7. Pay Cut for ‘Two-Midnight’ Rule for Observations Is No More
CMS announced a proposed rule in April that would have Medicare stop imposing an inpatient payment cut to hospitals under the “two-midnight” rule, according to a report in Modern Healthcare.10 The final rule went into effect in October.
The rule, which continues to be a contentious issue for hospitalists even with the pay cut being eliminated, was put in place in October 2013 to define which Medicare beneficiary hospital stays are appropriate for Medicare Part A payment by stating that if the physician expected the patient to stay for fewer than two midnights, then the services should be billed as outpatient (Medicare Part B) and not inpatient.
For two years, the only exception to the pay withhold was for those diagnoses that CMS designated as “inpatient only.” An overhaul of the rule in October 2015 stated that exceptions could be determined by the physician (or other practitioner) on a “case-by-case basis.”
But a legal challenge and withering criticism from SHM and other professional organizations prompted CMS to undo the withheld payments associated rule.11–13 In fact, hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates of the last three years. SHM has said it will continue to advocate for further changes to the rule.
8. Medicaid Expansion Takes Hold
Thirty-one states and the District of Columbia, under the auspices of the Affordable Care Act, have expanded Medicaid. One 2014 study in states including Minnesota, Kentucky, and Arizona showed a dramatic decrease in uninsured hospital stays and a significant increase in Medicaid stays. Meanwhile, in six states that did not expand, including Florida, Georgia, and Missouri, there was no significant change in payor mix.14
“What a lot of these early studies are saying is that when you expand Medicaid, people get on Medicaid, and that’s exactly what you hope will happen when you do a major public coverage expansion,” said Sayeh Nikpay, PhD, MPH, assistant professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn., and a lead author of the 2014 Health Affairs study. “Physicians are grappling with payment issues, and it should be quite a relief that people are coming in the door with some kind of insurance rather than uninsured.”15
While expansion from 2015 to 2016 was the main story for Medicaid, many observers are now watching to see what President-elect Donald Trump will do. As a candidate, he campaigned to repeal Obamacare, and that may have significant impacts on the expansion of Medicaid.
9. Antimicrobial Stewardship Rules Upgrade
In July, The Joint Commission announced a new Medication Management (MM) standard for hospitals, critical-access hospitals, and nursing care centers that goes into effect in 2017.16,17 Its stated purpose is to improve quality and patient safety. The Joint Commission move came a year after President Barack Obama made combatting antibiotic-resistant bacteria a national issue.
“If you review the scientific literature, it will indicate that we’re in crisis mode right now because of this,” said Kelly Podgorny, DNP, MS, CPHQ, RN, project director at The Joint Commission. 16
The standard encourages the prioritization of establishing antimicrobial stewardship programs. It suggests staff members at institutions receive training and education on dispensing, administering, and monitoring antimicrobial resistance and antimicrobial stewardship practice. And, in turn, those staffers should look to educate patients and caregivers on appropriate use of antimicrobial medications.
Lastly, when possible, an antimicrobial team should take a multidisciplinary approach and include an infectious disease physician, a pharmacist, and a practitioner.