PHILADELPHIA — On the evening of Jan. 3, Fran Bogom, 86, a resident of the Abramson Center for Jewish Life in Horsham, was sitting on her bed watching television when she dozed off, fell, and broke her arm.
Bogom, a widow with mild dementia, arrived at the Abington Memorial Hospital emergency room at 9:21 p.m.
Doctors decided to keep Bogom overnight, placing her in observation status, essentially making her an outpatient, and figure out the best plan in the morning.
If Bogom were covered by Aetna, Blue Cross or another private insurer, she would have been approved right away for a move to a nursing home, to help her get better.
But Bogom had Medicare.
And because of a regulation dating to 1966, Medicare would not pay for her rehabilitation in a nursing home unless she first stayed in the hospital for three days.
If Bogom stayed only one day at Abington, or two, she would have to pay the rehab bill herself. Her family feared it might be $5,000, even $10,000. It turned out to be far more.
So the stakes were high. Could she stay put at Abington for three days?
To appreciate Bogom's predicament, which has arisen in virtually every American hospital, one needs to see it in context.
The new health care law — besides expanding insurance coverage — triggers many experiments to deliver better care at less cost. But redesign will take years, if it is even possible.
More immediately, America faces soaring health costs.
Medicare spent $509 billion last year on care of America's elderly. More money flows out every year, so the agency running Medicare is becoming more rigorous in policing payments to hospitals and doctors.
It has empowered teams of auditors — review audit contractors, known as RACs — to examine hospital claims.
Most private insurers follow patients in real time, often requiring authorization for procedures, tests and drugs.
Medicare is different. It sets out exhaustive rules, and hospitals, doctors and rehab facilities promise to code and bill accurately.
If Medicare finds that a hospital billed for a patient who did not need to be admitted, or failed to document a claim, it can refuse payment for the entire stay and impose a fine. Even if the mistake was unintentional.
At Abington, six nurses inspect patient charts daily to ensure the best care and to make sure each has the documentation to satisfy Medicare and other insurers.
Also, a utilization committee reviews whether people like Bogom need to be there.
On Monday morning, Jan. 4, Daila Pravs, a family physician, visited Bogom and formally admitted her.
Bogom was born in Buffalo, and as a young woman in the 1950s worked in New York City in the public relations department of the Israeli Bonds Office. She met Golda Meir and talked on the phone with Albert Einstein. (The family joke is that she put him on hold.)
After getting married, Bogom and her husband returned to Buffalo, where she helped him run his accounting business and raise their children. After her husband died, she remained active, ushering at Broadway shows that came to Buffalo, delivering meals on wheels.
In recent years, osteoporosis, diabetes and dementia got the best of her. Her children last year moved her to Abramson. Her son lives in Philadelphia and her daughter in central New Jersey.
When she fell, Bogom was living alone in an assisted-living apartment.
Doctors were concerned with why she fell and quickly determined she could not go back home because she would need 24-hour care. What if she fell again and broke a hip, a death sentence for many elderly?
In the hospital Monday, Pravs ordered a workup to make sure neither stroke nor heart attack had caused the fall. She wanted Bogom, still disoriented and unable to walk, assessed by physical therapy.
On Tuesday, Pravs saw Bogom again. She wrote in the medical record: “Patient without complaints other than arm pain. ... Will require snf (skilled nursing facility) upon discharge. If bed available may discharge today.”
In theory, every patient in America must meet two qualifications to be admitted to a hospital. And in practice, every insurer wants to make sure these qualifications are met before paying.
Is the patient sick enough to need a hospital?
Is the hospital providing enough care to justify a patient's being there?
From day one, Abington's utilization committee wondered if Bogom met the criteria.
She “needed somebody to help with meals, toileting, bathing and rehabilitation,” said Kevin Zakrzewski, a primary-care physician who also heads the utilization review committee. “That is not what is considered hospital level of care. Compare that to someone who has a heart attack.”
The staff also realized she couldn't go home because she didn't have the support.
“So the hospital is really stuck,” Zakrzewski said. “And now the patient and family are stuck.”
He imagined a Medicare auditor asking Abington: “ ‘This patient was ready to be discharged on day two. Why didn't you discharge her?'
“Then they're revoking payments to the hospital, and we're eligible for a fine.”
Many hospitals share Abington's concern.
“The incentive for not admitting somebody and not keeping them for the full three days has actually grown even more as people anticipate the RAC audit,” said Carolyn F. Scanlan, chief executive officer of the Hospital and Healthsystem Association of Pennsylvania.
She called the three-day rule “quite obsolete.”
By Tuesday, Jan. 5, nurses and social workers who handle discharge planning were in touch with the patient's daughter, Rachel Bogom: Her mother would be discharged, probably that day, and would pay out of pocket for rehab.
This seemed absurd to Rachel Bogom.
Her mother had worked all her life, paying into Medicare. She was now paying her monthly Medicare premium. In Rachel Bogom's mind, her mother had insurance precisely for situations like this.
“It's maddening, really,” she said. “Because if somebody needs rehab after 24 hours, or 48 hours, just let them go. Why wait for 72 hours?”
When Congress created the nursing-home benefit in 1966, it was to be a final step before going home after a long hospitalization.
At this point, the recovering patient would not need a hospital. A nursing home's rehab unit would cost less.
Congress wanted everyone to understand this nursing home stay would be temporary, and not for frail elders who could no longer care for themselves and would spend their last days in a nursing home.
The fear was that families would put an elderly loved one in the hospital for a day just to qualify for Medicare's nursing home benefit, which pays for up to 100 days of care. Families would save thousands of dollars.
So the government created the three-day rule. It also stipulates the stay must be “medically necessary” so patients don't linger in the hospital just to get the rehab benefit.
But in 1966, nobody envisioned 2010, when hospital stays are much shorter.
Congress has given the Centers for Medicare & Medicaid Services, which runs Medicare, authority to end the rule — but only if this does not increase the cost.
Medicare — taxpayers — spent $25 billion in 2009 on this short-term nursing-home benefit, CMS said.
Covering beneficiaries such as Bogom after one day, or two, would increase that burden.
Hence, the three-day rule remains.
Copyright ©2012 Omaha World-Herald®. All rights reserved. This material may not be published, broadcast, rewritten, displayed or redistributed for any purpose without permission from the Omaha World-Herald.
