CORRECTION:  In the RACmonitor Nov 29, 2019 edition, Dr. Ronald Hirsch noted that resource use data on skilled nursing facilities (SNFs) was not available on the SNF Compare website. Upon further investigation, the resource use data is, in fact, available indirectly from the SNF Compare home page. Subregulatory guidance, however, is still pending, and won’t be released until spring 2020.

The deadline has come and gone for complying with the Centers for Medicare & Medicaid Services (CMS) Discharge Planning Conditions of Participation Final Rule, and yet hospitals find themselves being asked to do the impossible.

That’s the assessment of Ronald Hirsch, MD, who reported during a recent appearance on Monitor Mondays that subregulatory guidance for hospitals, as well as guidance for surveyors, is not expected to be released until spring of 2020.

“What that means is that if you are not offering patients information on skilled nursing facility (SNF) resource use, which is required by the regulation but is unavailable, you won’t have to worry, because the survey instructions do not yet include asking about whether information on resource use was provided,” Hirsch said.

What concerns Hirsch, though, is that there hasn’t been much in the way of guidance on how to deal with patients whose insurance is not Medicare fee-for-service (FFS). Hirsch noted that a case manager recently asked if case management staff across the country should apply the Final Rule provisions to their entire inpatient populations, in the spirit of treating everyone the same, or apply the requirements only to the Medicare patient population, in order to avoid treating patients differently on the basis of their insurance. One person, according to Hirsch, responded stating “nurses and other clinicians, in their experience, do not (or should not) treat patients on the basis of their insurance.”

“But that answer, in my opinion, is wrong,” Hirsch said. “First, if a patient is covered by an insurance that contracts with specific post-acute providers, the hospital should inform the patient of those providers.”

According to Hirsch, the patient, however, is free to choose any provider, noting that it would be rare that a patient with insurance would choose to go to a facility where they would have to pay the full cost themselves.

“Interestingly, the regulation actually allows the hospital to simply hand out their full list of all providers and tell the patient it is their responsibility to find out which providers are covered by their insurance,” Hirsch said. “But would anyone really do that? I sure hope not.”

Hirsch encouraged listeners to “always be aware of a patient’s insurance coverage – and that will result in many patients being treated differently.”

“I don’t think we do a good enough job of treating patients differently,” said Hirsch. “For example, say a patient comes in the emergency department (ED) with a broken ankle. They get a splint and are referred to the on-call orthopedist, the same doctor who will get all the orthopedic referrals that day.”

In continuing with this scenario, Hirsch explained that the next day, when the patient calls for an appointment and is told the doctor is out-of-network, the patient will have to pay cash to be seen.

“Did treating everyone the same work out well for this patient?” Hirsch asked rhetorically. “What if a doctor treats all patients with pneumonia the same, prescribing the same antibiotic for every patient, but one patient’s insurance does not cover that drug? How will that work out for the patient? Has a pneumonia ever been cured by an antibiotic that the patient never was able to fill?”

“So, as we start respecting a patient’s goals of care and treatment preferences, let’s also be sure to treat patients differently, if that benefits the patient,” Hirsch added.

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