"A elderly patient breaks her hip at home and happens to be both a diabetic and a cardiac patient. The medicare will ONLY cover treatment for the hip and will not cover medication for the other conditions. And they are NOT allowed to bring medication into a hospital. This leaves the other conditions untreated, or they have to pay directly out of pocket."
Medicare reimburses hospitals for inpatient care based on a number of categories of payment but the main one is called a Diagnostic Related Group.
Each DRG has a weight factor that is multiplied by a base payment to determine the payment for the case. The DRG assignment is based upon a computer calculation that looks at various things like what made the patient come to the hospital, what the problem really was, were there complications during the stay and were there "co-morbidities." The presence of some of those types of things can push the patient into a higher DRG category resulting in a greater payment.
What I believe they are trying to is separate out pre-existing comorbidities - diabetes would be one in this case - from specifically defined comorbidities usually acquired in the hospital. It appears that they do not want the impact of some hospital acquired problems factored into the DRG payment. Their argument is that hospitals need incentive to increase quality. Beginning in on 10/01/07 in a rule passed last year, they required hospitals to add information about all conditions upon admission. So,in your example, the fact that the patient was a diebetic upon admission propably entitled the hospital to a somewhat higher payment for the care for her hip. That is not changing and her care won't be affected. What would change is if she developed a new condition while in the hospital. 'Simple pneumonia' would be a classic example. What the proposed rule is saying is that the pneumonia (note: I'm using that as an example not saying that they aren't paying for pneumonia) could not be added to the computer formula which spits out what the hospital will get paid. On the surface, they are saying that this is an incentive to better quality of care. However it is also a disincentive to doctors who might regularly identify some condition or another in the patient records which they know will cause the hospital to earn more money. They appear to be trying to identify a set of specific co-morbidities which they are suspicious of. If this provision was to be included, it would result in the hospital getting less money, not the MD. The condition would be taken care of and covered by whatever Medicare paid them. The coverage issue I believe is between Medicare and the hospital, not the patient.
Part of what I said above is based upon this article, whic is somewhat technical but well written:
http://www.raconline.org/news/news_details.php?news_id=6244"Also, in the case of hip replacement, they are only allowed to remain in the hospital for three days, then they must go to a rehabilitation center and are only covered for three days worth of pain medication following that surgery. Any additional pain medication is also out of pocket.
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The only thing that I saw in my limited reading regarding inpatient rehab hospitals is that they changed somewhat how they got paid recently. My first thought when I read what your wrote was that your friend worked at a hospital which was also affiliated with an inpatient rehab unit which was hoping to move the patients out of the acute care setting and into the rehab setting for some financial reason. (Does she work at a for profit hospital?) All medication however while you are in the hospital is generally included in the covered charges. I'm hard pressed to believe that Medicare is telling doctors that they are overriding their med orders with no knowledge of the case.
HTH
PT
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