Academy comments to CMS on the proposed rule regarding "Medicare Program; Notification Procedures for Hospital Discharges" as published in the Federal Register on April 5, 2006

VIA E-MAIL

June 5, 2006

Mark B. McClellan, M.D., Ph.D.
Administrator, Centers for Medicare and Medicaid Services (CMS)
Department of Health and Human Services
Attention: CMS-4105-P
P.O. Box 8010
Baltimore, MD 21244-1850

Dear Dr. McClellan:

I am writing on behalf of the American Academy of Family Physicians (AAFP), which represents more than 94,000 family physicians and medical students nationwide. Specifically, I am writing to offer our comments on the proposed rule regarding “Medicare Program; Notification Procedures for Hospital Discharges” as published in the Federal Register on April 5, 2006. We are concerned that, although aimed at hospitals, this proposed rule may have a significant negative impact on physicians who treat Medicare patients in the hospital.

Currently, hospitals must provide Medicare beneficiaries with a general notice of appeal rights (referred to as the “Important Message from Medicare”) at or about the time of the patient’s admission. If a Medicare beneficiary expresses dissatisfaction with an impending hospital discharge, hospitals must also provide a hospital-issued notice of non-coverage to the beneficiary.

Under the proposed rule, CMS would establish a two-step notice process for hospital discharges that is similar to the process in effect in other settings, such as skilled nursing facilities. The first step would require hospitals to deliver, as soon as the discharge decision is made, a standardized, largely generic notice of non-coverage to each Medicare beneficiary whose physician concurs with the discharge decision. CMS considers delivery of the notice valid if it is delivered on the day before the planned discharge, contains all the necessary elements, and is signed and dated by the beneficiary (or beneficiary’s representative) to indicate the he or she has received the notice and can comprehend its contents. The second step, which would occur only in those situations in which a beneficiary wishes to dispute the discharge, would require hospitals to issue a single, detailed notice of non-coverage. The proposed rule is not clear on whether or not CMS would eliminate the “Important Message from Medicare,” and CMS invites comments on this and other aspects of its proposal.

Our concerns with this proposal relate to the first step in the proposed two-step process. First, it presumes that hospitals and physicians will always know the date of discharge a day in advance. That is not the case. Sometimes, patients are admitted and discharged on the same date. In this situation, it is impossible to provide the standardized notice of non-coverage the day before discharge. In other cases, a patient may be sufficiently well to be discharged earlier than expected. In such instances, the proposal would seem to require that the hospital keep the patient an extra day, just so it could provide the standardized notice a
day in advance of discharge. This makes no sense, either for the hospital or the physician who is responsible for the patient’s care.

Another concern is the apparent redundancy between the proposed standardized notice and current “Important Message from Medicare.” As noted in the proposed rule, both documents provide much the same information. We are not aware that the use of the “Important Message” has otherwise failed to provide Medicare beneficiaries or their representatives with the information that they need in this regard, and we see no need to provide them with two documents that say much the same thing, especially when the hospital stay is short. For example, as proposed, hospitals would be required to give beneficiaries both the “Import Message” and the standardized notice on the day of admission if the hospital expected the patient to be discharged the next day.

Finally, and most critically, this proposed rule presumes that hospitals will have active case management staff to handle all of this paperwork and that either the beneficiary will be competent to sign the standardized notice or that the personal representative will be readily available to do so. The reality is that in most small and rural community hospitals, active case management staff does not exist. As such, we anticipate that the burden of this paperwork will often fall to the attending physician, which in many cases will be our members. That burden will be exacerbated by the fact that many Medicare beneficiaries are not competent to sign such a document and their personal representatives will often not be readily accessible to the physician (e.g., because they live some distance away or have a schedule that makes them hard to reach).

Accordingly, we anticipate that this proposal may routinely extend the length of stay for many Medicare beneficiaries by at least one day, regardless of the severity of the cases involved. At a time when CMS is increasingly examining both hospital and physician quality, we are afraid such increasing lengths of stay will reflect negatively on our members and the hospitals that they serve.

For these reasons, we ask CMS to rescind its proposal requiring hospitals to provide a standardized notice of non-coverage the day before discharge and, instead, revise the current “Import Message” to include whatever information CMS believes is currently lacking in this regard. By revising the current “Important Message” and maintaining the requirement to provide it at or about the time of admission, CMS will maximize the opportunity beneficiaries have to discuss the eventual discharge with all concerned, including their family, primary physician and, perhaps, consultants. This approach ensures beneficiaries have adequate time to address discharge questions and issues without creating an additional burden for hospitals and physicians.

Thank you for your time and consideration of these comments.

Sincerely,


Mary E. Frank, M.D., FAAFP
Board Chair