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The origin and disposition of Medicare observation stays.

ABSTRACT: Growing use of hospital observation care continues unabated despite growing concerns from Medicare beneficiaries, patient advocacy groups, providers, and policy makers. Unlike inpatient stays, outpatient observation stays are subject to 20% coinsurance and do not count toward the 3-day stay required for Medicare coverage of skilled nursing facility (SNF) care. Despite the policy relevance, we know little about where patients originate or their discharge disposition following observation stays, making it difficult to understand the scope of unintended consequences for beneficiaries, particularly those needing postacute care in a SNF.To determine Medicare beneficiaries' location immediately preceding and following an observation stay.We linked 100% Medicare Inpatient and Outpatient claims data with the Minimum Data Set for nursing home resident assessments. We then flagged observation stays and conducted a descriptive claims-based analysis of where beneficiaries were immediately before and after their observation stay.Most patients came from (92%) and were discharged to (90%) the community. Of >1 million total observation stays in 2009, just 7537 (0.75%) were at risk for high out-of-pocket expenses related to postobservation SNF care. Beneficiaries with longer observation stays were more likely to be discharged to SNF.With few at risk for being denied Medicare SNF coverage due to observation care, high out-of-pocket costs resulting from Medicare outpatient coinsurance requirements for observation stays seem to be of greater concern than limitations on Medicare coverage of postacute care. However, future research should explore how observation stay policy might decrease appropriate SNF use.

SUBMITTER: Feng Z

PROVIDER: S-EPMC4134386 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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The origin and disposition of Medicare observation stays.

Feng Zhanlian Z Jung Hye-Young HY Wright Brad B Mor Vincent V

Medical care 20140901 9

<h4>Background</h4>Growing use of hospital observation care continues unabated despite growing concerns from Medicare beneficiaries, patient advocacy groups, providers, and policy makers. Unlike inpatient stays, outpatient observation stays are subject to 20% coinsurance and do not count toward the 3-day stay required for Medicare coverage of skilled nursing facility (SNF) care. Despite the policy relevance, we know little about where patients originate or their discharge disposition following o ...[more]

PMID: 25054826

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Project description:Background/objectivesObservation stays are increasingly common for older adults, yet little is known about the extent to which they are being used as the Centers for Medicare and Medicaid Services (CMS) originally intended for unscheduled or acute problems and whether different types of services are reflected in current billing practices.DesignObservational cohort study.Setting/participantsA total of 867,165 qualifying observation stays identified from 451,408 patients using Medicare fee-for-service claims data from a nationally representative 20% beneficiary sample between January 1, 2014, and November 30, 2014.MeasurementsUsing descriptive and multivariable logistic model analytic approaches, we evaluated the patient, stay, and hospital characteristics associated with the most common billing practice for observation stays (charge revenue center 0761 exclusively) vs all other practices.ResultsSixty-three percent of observation stays were billed exclusively under the 0761 revenue center and were more likely to be for preplanned chronic conditions consisting of short-term treatments (eg, chemotherapy, radiation therapy, wound care, paracentesis, epidural spinal injection). These stays appeared to be used for recurrent single-day visits, given their strong association with prior visits and a high rate of reobservation (41.4%), with frequent return stays appearing in a 7-day pattern.ConclusionNearly two-thirds of observation stays are billed using only the 0761 revenue code and appear to be for prescheduled, repeated treatments-differing substantially from CMS' explicitly stated purpose as a form of care used while a healthcare provider determines whether a patient presenting for unscheduled or acute conditions requires inpatient hospital admission or can be safely discharged. Guidance is needed from CMS to clarify the appropriate role of observation stays, with discussion as to whether episodic single-day, planned treatment for chronic conditions not originating in the emergency department should be billed as observation stays or placed under another mechanism. Subsequent research is needed to understand how the current use of observation stays impact patient out-of-pocket costs. J Am Geriatr Soc 68:1568-1572, 2020.

Project description:Objective To characterize rates and trends over time of emergency department treatment-and-discharge stays, repeat observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from observation stays.Design Retrospective cohort study.Setting 4750 hospitals in the USA.Participants Nationally representative sample of Medicare fee for service beneficiaries aged 65 or over discharged after 363?037 index observation stays, 2?540?000 index emergency department treatment-and-discharge stays, and 2?667?525 index inpatient stays from 2006-11.Main outcome measures Rates of emergency department treatment-and-discharge stays, observation stays, inpatient stays, any hospital revisit, and death within 30 days of discharge from index observation stays. Rates were compared with corresponding outcomes within 30 days of discharge from both index emergency department treatment-and-discharge stays and index inpatient stays.Results Among 363?037 index observation stays resulting in discharge from 2006-11, 30 day rates of emergency department treatment-and-discharge stays were 8.4%, repeat observation stays were 2.9%, inpatient stays were 11.2%, any hospital revisit was 20.1%, and death was 1.8%. Of all revisits, 49.7% were for inpatient stays. Revisit rates for emergency department treatment-and-discharge stays, repeat observation stays, and any hospital revisit increased from 2006-11 (P<0.001 for trend), while 30 day rates of inpatient stays (P=0.054 for trend) and 30 day mortality (P=0.091 for trend) were both unchanged. Averaged over the study period, 30 day rates of any hospital revisit were similar after discharge from index emergency department treatment-and-discharge stays (19.9%) and index observation stays (20.1%), as was 30 day mortality (1.8% for both). Rates of any hospital revisit (21.8%) and death (5.2%) were highest after discharge from index inpatient stays.Conclusions Hospital revisits are common after discharge from observation stays, frequently result in inpatient hospitalizations, and have increased over time among Medicare beneficiaries. As revisit rates are similar after emergency department and observation stays, strategies shown to enhance emergency department transitional care may be reasonable starting points to improve post-observation outcomes.

Project description:Most pharmacodynamic (PD) models of cellular response assume a time-invariant (i.e., constant) cellular disposition despite known changes in the disposition with time, such as the reticulocyte residence time in the systemic circulation during stress erythropoiesis. To account for changes in cellular disposition, a comprehensive PD model that involves endogenous erythropoietin (Epo), reticulocytes, and hemoglobin responses was developed in phlebotomized sheep that considers a time-variant reticulocyte residence time and allows for the simultaneous determination of changes in the cellular disposition and cellular production. Five sheep were phlebotomized to hemoglobin concentrations of approximately 4 g/dl. Epo concentrations, reticulocytes, and hemoglobin concentrations were frequently sampled for 5-7 days prior to and 25-30 days following the phlebotomy. Initial steady-state conditions were assumed and the time-variant reticulocyte residence time in the systemic circulation was semiparametrically represented using a constrained spline function. Hemoglobin production was modeled using a Hill function via an effect site compartment. The initial steady state reticulocyte residence time in the systemic circulation was estimated as 0.477 (0.100) (mean (SD)) days, which maximally increased 2.01- to 2.64-fold higher than the initial steady-state residence time 5.95 (0.899) days post-phlebotomy (P < 0.01). On average, the residence time returned to steady-state values 15.4 (2.36) days post-phlebotomy, which was not significantly different from the initial steady-state value (P > 0.05). The baseline hemoglobin production rate was estimated at 0.0929 (0.0472) g/kg/day and the maximum production rate under stress phlebotomy was estimated at 0.504 (0.0422) g/kg/day. These data indicate that endogenously released Epo under acute anemic conditions can increase hemoglobin production approximately 5-fold. The determined increase in reticulocyte residence time produced under stress erythropoiesis is similar to the commonly reported 2- to 3-fold increase observed in human patients.

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The origin and disposition of Medicare observation stays.

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The origin and disposition of Medicare observation stays.

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