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ACEP Now: Vol 33 – No 11 – November 2014

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1. Among those that do permit patients to take their own medications, some allow only nonformulary drugs, while others exclude controlled substances (eg, opioids, sedatives).
2. One approach is to not order noncritical home medications. Another is to reduce the amount patients are ultimately billed for these medications.

Until a policy solution is implemented, providers are left to identify local solutions. Four main strategies are being utilized: do nothing; allow patients to take their home medications (if they happen to bring them in); bill at a reduced rate; or not bill at all. The second option introduces significant logistical barriers because the Joint Commission and the Centers for Medicare & Medicaid Services both require medication verification, a time-consuming activity. After verification, medications typically still require specific orders, nursing involvement in their administration and documentation, and secure storage. Billing at the lowest contract rate or at hospital cost is another option that could mitigate patient fears but still leaves some potential exposure for those patients on many or particularly costly medications, and it does not account for the fact that patients already paid for the medication when they filled the prescription. Providing medications at no charge shields patients while shifting responsibility entirely to the hospital.

Reducing the exposure to this problem is a challenge to which no obvious solution exists. Advocating for our patients to find a workable solution and building a consensus across emergency physicians and nurses, pharmacists, and hospital administrators is no simple task. You should know how this issue is addressed at your hospital, and if a policy isn’t in place, now is the time to start working on one. If patients have not yet asked you how an observation stay will affect their out-of-pocket costs, just wait—one will soon.

Dr. Natsui is a Harvard-affiliated emergency medicine resident at Brigham and Women’s Hospital/Massachusetts General Hospital, in Boston.

Dr. Baugh is director of observation medicine in the department of emergency medicine at Brigham and Women’s Hospital.

References

1. Feng Z, Wright B, Mor V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff. 2012;31(6):1251-59.
2. Ross MA, Hockenberry JM, Mutter R, et al. Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions. Health Aff. 2013;32(12):2149-56.
3. Wiler JL, Ross MA, Ginde AA. National study of emergency department observation services. Acad Emerg Med. 2011;18(9):959-65.
4. Centers for Disease Control and Prevention. National hospital ambulatory medical care survey: 2008 emergency department summary tables. Table 26: Visit volume and metropolitan status of emergency department visits, by selected characteristics: United States 2008.
5. Mace SE, Graff L, Mikhail M, et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;21(7):529-33.
6. National Center for Health Statistics, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Health, United States, 2013: in brief.
7. Jaffe S. $18 for a baby aspirin? Hospitals hike costs for everyday drugs for some patients. Kaiser Health News. April 30, 2012.
8. Wright S. Memorandum report: hospitals’ use of observation stays and short inpatient stays for Medicare beneficiaries, OEI-02-12-00040. Department of Health and Human Services, Office of Inspector General. July 29, 2013.
9. Baugh CW, Schuur JD. Observation care: high-value care or a cost-shifting loophole? N Engl J Med. 2013;369(4):302-5.
10. United States Cong. HR 1179 and S 569. Improving access to Medicare coverage act of 2013. 113th Cong, 1st Sess.
11. Center for Medicare Advocacy. Observation status & Bagnall v. Sebelius. Available at: http://www.medicareadvocacy.org/medicare-info/observation-status. Accessed October 23, 2014.