Community Forum Questions and Answers
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The following four questions were submitted at our community forum on March, 13.
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Question #1:
According to our Certified Public Accountant, (name withheld), the costs to a Medicare-insured patient who does not have Medicare supplementary insurance will change under "critical access hospital" status, as follows:
Currently a Medicare patient without supplementary insurance who is admitted to the emergency room, and subsequently transferred to inpatient status in the hospital, would pay a single deductible cost for admission. Under CAH status, the patient would pay two deductibles, one for admission to the emergency room, and a second for admission to the hospital (following "discharge" from the emergency facility).
Can you please clarify this for us, and if possible provide numbers on hospital admissions for patients in this insurance coverage situation?
Response:
This assessment is correct. Medicare guidelines for Critical Access Hospitals require a change in our current practice for patients enrolled in Medicare only, i.e., patients without a Medicare supplement insurance. When a patient is admitted as an outpatient and later becomes an inpatient we can no longer legally combine inpatient and outpatient services onto one bill. Medicare patients seen in our emergency room must now be officially discharged and then admitted under a new account number for their inpatient stay. Under these circumstances, the patient will be billed for two deductibles.
Approximately 80% of Medicare patients at Sutter Lakeside Hospital have supplemental insurance. We estimate that these circumstances would apply to fewer than 10% of our patients with Medicare.
Question #2:
Do most people (Medicare recipients) have a supplemental insurance policy that takes up the slack?
Response:
As mentioned previously, approximately 80% of our Medicare patients have supplemental insurance. Patients with Medicare only, may qualify for MediCal funding, or through a rare exception to Medicare rules, be entitled to charity care under the Sutter Health Charity Care and Low Income Uninsured Program.
Question #3:
What government group sets Medicare reimbursement rates?
Please explain the role of Hospitalists under the new plan?
Response:
The government agency responsible for setting Medicare reimbursement rates is the:
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore , Maryland 21244-1850
Toll-Free: 877-267-2323
TTY Toll-Free: 866-226-1819
Hospitalists are physicians who limit their medical practice to the care of those patients who require hospitalization. Hospitalists currently work in about half of all hospitals in the U.S. and comprise the fastest growing subspecialty of medicine. Their services are in demand due to the improvements noted in quality of care and patient satisfaction when hospitalists are utilized. Hospitalists work with the local physicians to bridge the gap between care provided in the medical office and the hospital.
Our hospitalists care for our patients throughout their stay. They partner with the Emergency Department physicians and a patient’s primary care physician (PCP) to provide a seamless transition from admission to discharge to outpatient follow-up.
Question #4:
Does Sutter Lakeside have any level of responsibility in the quality of care given after patient is transferred to our convalescent hospitals?
Response:
Each skilled nursing center is independently owned and has overall responsibility, in collaboration with the patient’s physician, for the quality of care delivered to patients who are admitted there. Based on the responsiveness of the skilled nursing centers to physician requests and hospital requests for enhanced services and quality improvements, physicians often will share their opinion about which center he/she prefers with his/her patients. Because patients tend to choose facilities that their physicians and other care givers have confidence in, we do have some indirect influence on the quality of care provided.
When a patient qualifies for discharge from the hospital, our case managers review all of the options with the patient (and the patient’s family, if appropriate). Some of these options include going home with Home Health nursing, spending a short period of time at a skilled nursing center for rehabilitation after a prolonged hospitalization or major surgery, or being admitted to a skilled nursing facility for custodial care. By law, our case managers are required to review all options with patients and present all of the Home Health agencies and skilled nursing centers that are available. In the end, the patient makes the final choice of what discharge plan to follow. We do not use skilled nursing centers for patients who require hospital level care.
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