A Matter of Context

What is the difference between being observed, and being admitted?

Observation:  an activity of a living being, such as a human, consisting of receiving knowledge of the outside world (including knowledge of other humans) through the senses, or the recording of data using scientific instruments.

Admission:  the act of allowing to enter; entrance granted by permission, by provision or existence of pecuniary means, or by the removal of obstacles: the admission of aliens into a country.  Or, right or permission to enter: granting admission to the rare books room.

This is an important distinction when it comes to being precise about the written or spoken word.  It is even more important when these terms are applied by your local friendly hospital.

Note:  In a hospital context, it is possible to be observed after being admitted.  In fact, it is unavoidable.  When admitted to a hospital, ones every move is observed.  Movements are of particular import.  The absence of an expected movement can indicate a blockage (the state of being blocked;  an obstructed condition: the blockage of the streets by heavy snows.  The blockage of bowls by impacted.......stuff).

Note:  In a hospital context, it is possible to be observed without being admitted.  One may, in fact, be physically "in" the hospital, having one's blockages examined by all sorts of scientific instruments, passing knowledge to one's doctor, being "in" without being "admitted", without permission to say one is "here" more than momentarily, even thought a momentary observation might last days, even weeks.

In a hospital context, your doctor may allow you "in", without an admission that you have been admitted "in", that you do not belong "in" for anything other than to be "observed".  If you happen to be on Medicare, and you happen to have something wrong that will require further assistance or treatment, or "rehabilitation" (I'll not burden you with another definition), but the hospital is only "observing" you, not treating you, then Medicare MAY NOT PAY FOR YOUR REHABILITATION.  You will, like Arlo Guthrie, be doomed to answer, possibly forever, the question "Kid, have you been rehabilitated?" with a resounding "no, officer, I don't have the do-re-me."

Case in point:  Martha Leyanna, Newark, Delaware, fell.  Went to the ER.  Was placed in the hospital. Stayed for eight (8) days (I guess it took a few days to figure out that she could not walk).  Spent 40 days in a rehabilitation center (to which her doctor no doubt sent her after determining that mere observation was not helping her get back on her feet).  When the $11,000 bill for rehab arrived, her Medicare insurance would not pay it.  Why?  Because she had only been observed for 8 days.  She had not been admitted.

Under Medicare rules, they will pay for the first 20 days of rehab in a skilled nursing care facility, but only if the patient has spent at least three (3) full days in the hospital as an admitted patient. So for Martha, who was "in" the hospital for eight (8) days, receiving all the care that any "admitted" patient would receive, in fact the EXACT SAME CARE, the fact that none of those eight days of hospital care  were as an admitted person meant that she was not covered.

Now, there are those who would say that she should pay her own way lest she become one of those 47% of Americans who feel entitled to food stamps and health care, who do not take personal responsibility for their lives, who take advantage of the insurance they have already paid for to in order to somehow sponge off the rest of us.  As a politically agnostic blogger, I take no position on that.  But, given the rules as they are, if you are insured by Medicare, it is important you know the rules.

So here is what AARP says to do if you are "in" a hospital:

1. Ask about your status daily.  Your status can change at any time, without your knowledge.
2. If you are being "observed," ask the hospital doctor why.  Ask him to have the committee that decides this status to reconsider.
3. Ask you own doctor (if you can remember who he/she is) the same thing.
4. If you have been "observed" but need rehab care, ask your doctor if the rehab care can be done at your home so it costs less.
5. Worst cast scenario:  Rehab center needed, Medicare won't pay.  Then:
1. "Following the instructions given in your quarterly Medicare Summary Notice, formally appeal the ruling.  Explain that the basis for your appeal is that you should have been classified as an inpatient during your stay at the hospital."  Simple.
2. If denied, follow the instructions on your denial letter to appeal to a higher level.  Simple.
3. Yeah, right.  I've got macular degeneration and can't read, have no idea what pile of crap my Medicare Summary Notice is in, am not sure how to get back to my home to find it even if I COULD walk.  Yeah, right.

I guess it boils down to this:  If you are conscious when entering the ER, be sure to ask your doctor what your status is, why it is what it is, why he thinks why it is what it is is the right way to think should be, and if you are only being "observed", why you should not just go home to die instead of enduring the inconvenience of being "in" without belonging "in".  If you are conscious.  And aware.  Doesn't matter if you are 85 years old and believe that the women who says she is your daughter is some street walker that only wants to get in your underwear and steal you watch (that is where I always keep mine)(She IS in fact a street walker, because, now I remember, I DON'T HAVE ANY CHILDREN).  Just take some personal responsibility and fess up:  "Really, I can walk, I just don't CHOOSE to."
 
Or ask the daughter of the patient next to you (daughter, not son - you already know my feelings about sons and their worth when it comes to caring for elderly parents) to help, because frankly that fall and the concussion make you dizzy every time you even think about getting out of bed and walking to the bathroom.

Seriously, I wish there were better answers.  I wish the system included patient advocates that could protect old, confused, lonely people.  The American Medical Association has told Medicare that it supports the abolition of the three (3) day rule.  Others have lobbied to do away with the "observation" classification.  But when the AARP asked officials at the Centers for Mediare & Medicaid Services to comment for a recent article, they declined to be interviewed, citing ongoing lawsuits.

Lets hope the suits win.