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Providers Blast CMS on Two-Midnight Rule

Christopher Cheney, for HealthLeaders Media, July 1, 2014

"Our members have had a lot of difficulty with the two-midnight rule," Allison Cohen, senior policy and regulatory analyst at the DC-based group, said in an interview last month before the AAMC filed its comments. "Duration of stay really doesn't say anything about the patient."

She says the two-midnight rule unduly punishes large academic medical centers. "Based on mission, we have to treat all comers," Cohen said, noting large medical centers in urban areas face a high volume of "high-intensity" patients such as the homeless and people from disadvantaged communities who have suffered with multiple chronic conditions for years.

"Two-midnights was designed to provide clarity when it really hasn't. Then you're also underpaying these hospitals that are treating high-intensity patients… This is really something where clinical judgment should determine whether a patient is inpatient or outpatient."

If the two-midnight rule is implemented, the AAMC wants the threshold-setting clock to start as soon as a physician orders inpatient status. AAMC officials wrote to CMS:

"At high-occupancy hospitals, such as those of the AAMC members, it is not unusual for a patient to have to wait several hours or more for a bed to become available, even after a physician has written an inpatient order…"

"For example, a physician may write an inpatient order in the emergency room at 10 p.m. on a Monday night, the patient may be moved to the inpatient setting at 1 a.m. Tuesday morning, and the patient may be discharged at 7 a.m. on Wednesday morning. Under CMS' proposal, this case would not have qualified… even though the patient required inpatient care across two midnights."
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