Get Grandma Out Because There Are No More Copays Coming

Fundamentally, the US healthcare system is flawed. Access to mental health, obstetrical and gynecological care, essential health services for underserved populations, and comprehensive care for the elderly are where most of the gaps exist. A recent study looked at the discharge patterns of Medicare beneficiaries requiring skilled nursing services. Medicare pays for 100 percent of the fees billed for skilled nursing for the first 20 days following hospitalization. After the initial 20 days, the patient is responsible for a copay that is around $150 per day. 

While this study was not a controlled experiment that evaluated the outcomes related to the timing of discharge on population health, it did examine the demographics of those discharged on days 19, 20, and 21. Disproportionately, the group released on day 20 were made up of those who were economically disadvantaged, were racial or ethnic minorities, and had multiple medical conditions. Not surprising, the group also included those without supplemental insurance or the means to pay the required daily copay. 

One interpretation of the data is that skilled nursing facilities tend to discharge Medicare patients too early because covered benefits have been exhausted. Alternatively, some facilities could be retaining patients until their benefits end when medically speaking they could be released earlier. One thing is for sure if someone lacks a supplemental policy to Medicare, discharge at or near the time benefits change is standard practice and may be worth investigating for potential fraud or neglect. If patients are being discharged too soon and do not have adequate support to care for themselves, this practice will negatively affect some of our most vulnerable populations. Alternatively, if some skilled nursing facilities are taking advantage of those same people, they are directly increasing the risk of complications such as repeat hospitalizations, infections, and falls, and creating an environment ripe for fraud. Is it time to task the Medicare Fraud Task Force or Adult Protective Services to investigate? 

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Cynthia R Stuart DO

Dr. Stuart is Board Certified in Family Medicine. Originally from Georgia, she spent most of her youth in Miami, Florida and has been a Texas resident since the early 1990s. She attended UNTHSC-Fort Worth and completed her residency at UTSW/Methodist Hospital System where she was Chief Resident in her senior year. She is an Associate Professor at UTSW and UNTHSC, participating as a preceptor for medical students and residents. She completed a two-year course at SMU Cox School of Business in Advanced Leadership that enables her to advocate for quality health care providers and local public health programs in her community. She is the head of the Credentials Committee, sits on the Medical Executive Committee and the Ethics Committee at Baylor Scott and White Hospital of Carrollton. She has appeared on numerous news and radio programs to educate the public about various health topics. Dr. Stuart has managed her private practice in Carrollton since 2005 and is now a Direct Primary Care Physician.