Approaching obs vs inpatient discussion with patients

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

EM4life

attending
10+ Year Member
Joined
Jan 13, 2011
Messages
122
Reaction score
49
Wanted your opinions on how you approach these discussions when a patient doesn't feel comfortable being discharged or don't fully meet inpatient criteria but want to be admitted, how do you approach informing the patient that an observation stay would mean a greater out of pocket cost? Do you do it at all? I've had some discussions with patients and families, most of them going well, few select patients are frankly upset and completely misunderstand my intention to purely inform. What do you guys think is the best way to go about this? Thanks!

Members don't see this ad.
 
Any financial info you're giving the patient is going to be misconstrued by enough of your patients to not be worth it. Stand strong on the medical aspects where you are the expert. The financial intricacies change often enough and are emotionally charged enough that it's best to leave alone.
 
Last edited:
Tell them it'll cost more to sign out AMA... ;-)
 
Members don't see this ad :)
Inpatient for all. Never checked the "I predict that this patient will be here for less than two midnights because..." box.

Why? Because I don't have a crystal ball. And its absurd to demand that I try to peer into one when I've had 2 hours to spend with a patient, and need to make a judgment about... whatever.

I'm a real patriotic guy, but maaan, do I hate what Uncle Sam has become these days. Its unreal. Unreal.
 
Inpatient for all. Never checked the "I predict that this patient will be here for less than two midnights because..." box.

Why? Because I don't have a crystal ball. And its absurd to demand that I try to peer into one when I've had 2 hours to spend with a patient, and need to make a judgment about... whatever.

I'm a real patriotic guy, but maaan, do I hate what Uncle Sam has become these days. Its unreal. Unreal.

CMS disagrees with you and may consider this fraud. They expect the ED physician to know when the initial admission is made whether the patient will be an inpatient or observation stay despite the fact that we never take care of these patients once they are admitted.
 
CMS disagrees with you and may consider this fraud. They expect the ED physician to know when the initial admission is made whether the patient will be an inpatient or observation stay despite the fact that we never take care of these patients once they are admitted.

Exactly.

I consider what they do fraudulent.
 
  • Like
Reactions: 1 user
Inpatient for all. Never checked the "I predict that this patient will be here for less than two midnights because..." box.

Why? Because I don't have a crystal ball. And its absurd to demand that I try to peer into one when I've had 2 hours to spend with a patient, and need to make a judgment about... whatever.

I'm a real patriotic guy, but maaan, do I hate what Uncle Sam has become these days. Its unreal. Unreal.

Unfortunately we need to know the criteria for inpatient vs. obs.
You can check whatever you want, but if they don't meet inpatient criteria nobody is getting paid.
 
Nobody is getting paid. And nobody along the line is going to stand up, be honest, and say: "Okay, listen: this is absurd, and you can't predict Y from X 2 days ago."

Time to hold the government's feet to the fire. On so many levels.

Hey, federal government... GTFO.

Every G.I.Joe from the WWII days and beyond paid into your scheme... and now, you (politicians) vote your own golden parachutes and pay-raises into reality while the boomers and post-boomers look around and say - "Wait... stars-and-stripes forever... what happened ?!"

Every congressman. Every senator. Every representative. Every governor. Ever mayor. Every whoever.

Get real. Or get out.
 
The admitting doctor should be checking this box, not the EP. It's the admitting doc that has control over when they are discharged in the first place. If you must check this "Obs," vs "Admit" box, just make a quick decision. Most people by far, will stay beyond the Obs cutoff. If you're sure they will likely leave short of that, put Obs. I was always told that if they stay longer, it just defaults to an "admit" anyways, doesn't it?

Realistically, I don't think the ER doctor should have to have a lengthy discussion of the economic of "admit vs Obs" with a patient. All insurance plans could be different anyways. There's no way for you to predict, at the bedside, what the bill ultimately will be to the patient. If they have detailed questions, turf to the administrator on call. Or they can call their insurance company or Medicare and complain to them that their coverage sucks. It's not your job, though I wouldn't doubt it if there's some administrator somewhere trying to get ER doctors to perform this job as on of the many form of uncompensated care being heaped upon doctors, especially EPs. If the patient has a problem or complaint based on this type of issue, administration and the billing people need to pre-empt this stuff at the point of admission. This is an "NMP" (Not My Problem).

This is a sign of the times, as the level of lunacy of insurance, particularly Medicare/Medicaid reach unfathomable proportions.

Read this:

http://newoldage.blogs.nytimes.com/...bservation-status/?_php=true&_type=blogs&_r=0

Just remember, as these people confuse, jumble and destroy our healthcare system more and more, be prepared for when they, ie, the Government, propose that the only solution to the crisis they singlehandedly worsened, is that we allow them to be more involved and take complete control. Be prepared to say, "No." The amount of damage this crew is doing to our healthcare and insurance system is catastrophic.
 
Nobody is getting paid. And nobody along the line is going to stand up, be honest, and say: "Okay, listen: this is absurd, and you can't predict Y from X 2 days ago."

Time to hold the government's feet to the fire. On so many levels.

Hey, federal government... GTFO.

Every G.I.Joe from the WWII days and beyond paid into your scheme... and now, you (politicians) vote your own golden parachutes and pay-raises into reality while the boomers and post-boomers look around and say - "Wait... stars-and-stripes forever... what happened ?!"

Every congressman. Every senator. Every representative. Every governor. Ever mayor. Every whoever.

Get real. Or get out.

Agree with one caveat: We shouldn't throw all of them out. It's very easy to decide who to throw out in this Fall's election. If you voted for Obamacare, "You're fired." If you voted against it, you keep your job.
 
I agree with above posters, I would like nothing more than to not even have this discussion with patients, because I'm treating them the same no matter what, but there is some pressure at our institution from hospitalists to have this discussion, which is very very frustrating.
 
CMS disagrees with you and may consider this fraud. They expect the ED physician to know when the initial admission is made whether the patient will be an inpatient or observation stay despite the fact that we never take care of these patients once they are admitted.

Agree. At my shop Ed doc asks me in phone do you want Inpt or obs. I make my best guess from what data I have at that moment but it's really a guess. And the two midnight rules makes the problem worse. If you call me for admission at 12:02 am and I say inpatient, they have to stay two more nights before they are discharged, or else they come after us for why this pt wasn't observation. Whereas if you call me at 11:58 pm and I say Inpt they can go home the morning after and have had two mid nights. The system sucks. We have case managers who help us make the decision in the Ed but they are often wrong, how could one be right it's often a guessing game and sometimes they look over there data two closely and not the pt.

For instance if I admit a 40 year old COPD exac at noon who I am fairly certain will be able to go home the next day, they will state based in level of hypoxia and whatever else's pt should be Inpt. Then I dc them the next day as I said I would, and I get crap from CM about two mid nights.
Also there are other sideshow issues. For instance to dialyse someone in the hospital they have to be inpatient. So if you send me a chest pain obs at 4am, who won't rule out till around 6pm, and it is there dialysis day, they have to be inpatient to get dialysis paid for, but that also means they need to stay two nights in addition to the night they spent in the Ed with you,as they came to me after midnight.

The whole system sucks and it's putting another constraint on you guys as well as me to guess how long this pt will be in the hospital for, in reference to what time they came in before/after midnight.

We do not however, discuss that with the pt. if they need to come in, they come in, whether it's Inpt or obs. The fact that they get a big bill for an obs admission when they could have had two sets of trops and sent to office for an outpt stress is not our fault. That's them system we are apart of. We have such pressure to get pts out of the Ed here that that wouldn't really be an option anyway. Administration wants you to admit me the pt to rule out, then dc them for the stress outpt the next day. Who suffers? The pt. but not the Ed doc or hospitalists fault, it's just the system.
 
Members don't see this ad :)
Its a ridiculous system.

We have case management in the ED most evenings to help.
We are NOT the experts in this (we = ED docs).
That said, we try to help the hospital by making the obvious things OBS status.
What are those things? (1) Chest Pain (2) Syncope (3) cellulitis (4) back pain (5) fall-down-go-boom-no-findings-but-is-90-and-lives-alone

Assuming your ED workup is negative, and there is nothing odd about the case, most of the above Dx's are typically OBS.

We do have the ability to do OBS in our ED but it is limited by physical space, so we rarely do more than a couple a night (typically we try and do chest pain rule outs that way, for the younger / lower risk, though sometimes vomiting/diarrhea needing extended treatment, pyelo with vomiting, or cellulitis can be easy 16-20 hour ED OBS cases also. Intoxication is also generally kept as ED Obs, and of course the entire sideshow of psych holds).

I have many patients ask about OBS/inpatient now. I try to send the case manager if they are around. Otherwise, the #1 point I try to get them to understand is that despite the fact that I put them in obs/inpatient when I place the admitting order, their insurance can OVERRULE anything I type if they feel it doesn't meet their arbitrary criteria. I personally try to paint it as Us against Them, with the patient and I on the same side-- which is exactly how I feel about the entire system.
 
I have had several patients ask me about this in the past week whereas I had never had this question before. Was there some sort of 60 minutes documentary or news story I missed? Maybe just growing awareness...
 
This article actually does sum it up nicely as far as expenditures go for patients http://m.us.wsj.com/articles/SB10001424052702303376904579135732284488114?mobile=y

There is a subset of patients, mostly on Medicare who are used to how things were, hence the "I simply don't feel good" equates admission, whereas our system now requires objective criteria to warrant admission. These are the patients that I worry about, who if uninformed about the status of observation versus impatient, are hit with a huge bill and pissed in 2 weeks or are upset you can't somehow finagle an inpatient admit. It is frustrating bc this pt subset has a high bounceback rate anyway due to age and comorbidities. We are getting more pressure to have this conversation with our patients and it often can distract and hurt the physician patient relationship. Next time I will try the us vs big bad insurance conversation, but maybe I'll just avoid the whole issue all together.
 
I have no control if they get discharged in one day or ten. I guess on certain ones. If someone asks about the two statuses, I state the above. I do not have discussions with patients on this
 
This article actually does sum it up nicely as far as expenditures go for patients http://m.us.wsj.com/articles/SB10001424052702303376904579135732284488114?mobile=y

There is a subset of patients, mostly on Medicare who are used to how things were, hence the "I simply don't feel good" equates admission, whereas our system now requires objective criteria to warrant admission. These are the patients that I worry about, who if uninformed about the status of observation versus impatient, are hit with a huge bill and pissed in 2 weeks or are upset you can't somehow finagle an inpatient admit. It is frustrating bc this pt subset has a high bounceback rate anyway due to age and comorbidities. We are getting more pressure to have this conversation with our patients and it often can distract and hurt the physician patient relationship. Next time I will try the us vs big bad insurance conversation, but maybe I'll just avoid the whole issue all together.

<rant> So you're doing something that hurts the patient relationship, that you aren't well prepared for, and that you have very little ability to influence? I expect the threat of the government fining me into the Stone Age before I start acquiescing to those types of demands. And honestly, maybe if the patient has to pay for the expense they're generating then they'll improve compliance with outpatient regimens and not come into the ED to be admitted for psychosocial issues. </end rant>
 
...but maybe I'll just avoid the whole issue all together.

The asteroid that is this dysfunctional healthcare/insurance system is so far off course at this point, that there is little a 2 minute conversation with the ER doctor, at minute 120 of the hospital stay, that is going to prevent a person from being pissed off about their outrageous hospital bill that comes 6 weeks after they are seen in the ED.

Don't ER doctors have enough to worry about without having to be the safety net for this government disaster also, while having to deal with heart attacks, codes and cardiac arrests at the bedside?

Is that the next role for ER doctor?

Medicare complaint officer and billing department concierge?

It's enough to make my head explode.

Where is the breaking point for this insanity?
 
Not my decision.
We have case managers whose entire job is to determine if they meet criteria. They speak directly with admitting who makes that call.

If someone specifically asks, I tell them that it's not really my decision, and try to get case mgmt to talk to them.
 
This definitely should not be an EP's role. We are trained to determine who needs hospitalization. The inpatient course and its length is the domain of inpatient services.
 
At the military facility I work at this is a non-issue.
At the civilian facilities, my discussion with the admitting doc goes something like..

Me: What floor would you like me to admit them to?"
Admitting Doc: Umm, general medical.
Me: Ok, and would you like inpatient status or observation?
Admitting Doc: as their admitting doc, I appreciate that you are asking me for this determination as it is my responsibility and after lengthy consideration I have decided on...

Well ok, that last line is a bit of a lie. But I do ask the admitting doc to make the determination during my phonecall with them. And in my chart I write "Doc X requested that pt go to tele floor, obs status" or whatever they decide.
 
At first, I used to try and have this discussion. I don't anymore. All this is going to do is encourage people to sign out AMA, thereby increasing my malpractice risk.

I admit almost everyone as obs except for obvious medical train wrecks, big traumas and non laparoscopic surgical candidates. I'm more likely to make someone a full admit after 5 PM (when they are only 7 hours away or less from crossing that first midnight threshhold and there's no chance a specialist is going to see them until the next morning) than I am at 9 or 10 in the morning. It's a lot easier for the inpatient physician to upgrade the admit than it is for someone on the inpatient side to try and downgrade an admit (or so I've heard).

Nobody has complained about this strategy yet.
 
I expect the threat of the government fining me into the Stone Age before I start acquiescing to those types of demands.

They aren't going to have to fine anyone. They're going to get universal compliance with CMS, obamacare, etc - all they have to do is threaten to take away that little DEA card you pay for every few years.
 
I have had several patients ask me about this in the past week whereas I had never had this question before. Was there some sort of 60 minutes documentary or news story I missed? Maybe just growing awareness...

We had commercials about it and it was on the news. I get asked quite often at one location, not as much at another.
 
Top