“Of course she’s admitted,” her mother said. “Didn’t I just tell you she was in the hospital?”
But like a sharply growing number of Medicare beneficiaries, her mother’s friend would soon learn that she could spend a day or three in a hospital bed, could be monitored and treated by doctors and nurses — and never be formally admitted to the hospital. She was on observation status and therefore an outpatient. As I wrote last year, the distinction can have serious consequences.
The federal Centers for Medicare and Medicaid Services tried to clarify this confusing situation in the spring with a policy popularly known as the “two-midnight rule.” When a physician expects a patient’s stay to include at least two midnights, that person is an inpatient whose care is covered under Medicare Part A, which pays for hospitals. If it doesn’t last two midnights, Medicare expects the person to be an outpatient, and Part B, which pays for doctors, takes over.
It’s rare to have hospital and nursing home administrators, physicians and patient advocates all agreeing about a Medicare policy, but in this case “there’s unanimity of dislike,” said Carol Levine , director of the Families and Health Care Project of the United Hospital Fund. Despite protests , the rule took effect on Oct. 1, but Medicare agreed to delay penalties for 90 days.
Meanwhile, administrators at the Johns Hopkins Hospital in Baltimore have taken to calling the policy the Cinderella Rule, said Amy Deutschendorf, senior director of clinical resource management: “If you cross two midnights, you’re an inpatient. If not, you’re a pumpkin.”
Being a pumpkin can cost patients a lot of money. Under Part B, they’re billed separately for every procedure and visit and drug, and the co-pays can mount until patients owe hundreds or thousands of dollars — which they may only discover upon receiving the bills. “People are shocked,” Ms. Levine said. “Nobody is required to tell them they’re outpatients.” (Except in New York State, where the governor just signed legislation requiring that Medicare beneficiaries be informed of their observation status and be able to appeal it.)
More expensive, though, are the fees at rehab places or nursing homes, which Medicare will pay for after three days of inpatient care. Those who’ve been outpatients don’t qualify for that benefit and can find themselves on the hook for five-figure sums.
So patients are complaining, and so are hospitals. Older people in emergency rooms often have complex problems, and they are strangers to the physicians who must decide whether to admit them or not. “Nobody looking at the patients who come through the door can predict who’s going to be here for two midnights,” Ms. Deutschendorf said. Yet a hospital that admits patients who don’t need two midnights’ worth of care may face Medicare audits, denied payments, fraud accusations and financial penalties.
Johns Hopkins at least gives observation patients an information sheet telling them they’re outpatients, to forestall later shock. But “it causes them angst and results in deteriorating patient-physician relationships,” Ms. Deutschendorf said. She estimated that under the new rule, observation stays will double. “We don’t want to be the bad guys here,” she said.
Hospitals will lose money, too, it appears, since Part A reimburses at higher rates than Part B. An 18-month study of observation patients at the University of Wisconsin Hospital, recently published in JAMA Internal Medicine, found that they accounted for more than a quarter of adult general medicine stays. The hospital lost about $500 for each adult general medicine inpatient (the difference between cost and reimbursement); for observation patients, it lost nearly $1,400.Other studies have found that observation costs less, however.
Money matters, of course, but opponents of the two-midnight rule also point out that it lacks logic. “Hospital care is hospital care,” Ms. Deutschendorf said.But not always.
Say Patient X arrives at the emergency room complaining of chest pains at 11:58 p.m. on Tuesday and gets discharged from the hospital on Thursday morning after breakfast. Patient X will have stayed for two midnights, so he was an inpatient, covered by Medicare Part A.
Say Patient Y arrives with the same condition five minutes later, at three minutes past midnight on Wednesday morning, and also leaves Thursday.Patient Y stayed only one midnight, so even if he received precisely the same care, he’s a pumpkin, facing higher Part B co-pays.
Moreover, if Patient X receives medically necessary services and gets discharged Friday morning instead of Thursday, he will have stayed three days, and so Medicare will cover rehab care if he can’t safely go home. Patient Y has been an outpatient, so even after three days, he’ll have to pay for rehab himself.
What patient advocates really want is to get rid of that three-day hospitalization requirement for the Medicare nursing home benefit. But the odds don’t look encouraging. Last month, a federal court in Connecticutdismissed a class-action suit brought by the Center for Medicare Advocacy and the National Senior Citizens Law Center, seeking to overturn the rule. They have decided to appeal. (Therefore, federal officials at Centers for Medicare and Medicaid Services will not comment.)
Legislation to allow any time spent in a hospital — as an inpatient or outpatient or both — to count toward the three-day requirement for skilled nursing coverage has gone nowhere in two Congresses, but it has acquired more than 100 House sponsors from both parties and more than 20 in the Senate. That may be the more likely situation, someday.
Meanwhile, families should at least ask, as the staff members fasten the plastic ID bracelet around a relative’s wrist: Is she an inpatient? Or an outpatient?
Pediatricians at the American Academy of Pediatrics have offered new recommendations on how long children should be allowed to use the internet, watch television, cell phones, tablets and more, in an effort to stem health problems that can be suffered later in life.
Put plainly, all electronic media should be off after bedtime and during meal times, a “no device rule.” Daily screen time for entertainment should be less than 2 hours per day and children under the age of 2 should not have any screen time at all.
Some of this is a reiteration of previously offered guidelines, but the trend is a near round-the-clock-use of devices in which kids are engaged in their devices, not their surroundings. The problems stemming from that are obesity, bad grades in school, aggressiveness disorders and poor sleep patterns.
Of course, the AAP also admonishes that parents need to be the example of the health model and follow the same rules, turn the devices off, limit time in front of the TV and do not use them in bed. We wish everyone the best of luck as device usage amongst kids under the age of 8 grows dramatically. Common Sense Media, an advocacy group in San Francisco says that at least 17% of children under the age of 8 use mobile devices daily, just about 1 in 5. That is up from less than 1 in 10 in 2011.
Pancreatic cancer is one of the most lethal tumor types because it's too often diagnosed in a later, advanced stage. But a new study suggests that a simple blood test might help spot the disease earlier.
The study is described as small and preliminary, and investigators cautioned that the initial findings will need to be confirmed in larger trials.
"Pancreas cancer is the fourth leading cause of cancer death in the United States," said study coauthor Dr. Nita Ahuja, an associate professor of surgery in the department of oncology and urology at the Johns Hopkins University School of Medicine, in Baltimore. "There have been minimal to no improvements in the survival from this disease in the last 40 years. There are over 40,000 people diagnosed every year and about that many deaths."
"One of the main reasons for the lethal nature of this cancer is that most cancers are diagnosed too late once they have spread to other organs," Ahuja said. "Around 8 percent have spread to distant organs such as the liver or lungs, while another 10 percent have locally spread to major blood vessels. However, in the patients where cancer can be detected early and has not spread, a long-term cure is possible with surgical removal of the cancer with the surrounding lymph."
Any means of spotting the cancer early would therefore be crucial, Ahuja added."We have mammograms to screen for breast cancer and colonoscopies for colon cancer , but we have had nothing to help us screen for pancreatic cancer," she said.
Ahuja said the new study sought to find blood "markers" for pancreatic cancer "in patients who are at increased risk for developing this cancer, such as [those with a] family history or heavy smokers."
Ahuja's team had previously identified mutations in two genes, called BNC1 and ADAMST1, that typically occurred in the presence of pancreatic cancer.Since both mutations are found in 97 percent of early stage pancreatic cancer tissues, the researchers developed tests to search for signs of the mutations in blood samples collected from 42 people already diagnosed with early stage pancreatic cancer.
Reporting in the current online edition of the journal Clinical Cancer Research, Ahuja's team said both genetic markers were found in 81 percent of the tested blood samples, but not in samples taken from patients who either did not have pancreatic cancer or had a history of pancreatitis (an inflamed pancreas).
The researchers said the results are much more impressive than, for example, the prostate-specific antigen (PSA) test used to screen for prostate cancer , which has roughly a 20 percent success rate.
Still, an 81 percent accuracy rate is "far from perfect," Ahuja said. The test also had a false-positive rate of 15 percent, meaning that 15 percent of people who get the test initially will be told they might have pancreatic cancer when that is not the case.
A large trial funded by the National Institutes of Health (NIH) will investigate whether vitamin D supplements can stall the development of type 2 diabetes in patients at high risk for the disease.
The Vitamin and Type 2 Diabetes (D2d) Study will randomize patients with prediabetes to 4,000 IU per day of Vitamin D3 (cholecalciferol) or to placebo to determine if the supplement is an "affordable and accessible way to help prevent or delay type 2 diabetes," Griffin Rodgers, MD , director of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), said in a press release . NIDDK is the primary sponsor of the study.
The dose of cholecalciferol being used in the study far exceeds the typical adult intake of 600 to 800 IUs a day.
The study aims to enroll about 2,500 patients who will be seen at 20 centers across the country. Patients will check in with their investigators twice a year, while still receiving regular care from their own doctors.
The study builds on previous NIH-funded studies, such as the Diabetes Prevention Program, that found lifestyle changes that help patients shed a modest amount of weight as well as the drug metformin can both help slow the development of type 2 diabetes in at-risk patients.
You can live a full and active life even when you have allergic asthma.
Joanna Thomas has had severe allergic asthma since she was 2 years old. Her asthma is triggered, she says, by "just about everything." But today at 72, she travels, volunteers, exercises, and generally enjoys life.
There's only so much you can do about outdoor air quality, but you can control the air quality inside your home. For starters, keep your windows shut.
Thomas finds that a HEPA filter (which stands for high-efficiency particulate air filter) keeps the air in her house clean by filtering out dust mites, pet dander, and other allergens.
Plan for Exercise
You can and should exercise. It helps your lungs and heart work better, and it builds your strength and endurance. If you choose an outdoor activity, try to limit the pollen and irritants you bring inside with you. As soon as you come in, take off your clothes and shower. Make sure to wash or rinse your hair.
On some days, when the pollen count is high, that might not be enough.Exercise inside on those days. Thomas has a folding, rollable treadmill that she can use in her home. She even takes it with her on vacations in her RV. Other people with allergic asthma find that yoga is a good inside alternative.
Rethink Your Home Decor
The surfaces in your home are as important as the air. Wash your curtains or, even better, replace them with blinds or other non-fabric window dressings. You can vacuum upholstered furniture. Dust items that are leather, plastic, vinyl, or wood with a damp cloth, Thomas says.
Thomas replaced all the carpet in her home with hard-surfaced flooring. Carpets can harbor allergens including dust mites, cockroach droppings, pollen, and mold spores.
Clean With Care
If you can't get rid of your carpet, the American Lung Association recommends vacuuming at least three times a week using a HEPA filter and while wearing a mask.
In fact, you should wear a mask for any type of cleaning. "I wear an ear-loop face mask," Thomas says.
What else can you do? Take out the garbage every day. Only empty the vacuum bag outside.
Protect Your Bed
Many companies make mattress and pillow covers. "They basically seal your mattress and your pillow case so you don't have a reaction," says Kim Franklin, 47, a nurse in Omaha, Neb. She was diagnosed with allergic asthma in 2002.
Thomas says you can also vacuum your mattress or use an upholstery tool to keep dust mites and other allergens at bay.
The American Lung Association recommends washing sheets, other bedding, and pajamas at least once a week in very hot water.