIO — not an easy process."

The burden the proposed rule represents for hospital case managers "already overloaded with high caseloads and workloads" is the biggest concern of Sandra Lowery, RN, CRRN, CCM, CNLCP, president of CCMI Associates in Francestown, NH.

Like Pryga, she also is concerned about how the extra step would affect lengths of stay, Lowery adds.

CMS cost estimates included in the Federal Register article were about $5,200 for issuing the standard discharge notice to all beneficiaries and about $1,875 for issuing a more complex notice of noncoverage, she points out. "I am not sure they took into account:

  • physician education;
  • review and approval of the notice by hospital administrators and others;
  • copying the medical record (for appeals);
  • mailing or courier expenses (for appeals);
  • monitoring, evaluation, and improvement measures to ensure we are following whatever process is established to meet this requirement," Lowery says.

Lowery, Pryga, and Leach all point out the folly in the agency's estimate that the process of delivering the notice will take about five minutes.

Consider the need, says Leach, to explain to older patients — increasing numbers of whom do not speak English — that they are scheduled to go home the next day, but have the right to appeal that decision by contacting a QIO, and that their stay beyond that point may not be covered by their payer.

Then staff must have the person sign a form acknowledging that he or she understands what is being explained, she adds. "Five minutes will not begin to do this justice, and a quality case management department will spend many more than five minutes preparing and executing this process. The cost will be great."

After the form is signed, notes Pryga, hospital staff must copy it, file it, and maintain those files — on some 12 million admissions a year.

At a time when the industry focus is on electronic records, she says, "there is no provision made other than dealing with paper copies."

[For more information, contact Barbara Leach at LeachB@sutterhealth.org. Sandra Lowery may be reached at ccmi@lowery.mv.com.]