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Two-Midnight Rule Must be Fixed or Replaced, Say Providers

Christopher Cheney, for HealthLeaders Media, March 3, 2014

CMS's prepared statement includes this comment from Administrator Marilyn Tavenner: "This rule helps improve hospital care and establishes clearer guidance to hospitals for when we will consider inpatient care to be appropriate so the system works better for patients and providers."

Rule Resistance
From the AHA's perspective, "This Two Midnights standard is just arbitrary," Bathija said, adding the policy penalizes hospitals for being efficient in patient care or providing treatments that involve a short-term hospital stay.

Bathija said the AHA is asking CMS to either develop a better payment methodology within the Two Midnight policy or to replace the rule with a better method to pay for short-term hospital stays.

The American Medical Association, which has also been an outspoken critic of the new policy, expressed an even more skeptical view following the release of last week's guidance letter.

"The new policy does not solve the problem of unanticipated financial liabilities for patients, and increases documentation burdens for physicians," AMA President Ardis Dee Hoven, MD, told HealthLeaders on Thursday. "Recent guidance from… CMS on the order and certification requirements for physicians leaves many questions unanswered, and has not alleviated confusion. While we are encouraged by CMS's recent delay in enforcement and the decision to have Medicare Administrative Contractors review their application of the new policy, these issues continue to cause tremendous difficulties for physicians and patients."

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3 comments on "Two-Midnight Rule Must be Fixed or Replaced, Say Providers"


Lisa Sams MSN, RNC (3/11/2014 at 12:31 PM)
As an APN of many years I would like to bring the focus back to The Patient. On the surface the Two Midnight Rule looks very much like a way to establish two standards of care. It is a woeful development for patient care and the clinical patient relationship. The unintended consequences of most regulations is the very human behavior that will find work arounds to rules that make little sense for the problems at hand. This rule is all about the money. Do we want to improve the systems of care, the outcomes for the people who trust us to care for them? Or will misguided regulations continue to erode the heart of health care...the patient clinicians relationship? The window of time to re-focus and get things on the right path is very limited.

Cheryl (3/7/2014 at 7:49 AM)
Some hospitals appear to have used observation stays to circumvent the re-hospitalization penalties or other payment/penalty issues. This rule helps those people who had a 3 day hospital stay but were denied their Medicare Part A benefits as the stay was considered "observation". In many cases the patient had no idea that they weren't inpatient. The decision define stay as observation or inpatient is also often made retroactively. I have called to determine status of a stay only to be told a week later that the stay is something different. In this instance the benefit to the patient is after the acute stay when they then require subacute skilled services.

Stefani Daniels (3/3/2014 at 9:27 AM)
In my opinion, this whole '2 MN' rule is a product of poor patient management. If hospitals had clamped down on physicians who let their patients linger in observation for more than 23 hours; if hospitals hadn't cohorted observation patients with inpatients and allowed community based physicians to manage them on a day to day basis rather than the hour to hour basis that they require; if hospitals had kept observation patients 'vertical' in an area cleared marked as 'outpatient observation;' if hospitals had invested in nursing staff who were schooled in the management and information needs of observation patients and their families; and if hospitals spent time educating their community about the kinds of services an acute care facility provide, then all of this 'mess' could have been avoided. Like the 24 hr guidance previously on the books, the 2MN rule doesn't change the fact that complete and accurate documentation must support the physicians decision to admit a patient to acute level of care, despite the anticipated or actual length of stay.