On December 15, Michael Salvatore, MD, FACP, CHCQM posted this comment on the popular RAC-Relief message board:
“Today we have 166 patients in beds [at our hospital] and 25 of them have either a human or electronic sitter – this is 15% of our inpatients whose minds are not working. They are all minds ravaged by mental illness, Lewy bodies, alcohol, amyloid, narcotics, trauma, and other things that most of us cannot imagine. Some are permanently lost, others just for the moment. Almost everyone is very old and either living alone or with a spouse who may have more or less mind left than they have.
As a recent Noble Laureate wrote, “The times they are a changin’” – well they are, and CMS has not changed with them.
Instead of meaningful changes in policy to deal with the hospitalization of the demented, the pelvic fractured, the socially isolated, the non-compliant, the non-adherent, the ‘fallen and I can’t up’, the mentally ill, the psycho-socio-pathophysio-familial - whatever - we are given the 3 day SNF rule, the 2 midnight medical necessity muddle, and now the MOON.
1965 was a watershed year for the medical care of the elderly but that was for 1965’s elderly. We are caring for the 2016 elderly, 15% of whom on some days cannot be left alone in a bed. It may sound self-aggrandizing and self-pitying to say it, but we do care for people. [CMS] cares for policy and the policy it cares for does not foster the best care of people.
I am 68 and my ‘Tele-sitter’ is screaming: “DO NOT HIT SEND! WE ARE ON OUR WAY!”
Too late…”
Howard Stein, MD, added:
“Michael’s observation that CMS needs to update the care they provide for elderly patients in 2016 is an understatement to say the least. The 3-day requirement for SNF requirement was apparently an early 1980’s rule. It is common for an elderly patient with falls, pelvic fracture, altered mental status or simply failure to thrive to be “observed” overnight; leaving case managers and social workers to provide the scant resources available to augment their care at home. This is a huge gap in coverage for these patients that can be partially remedied by abolishing the 3-night minimum for SNF consideration. It is one of the few areas where a Medicare Advantage plan provides valuable benefit besides free eyeglasses.”
My comments:
It's ironic that at the same time we do too little for the frail elderly who need basic supportive care, we do too much when they enter our dysfunctional health care system. How many 90-plus-year-olds enter hospitals for symptoms of end of life decline and are treated like young people who have an acute reversible illness? We know this happens many times every day. Futile attempts to reverse old age waste immense amounts of resources that could go to maintaining comfort and meeting basic needs, yet that's not what Medicare is designed to do and that’s not what doctors and hospitals are paid to do.
Our legal tort system needs a real overhaul so that doctors are freed from the fear of being sued when that 92-year-old dies due to the end of their natural life span, health care needs to recognize that there are limits on medically appropriate care for the very old and those with hopeless diseases and irreversible decline, and Medicare needs to recognize that health care is not just what happens in hospitals and doctors' offices.
We all hope to live long enough to reach such an advanced age, but is this the kind of health care system we would want for ourselves if we do?