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J Hosp Med. 2015 Nov;10(11):718-23. doi: 10.1002/jhm.2436. Epub 2015 Aug 20.

Patient financial responsibility for observation care.

Author information

1
Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
2
Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
3
Penn Center for Community Health Workers, Philadelphia, Pennsylvania.
4
Centers for Medicare & Medicaid Services, Baltimore, Maryland.

Abstract

BACKGROUND:

As observation care grows, Medicare beneficiaries are increasingly likely to revisit observation care instead of being readmitted. This trend has potential financial implications for Medicare beneficiaries because observation care-although typically hospital based-is classified as an outpatient service. Beneficiaries who are readmitted pay the inpatient deductible only once per benefit period. In contrast, beneficiaries who have multiple care episodes under observations status are subject to coinsurance at every stay and could accrue higher cumulative costs.

OBJECTIVES:

We were interested in answering the question: Do Medicare beneficiaries who revisit observation care pay more than they would have had they been readmitted?

DESIGN:

We used a 20% sample of the Medicare Outpatient Standard Analytic File (2010-2012) to determine the total cumulative financial liability for Medicare beneficiaries who revisit observation care multiple times within a 60-day period.

PARTICIPANTS:

Participants were fee-for-service Medicare beneficiaries who had Part A and Part B coverage for a full calendar year (or until death) during the study period.

MEASUREMENTS:

Our primary measure was beneficiary financial responsibility for facilities fees.

RESULTS:

On average, beneficiaries with multiple observation stays in a 60-day period had a cumulative financial liability of $947.40 (803.62), which is significantly lower than the $1100 inpatient deductible (P < 0.01). However, 26.6% of these beneficiaries had a cumulative financial liability that exceeded the inpatient deductible.

CONCLUSIONS:

More than a quarter of Medicare beneficiaries with multiple observation stays in a 60-day time period have a higher financial liability than they would have had under Part A benefits.

PMID:
26292192
DOI:
10.1002/jhm.2436
[Indexed for MEDLINE]

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