E6 Health&Science Homebody house sparrows


By September, house sparrows have ceased breeding and are congregating in small flocks, feeding and roosting together.


Bands of juvenile birds began forming months ago aſter leaving the nest. Tey spent a few days with their father, then became independent enough to find grain, weed seeds and invertebrates on their own.


Te adults, which choose one mate for the season, soon went back to breeding, raising as many as four clutches before the end of summer. Each clutch holds about five eggs.


Tough juveniles may stray short distances, house sparrows are nonmigratory, stay in human-modified areas (such as cities and farms) and stick close to where they were born. Males


*1966-2004 data


may even choose nesting sites in the autumn, use the site for a winter roost and convert it to a nest in the spring.


Te birds have been in North America since the 1850s, when 50 breeding pairs were introduced from Europe. By 1943, 150 million house sparrows had colonized the country, coast to coast.


Te American landscape of the late 1800s encouraged the spread of the house sparrow. Te country was dotted with small farms that supplied the cereal grains and livestock fly larvae on which the birds thrive.


Since the 1950s, pesticides have reduced insect numbers, livestock is less spread out, and grain harvest and storage is more efficient, all contibuting to an overall decline in the house sparrow population, which is falling at a rate of about 2.6 percent every year.*


KLMNO


The changing natural world at our doorsteps. URBAN JUNGLE


Adult male, April Adult male, Sept.


Juvenile male (Juvenile females look very similar to adult females)


Of 10,000 eggs laid . . . House sparrow mortality


Adult female


Passer domesticus


Aſter breeding, adult house sparrows begin to molt. Males replace their bright “nuptial plumage” with a drab set of feathers for the winter. Juveniles also shed their baby feathers once before fall.


SOURCES: Cornell Laboratory of Ornithology; “Biology of the Ubiquitous House Sparrow: from Genes to Populations,” by Ted. R. Anderson


9,186 will hatch 5,729 nestlings will survive 3,699 will successfully fledge 1,110 will remain by October 588 will endure the winter 312 will see a second October 203 will live 2 years 132: 3 yrs. 86: 4 yrs. 56: 5 yrs. 36: 6 yrs. 23: 7 yrs. 15: 8 yrs. 10: 9 yrs. 6: 10 yrs. 4: 11 yrs. 3: 12 yrs. 2: 13 yrs. 1: 14 yrs.


PATTERSON CLARK /THE WASHINGTON POST clarkp@washpost.com


TUESDAY, SEPTEMBER 7, 2010


‘Observation’ status limits Medicare patients’ benefits Ask your doctor for help in guaranteeing your coverage


inpatient continued from E1


tion,” a spokeswoman said. How- ever, Karen Jerome, a physician who is an adviser on care manage- ment at Holy Cross, said in a statement that the hospital has a policy of informing patients when they are in observation care and that patients receive a thorough review to determine their status. While patients generally stay in


observation status for no longer than 48 hours, she said, it is the patient’s condition and need for medical care that doctors have to consider most, not the clock. Sometimes the patient does not meet criteria for inpatient care af- ter 48 hours but hasn’t improved enough to go home. When that happens, the hospital will keep the patient until he or she has “a safe discharge plan.”


Conflicting mandates Claims from hospitals for ob-


servation care have grown steadi- ly and so has the length of that care, says Jonathan Blum, deputy administrator at the Centers for Medicare and Medicaid Services (CMS), the federal agency that runs Medicare. The most recent data show claims for observation care rose from 828,000 in 2006 to more than 1.1 million in 2009. At the same time, claims for observa- tion care lasting more than 48 hours tripled to 83,183. In a report to Congress in


March, the Medicare Payment Advisory Commission said the in- crease may be explained by hospi- tals’ heightened worries of more- aggressive Medicare audits of ad- missions and Medicare’s decision in 2008 to expand criteria that al- low patients to be placed in obser- vation status. Yet the number of people admitted to inpatient sta- tus remained stable, the report said. The trend is emerging as hospi- tals cope with increasing con- straints from Medicare, which is under pressure to control costs while serving more beneficiaries. In addition to more stringent cri- teria for inpatient admissions, hospitals face more pressure to end over-treatment, fraud and waste. In this environment, doctors


How do I know what my hos-


pital status is? Ask your doctor or other hos-


pital officials if you are in the hospital for observation or as a regular inpatient. If you are an observation patient, ask why. Even if you are admitted as an inpatient, the hospital can switch you to observation sta- tus; in that case, the hospital is required to notify you. If you do not have three con-


secutive days of hospitalization as an inpatient — excluding the day of discharge — Medicare will not cover a subsequent stay in a nursing home. For those who do qualify, Medicare pays for up to 100 days of rehabilita- tion or skilled nursing care.


How long can the hospital keep me for observation?


Medicare expects patients to remain in observation status for no more than 24 to 48 hours. But there are no rules limiting the time; some patients spend several days in observation.


What can I do if the hospital


won’t change my observation status to inpatient?


“You cannot directly appeal the hospital’s determination that you are or were an observa- tion patient,” says Ellen Griffith, aMedicare spokeswoman. If you think you should be considered an inpatient, ask your personal physician to call the hospital and request a change in status, although your doctor cannot mandate this. If that is not successful, there are other steps you can take.


If the nursing home or hos-


pital says Medicare won’t cover my nursing home stay, what can I do?


Ask the nursing home to bill


Medicare when you enter the facility, Griffith says. Medicare will deny the claim if you do not have the required three in- patient days. The next step is to appeal that decision to the Medicare billing contractor, which will probably also deny your request. You can then ap- peal that decision.


If the nursing home won’t


bill Medicare, the Center for Medicare Advocacy, a public interest law firm, recommends that you complete a “Notice of Exclusions from Medicare Ben- efits: Skilled Nursing Facility” form. Ask the nursing home to


submit it to Medicare to get a decision about coverage. The nursing home will not bill you while you wait for a response. You can also question your


Medicare Summary Notice, which is the explanation of ben- efits, says the advocacy center’s Toby Edelman. It probably will show limited coverage — for re- habilitation services — instead of a full nursing home benefit. You can appeal to the Medicare billing contractor for full nurs- ing home coverage, which gen- erally is denied. To appeal that denial, follow the instructions in the Medicare Summary No- tice, says Griffith. If Medicare ultimately does


not pay the nursing home, you will be responsible for the charges.


—Susan Jaffe


they have not been refused ben- efits. “There’s no official appeal,” says Edelman. “Medicare has not de- nied coverage. You’re in no man’s land.”


Following the rules Hospitals officials say they pay


a price if they give inpatient sta- tus to a Medicare patient who should only be under observation. When that happens, the hospital is overcharging Medicare and can be required to refund some of the money the government paid. During a three-year pilot proj-


ect in six states, Medicare audi- tors, who received commissions based on overcharges they uncov- ered, forced hospitals and other health-care providers to return $1 billion in improper payments. The program is being expanded every state this year. Pressure to increase the use of


observation status may also come from the new federal health law, which includes penalties for hos- pitals that have unusually high rates of preventable readmis- sions. Because observation pa- tients have not officially been ad- mitted, they wouldn’t count as re- admissions if they need to return. The stepped-up audits and the


have to make difficult judgments about their elderly patients, says Steven Meyerson, medical direc- tor for care management at Bap- tist Hospital of Miami. “Under a set of rather arbitrary


definitions, which are very vague and difficult to understand and apply, we have to decide who’s an inpatient and who’s an outpatient when sometimes the distinction can be two or three points in their sodium level or the amount of IV fluids they are receiving,” he told CMS officials at an information- gathering session Aug. 24. If the distinction isn’t always clear to doctors, it’s even more elusive for patients. Toby Edelman, a senior policy


attorney at the Center for Medi- care Advocacy in the District, has received dozens of complaints from seniors who assumed they would have the fuller coverage provided to inpatients. “People have no way of know- ing they have not been admitted


to the hospital,” says Edelman. “They go upstairs to a bed, they get a band on their wrist, nurses and doctors come to see them, they get treatment and tests, they fill out a meal chart — and they assume that they have been ad- mitted to the hospital.” Setting a patient’s status is complicated. More than 3,700 U.S. hospitals use a tool created by McKesson Health Services to guide the decision. It provides cri- teria for medical conditions and treatment based on scientific evi- dence to identify “over 95 percent of all reasons for admission to any level of care,” Rose Higgins, McKesson’s vice president for care management, said in a state- ment. Higgins said that hospitals can tell patients the criteria used to assess their status, but the com- pany’s recent filing with the Secu- rities and Exchange Commission describes the decision-making tool, called InterQual, as a trade secret.


Many patients are not told by hospital officials that they haven’t been admitted. (Medicare does not require such notification.) And the designation can change during a person’s hospital stay. Sometimes a physician who hasn’t seen the patient will deter- mine that the case does not merit inpatient status; Medicare re- quires that patients whose status is downgraded must be informed.


‘No man’s land’


Ed Timmins, 88, has been in a nursing home in Springfield since he was discharged from Inova Fairfax Hospital after falling in a restaurant parking lot in June. The Defense Department retiree was an observation patient dur- ing his four days at the hospital, where he was treated for extreme back pain and received an MRI and other treatment. But without the three-day in-


patient stay, Medicare will not cover his nursing home bill,


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which reached $23,864 through the end of August. On his first day in the hospital, Timmins, who has Alzheimer’s disease and was taking powerful painkillers, received a notice say- ing he was being “placed into an outpatient status for Outpatient Observation or Extended Recov- ery. You are still considered an ‘outpatient’ but are being cared for on a nursing unit for further evaluation of your symptoms by your physician. Within 24 hours, your physician should make a de- cision to either . . . Admit you for inpatient treatment or Discharge you for continued outpatient fol- low-up care.” “For him to be treated at an In-


ova hospital for four days and then be considered an outpatient is ludicrous,” says his daughter, Lynn Hollway. She was in his room — on the phone updating her mother — when he received the notice but assumed they could deal with the issue once his condition stabilized. Hospital officials say status de- cisions are often not in their hands. “Medicare rules require us to make sure that a patient meets what’s called medical necessity to be in an inpatient status,” says Linda Sallee, vice president for case management for the Inova Health System. A hospital spokes- woman said Inova physicians would not discuss details of Tim- mins’s care. Even if patients know they are


observation patients, there is lit- tle they can do to change their sta- tus. Medicare has covered their care on an outpatient basis, so


new law’s financial incentives are intended to control skyrocketing Medicare costs and to reward bet- ter care. That could be jeopar- dized by an increase in costly in- patients. Easing the standard for inpatient status would also raise the agency’s nursing home spend- ing. “We’ve asked them to change


it,” says Sallee. “But I would be very surprised if they did, because it would cost a lot of money.” Blum says that many factors


are involved in the increasing use of observation care. “It’s not clear to us whether or not this trend is due to financial incentives,” he says. “There could be lots of other things going on.” For example, he says, doctors


may be “doing the right thing” by keeping vulnerable seniors in the hospital for observation if they lack a support system at home. Medicare officials are weighing


changes to the admissions policy and sent letters to hospital associ- ations in July soliciting sugges- tions. Among the options are re- quiring hospitals to notify pa- tients that their stay is considered observation, setting a strict time limit for observation care and changing how the agency pays hospitals for such care, Blum says. For some, changes may not come soon enough. “This system is impracticable and just locks up patients in the hospital,” Meyerson told CMS offi- cials last month. “They are not well enough to leave and not sick enough to admit. So what do you do with them?” health-science@washpost.com


GLEN ECH O PARK


This article was produced through a collaboration between The Post and Kaiser Health News. KHN, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health-care-policy organization that is not affiliated with Kaiser Permanente.


How to learn more


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 Call Medicare at 800-633-4227.


 Obtain a Medicare pamphlet about observation care at www. medicare.gov/publications/pubs/ pdf/11435.pdf.


 Find information prepared by the Center for Medicare Advocacy at www.medicareadvocacy.org/ InfoByTopic/ObservationStatus/ ObservationMain.htm.


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