Comments 47 and 48

OMB DEP DIR MGMT

Kimberly W. Daniel
Ext. 420
Email: kdaniel@hd)n.com

May 4,2007
VIA FACSIMILE 1202-3954974) AND U.S. MAIL
OMB Human Resources and Housing Branch
Attention: Carolyn Lovett
New Executive Office Building
Room 10235
Washington, D.C. 20503

Re: Comment to Final Rule CMS-4105-F
Dear Ms. Lovett:
I am writing to you on behalf of MediCorp Health System ("MediCorp"),
located in Fredericksburg, Virginia., MediCorp is a not-for-profit regional health system,
comprisea of twenty-eight health care facilities and wellness services. After reviewing
Final Rule CMS-4105-F, published in'the Federal Register on November 27,.2006,
MediCorp is concerned about the impact certain aspects of this' Rule might have on it
and other similar health systems. . :
. . ..
..
I

I.

Specifically, MediCorp's concerns center on the requirement that, at
discharge, pat~entsbe shown'a copy of the IM notice they signed upon admission.
MediCorp feels this is an unnecessarily cumbersome requirement. MediCorp has
developed standardized admission and discharge processes to ensure patients receive
all required and helpful information and documentation. The Rule will require MediCorp
to take part of the admission packet/documentation and to add it to the discharge
information packet. Requiring the tracking and transfer of the original signer! notice 50 it
is available at discharge as required creates a significant burden and does not seem to
improve the care or information provided to the patient. Giving the patient a copy of the
IM notice or another original IM notice would be equally effective and much less difficult
to accomplish.
A s an alternative, MdiCorp suggests that providers be given the option to
provide the first IM notice to the patient within a specified time period, and give the
patient a second IM notice
. ( ......
form upon discharge. The result of this practice would be
that' hdbc6igned 1~'notice
f o h i ' ~ o u l dbe included in the patienls medical record,, mther
than orie. The patient would receive the same infomiation under this practice as.he
would'under the sy&em set blm in the Firial Rule, but provi,ders'would 'Ce;telieved.
. .... . , of
the additional burden
,
of
.. accessing the original signed fob-:.at"dis&harge.
. \. , . :. . . ..
. .
"

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HANCOCK, DANIEL, JOHNSON & NAOLE, P.C.

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OMB DEP D I R MGtlT

395 6974

P. 03/06

M Human
B
Resources and Housing Branch
Attention: Carolyn Lovett
May 4,2007
Page 2

I hope you find this comment useful as CMS moves forward in
implementing this Final Rule. Should you have any questions regarding the foregoing,
please do not hesitate to contact me.
Sincerely,

Kimberly W. Daniel
cc:

MediCorp Health System

::ODMA\PCDOCS\DM-LIBRARMM208\1

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P.04/06

Becky Sutherland Comett, Ph.D.
564 Dark Star Ave.
Columbus OH 42330
May 3,2007

OMB Desk Officer
Human Resources & Housing Branch
Attention Carolyn Lovett
New Executive Office Building
Room 10235
Washington DC 20503
Dear SirMs.:
I am writing to comment on the proposed "Detailed Notice of Discharge" (CMS10066; OMB 0938 - New) discussed in the April 6,2007Federal Register at pages
17169-17170. The requirements listed in the Notice Instructions accompanying the form
are problematic for hospitals and for beneficiaries for the following reasons:
Bullet #2 "explanation of Medicare covzrage policies that we used to determine
that Medicare will no longer cover your hospital stay." Physicians and case
managers do not use Medicare coverage policy per se to determine when a patient
no longer needs an acute-care hospital level of care. Physicians are paid to make
very careful, informed decisions about a patient's needs based upon their
experiences, the patient's specific circumstances, and research evidence published
in the medical science literature, by medical practitioner societies and
associations, and local hospital or physician department protocol. The only
guidance CMS provides regarding a patient's need for an acute-care inpaticnt stay
is in the Medicare Benefit Policy Manual, and that is not very specific. There are
no other policies I can find that could be listed for beneficiaries that definitively
state when a beneficiary should be discharged to a less restrictive level of care.

Last statement on the form: "If you would like a copy of the Medicare coverage
policies or Medicare managed care plan policies used to make this decision.. .."
Again - what policies are being referenced here? Surely CMS administrators do
not want or expect hospitals to copy sections of the Medicare Benefit Policy
ManuaI for the beneficiaries!
Please provide a specific list of policies that CMS believes are applicable so we
all know what to use to consider discharge decisions and what to print for
beneficiaries to read.

MRY-15-2007

14:42

OMB DEP D I R MGMT

With these enhanced discharge appeal notice requirements, CMS is creating a
potential flood of discharge protests as the Medicare beneficiary population
increases, national health policy does not address the growing need for custodial
care, SNF stay and payment requirements continue to be so restrictive, there are
inadequate provisions for home care, and adult children do not want to bother
with their aging parents. Hospitals cannot bear the burden of our failed nalional
health care "system." Please do not punish all acute-care hospitals for the sins of
a few rogue hospitals. Go after the hospitals that dump homeIess patients on the
streets in Los Angeles, not hospitals who in good Eaith discharge patients based on
solid medical criteria (and not Medicare coverage policies).

Thank you forthe opportunity to comment.

Sincerely,

Becky ~>drlarland cornen

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395 6974

-LION
New River Valley
Medical Center

Date:

May 2, 2007

To:

The Centers for Medicare and Medicaid Services

From:

Clinical Effectiveness Department of Carilion New Riva Valley Medical Center
Christiansburg, VA 24073

Re:

Commtna regarding "Important Messase fromMedicare" and "Dctaikod N e b of Discharge"

Hospital leaders agree that patients and their families have the right to know about their discharge appeal
rights. The difficulty for us lies in the actual carrying out of the process as Medicare has outlined it. Our
concerns are as follows:
How do we accurately pin-point when a patient is being diecharged7 The Medicare population by
1.
definition ie either disabled or 65 and over. Their healthcare course, in the hospital, is no1 always
predictable. For many of theq their hospital stay goes fiom day-today.. .especially if they are waiting for
a nursing home bed. It would be a terrific burden on hospital resources to rmeatedly issue the IM in o r d a
to d e sure rhc patient receives it within 2 days of discharge.
2.
We do provide case management weekend coverage, but it is for patient care issues, certainly no1
at the level required to provide the second Important Messages fiom Medicare AND the Detailed Notices
of Discharge (if the patient appeals the discharge decision). To meet the requirements of this ruling, 1
foresee a terrific strain to our system, both departmentally and organizationally.

3.
Our facility has limited capacity. Delay in discharge for two days, while an appeal is reviewed,
will impact our ability to provide care to those who have w a t e r needs. Our projection is that our
psychiatric care unit will be housing patients that should have b t n discharged, but have appealed.
Currently the Commonwealth of Virginia has limited psychiatric facilities. Our Emergency Departments
have Seld prtiezts waiting far a ~;sychafxicbed for up ta f o u days. Eoes the right of the discharged patient
exceed the right of those seriously ill patients seeking care? Also keep in mind that our hospital is
reimbursed for inpatient psychiatric patients under the prospective payment system which could result in
increased Medicare cosrs.
As a compromise we feel it would be appropriate to require thc initial admission I
M to be delivered and
signed for, but the second IM before discharge has presented itself as an unnecessary waste of resources
and a bother to our patients and their families in time of illness.

Sincerely.
GC Duck Manager Clinical Effectiveness
CNRVMC

P. 06/06