Proposed discharge change less oppressive in final form

Rule requires 'Important Message' revision

A potentially onerous hospital discharge rule proposed in April 2006 by the Centers for Medicare & Medicaid Services (CMS) is significantly less burdensome in its final form.

The new rule, released Nov. 29, 2006, will require hospitals to issue a revised version of the Important Message from Medicare that fully explains patients' discharge rights. Rather than issuing a second and different notice 24 hours before discharge as was proposed, hospitals will issue the Important Message within two days of admission, answer any questions, and get the signature of the patient or his or her representative on the notice.

Hospitals will be required to provide a copy of the signed notice before the patient leaves the hospital, but not more than two days before the departure. For short stays, this means the copy of the notice need be provided only once.

CMS has said that it will be developing the revised notice text, but before submitting it to the Office of Management and Budget for public comment and paperwork clearance will test it with beneficiary focus groups. The rule becomes effective July 1, 2007.

Opponents of the proposed rule had noted that it would add more bureaucracy to an already complicated and confusing discharge process for a patient population — generally more than age 65 — that needs assistance and guidance.

Proponents, meanwhile, had contended that the Important Message is not timely notice because it is not issued close enough to discharge.

The American Hospital Association (AHA) had expressed several concerns about the proposed rule, including that it would have the unintended consequence of unnecessarily extending the hospital stays of Medicare patients by an extra day because hospitals often cannot predict the date of discharge one day in advance.

"By requiring that [the notice] be rendered after the discharge decision is made and yet 24 hours before discharge, you end up in many cases keeping people another day," noted Ellen Pryga, AHA's director of public policy development. "With diagnosis-related groups, hospitals don't get paid for that."

Another concern was that the proposal was written in an "alarmist" way, Pryga said not long after it was issued. She said it would have created the impression that it was likely the patient would be sent home too soon and should automatically be asking a quality improvement organization to review the decision.

In other action, CMS has finalized its proposal to relax four requirements or conditions that hospitals must meet to participate in the Medicare and Medicaid programs.

That final rule, effective Jan. 26, 2007, gives hospitals up to 30 days before a patient's admission or 24 hours after admission to complete a medical history and physical examination, and allows more health care professionals to perform the exam. The record of the exam must be entered into the patient's medical record within 24 hours after admission.

In addition, the rule provides that all verbal orders given by a medical professional must be recorded within 48 hours in the patient's record by the medical professional or another practitioner responsible for the patient's care.

Previously, verbal orders could be entered in the medical record only by the physician who issued them.

The regulation also requires hospitals to secure all drugs and biologicals and, finally, permits any individual who is qualified to administer anesthesia, rather than just the person who administered it, to conduct the post-anesthesia evaluation.