TIME AND RISK

With the 2 midnight rule, CMS declared a (somewhat) bright line between hospital stays that were “observation” and those that were “inpatient”. By “bright line” I assume they meant something clearer than 

“complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting.” 

In the past CMS has attempted to clarify this a bit by stating “the decision to admit a patient should be primarily based on the severity of illness and intensity of services rendered”.  Based on how the Feds language in publications is construed, one could conclude these items (severity of illness and intensity of service) define “medical necessity”.

Managed Care, through Medicare Advantage plan management, has pushed back on the 2 MN rule, even with the “Final Rule” of 2024 requirements.  The response of Managed Medicare plans has been to focus on “medical necessity” and the permission they have to continue using their “clinical criteria”.  But something is missing in this “discussion”: Risk 

As an illustration of “risk” I present two common conditions:

• 71 year old female who presents with encephalopathy, abdominal pain with an elevated WBC and a positive urinalysis.  Classically such a patient  is placed in a hospital bed, given IV antibiotics, IV fluids and other appropriate measures all while waiting for clinical improvement and final urine and blood cultures to determine a safe discharge plan.  This medically appropriate care will typically take 2-3 days and uniformly two midnights.

• 71 year old female who presents with acute right-side weakness and aphasia with an MRI confirmed ischemic stroke who continues with her deficits but does not deteriorate in the 1st 24 hours.  In an efficient stroke program such a patient can have an appropriate and safe discharge to a post acute rehabilitation setting in the first 2 days, usually 2 midnights but occasionally less than.

I assume we’d all say the second patient is “sicker”.  I believe that is true but when I drill down on those assumptions, especially in light of the rules for inpatient as described above, I find it less clear.  Is there a scale to measure “intensity of services” or one for “severity of illness”?  I would suggest we more often than not use the “gestalt” method, (i.e. “she just IS sicker”)  One aspect of these cases that can aid us in this (and one that CMS in other publications mentions) is “risk”.  I would suggest that the second patient does run a risk of serious, life threatening neurological deterioration and death.  The first patient is not risk free but research would support that the second patient is at greater risk than the first.    Thankfully, the usual criteria tools that Managed Medicare plans use (MCG and Interqual) would also support inpatient status for the second patient.

So why bring this up?  Well first let me state emphatically that I’m not trying to declare that the first patient isn’t inpatient appropriate and that, therefore, I’m fine with Managed Medicare plans denying inpatient status on such a patient.  I’m not.   My real purposes are two-fold

1. How do we better document our risk concerns in documentation to support acute inpatient status, even when we may not expect a 2 midnight stay?

1. What is the “care”  that we use to address this risk?  Does acute inpatient status in and of itself address this risk?  Would our care for the stroke patient be any different if we put them in observation status?  What is the “definable” clinical reality the inpatient status confirms that is not there with an observation order?

Finally, I would suggest that if we can’t easily answer these questions we will find what I call “the reverse cliff” when our more and more efficient care leads to shorter and shorter stays as we’ve seen with patients like our stroke patient.  In doing so will we invite payers to say “no” when we ask for acute inpatient status?