When you're not a hospital inpatient: observation care
March 09, 2009
"Observation" is a patient classification used by U.S. hospitals and it can cost the patient out of pocket dollars not covered by Medicare or other insurance plans.
Have you ever heard of observation care? If not, you’re not alone. Few people know about this increasingly common category of hospital care.
In a story today, I describe it as one step up from the emergency room and one step down from a hospital admission. People whose symptoms are troubling but not clearly defined can be candidates.
Think of a man who comes to the Emergency Room with chest pain that could be a symptom of a heart attack or just indigestion. In observation care, doctors can administer tests and short-term therapies and try to figure out what’s going on.
When I asked Blue Cross and Blue Shield of Illinois about the practice, they put me in touch with Gail Larsen, divisional vice president for provider relations.
She explained the purpose of observation care is to answer an important question: Does this patient need to be admitted to the hospital or should he be sent home?
"What you don’t want to do is admit a patient and send them up to a [hospital ward] if you don’t really need to," Larsen explained.
Blue Cross and Blue Shield of Illinois – the state’s largest health insurer -- has strict limits on how long a patient can remain in observation care, she said. The upper threshold is 23 hours; if a patient stays longer, he or she is automatically admitted to the hospital.
"What we don’t want is for patients to sit around for days in observation status," she said.
I asked Larsen what might be fueling the rise in observation care. She cited the aging of America (the older people get, the more medical problems they develop), medical advances that permit more patients to be treated in outpatient settings, and heightened awareness of patient safety issues in hospitals, including the risk of infection.
What about the financial consequences, I asked? Patients may end up paying more, depending on the terms of their policies, Larsen admitted. And yes, some patients have no idea they’re in observation care and find their bills confusing, she said.
As for other insurers, their policies differ.
United HealthCare chief medical officer Dr. Sam Ho said the insurer didn’t cap the time patients can spend in observation care but noted that "the overwhelming majority" of cases last less than 48 hours.
The company is developing a one-page summary of medical conditions that can be treated in observation care and plans to share it with doctors and patients, Ho said.
Officials representing Medicare, the giant government health program for the elderly, acknowledged there is no upper limit on the time patients can stay in observation care. The average observation stay is about 24 hours, and only 5 percent of cases extend beyond 48 hours, they said.
Most of the problems with observation care to date have been reported by Medicare patients who stayed in hospitals for days or even weeks only to learn they were never considered inpatients. Patients have faced extra costs as a result.
The Medicare officials said patients can appeal the hospital’s classification of their care to their regional Medicare contractor. These contractors implement Medicare policies in various regions. If that doesn’t work, try contacting Medicare’s regional office, the officials suggested.
Source:
Writer: Judith Graham