Let’s Talk about the Improving Access to Medicare Coverage Act

In the scheme of healthcare today, this may seem like a relatively small piece of legislation  in terms of its length but the implications are major and I can’t understand how it seems to have slipped under my radar. The lack of attention makes me suspect that it has also slipped past a number of my colleagues as well. But honestly, I am not surprised. I am not a professional lobbyist or legislative aide, I don’t run a political blog, and I do not count political activism in my top three responsibilities on a day-to-day basis.  I am a nurse case manager. I wear a few different hats, including assisting with care coordination of private clients, facilitating the transformation of professional case management practice, and  educating healthcare professionals as to the purpose and value of case management in healthcare delivery… to name but a few. With that in mind, what I have learned over the years is that where healthcare is concerned, political activism is an absolutely necessary responsibility of any healthcare professional… and the skills learned in the process of advocacy are invaluable. Where the Improving Access to Medicare Coverage Act is concerned, advocacy is more important than ever.

So, what is up the Improving Access to Medicare Coverage Act about… and why should you care? Let me address why you should care first.  

If you or a loved one is covered by Medicare and have experienced a health crisis, it may have resulted in a trip to the doctor’s office or hospital emergency room.  Once evaluated and treatment initiated, the next step is to determine the appropriate disposition for care delivery.  A person may be admitted to the hospital as an inpatient or to observation status as an outpatient. Observation status is utilized when it is unclear that the level of care required by a patient rises to the intensity and severity required to meet inpatient status criteria. When admitted to inpatient status, the patient begins a three-day count down to qualification for coverage of a subsequent skilled nursing facility (SNF) admission.  When your loved on is placed in observation status, there is no count down because they are still considered an outpatient as far as their hospital status is concerned. So, if SNF level care is deemed to be an appropriate next step, they will NOT qualify for Medicare coverage of that SNF admission and will have to bear the financial burden for that care as an out-of-pocket expense. This can add up to tens of thousands of dollars in medical expenses being the full responsibility of your loved one.

If you want to read up more about how the three-day rule impact, just look to the case Bagnall v. Sebelius (No. 3:11-cv-01703, D. Conn), filed on November 3, 2011. A summary of this may be found at: http://www.medicareadvocacy.org/medicare-info/observation-status/. The topic was covered at the Kevinmd blog: http://www.kevinmd.com/blog/2010/10/observation-admissions-affect-medicare-patients.html and in a Bloomberg report article http://www.bloomberg.com/news/2010-07-12/hospital-fraud-audits-spur-unintended-cash-penalty-to-elderly-on-medicare.html written by Drew Armstrong on July 12, 2010.

And what of these two pieces of proposed legislation…

These bills (S. 818 and H.R. 1543) were introduced in April 2011. The intent of this is as an amendment to Title XVIII (Medicare) of the Social Security Act is to addresses the longstanding and egregious coverage gap experienced by Medicare beneficiaries who are kept in observation status at acute hospitals and are unable to qualify for SNF level care which in an overwhelming majority of instances is the most appropriate level of care for that person. This amendment effectively eliminates the three-day rule for beneficiaries in observation status over 24 hours.

This is not an issue of care quality or access to some services but not others… but rather it is a matter of out-of-pocket cost to the beneficiary and uncovered care cost for the hospital.  In instances when a beneficiary has a qualifying inpatient admission, Medicare pays 100 percent of the payment rate for the first 20 days of care at a SNF and from day 21, the beneficiary is responsible for copayments (currently the copayment is $144.50 per day). When left in observation status, the beneficiary is not entitled to this coverage for the SNF admission. As a nurse case manager, I have had to work around the “three-day rule” for as long as I can remember. The beneficiary has little to no control over the status to which they are admitted and it has resulted in a tug of war between hospital administrations and admitting physicians for over a decade.  In the end, no one is winning this battle.  The hospital is often not reimbursed for care that does not meet intensity and severity criteria, the beneficiary is ‘stuck’ in an acute hospital setting consuming more resources than necessary simply because they are not safe for discharge to home and not qualified for a covered discharge to SNF care.

The current three-day rule has resulted in ongoing transition of care challenges because beneficiaries remain in observation limbo for days on end. These two bills (H.R. 1543 and S. 818) address this coverage gap by allowing observation care over 24 hours to count toward the three-day admission qualification requirement for coverage of skilled nursing facility services under Medicare.

What can you do???

As I noted at the start of this entry, advocacy is essential in today’s healthcare environment. This is an opportunity to take action because these respective bills need your help. Sponsors are signing on but more needs to be done.

1. Contact your legislator to support the passage of this bill. You can track the progress of legislation at GovTrack.us: http://www.govtrack.us/congress/bills/112/hr1543?utm_campaign=govtrack_email_update&utm_source=govtrack/email_update&utm_medium=email. 

2. Go to the American Health Care Association website: www.ahcancal.org and visit their Advocacy resource page which provides formatted letters and the means to send your legislators a clear message to support this legislation.

Now get out there and creatively collaborate!

Ascent Care Man…


Ascent Care Management, LLC is a case management consulting company.

Ascent provides a wide range of services in support of high quality care management. Formed in 2009 following years of corporate and practice management experience, Ascent combines expertise and experience to develop meaningful solutions tailored to each client’s needs. Ascent provides consultative services related to case management in hospital, payor, and medical group practice settings to align case management practice within the framework of the patient-centered primary care home / Accountable Care Organization rubric. We enhance quality through alignment with healthcare regulations and accreditation standards to deliver cost-reducing care management strategies.

So what is the blog for?

The desire is to provide unfiltered information as to what case management really is… and what it is not.  So much attention is being showered on case management as a result of the Patient Protection and Affordable Care Act that it seems everyone has put a stake in the ground as to their territory. . . unfortunately a large number of these sources simply seem to be jumping on the care coordination bandwagon because it is the latest buzz in the healthcare industry.

There is also the matter of organizations using — or should I say misusing — the title of “Case Manager”.  Heck, even I get dizzy looking at all of the current iterations that claim case management as answer, when it is not case management that is being performed. Sadly, this has become a major source of confusion for our valued clients and potential clients, who just don’t understand what is really involved in being a case manager.

The blog will also take a look at the core functions and competencies of what real case management is about in terms of professional and collaborative practice across the healthcare continuum.

Finally, the topic of case managers themselves… who we are, why we got into case management to begin with, and how we can take better care of ourselves as more and more demand is heaped upon us.  Believe me, if we don’t take care of ourselves and eachother, there isn’t a line forming of those who are willing to step up and do it.

So, lofty goals – perhaps. Worthy ones – definitely!

Stay tuned… this promises to be an interesting journey.

Now, get out there and constructively collaborate!