Patient Strategies

A. How Patients Can Manage Risk

The heavy penalties which Medicare puts on hospitals for readmitting patients, mean that doctors and hospitals may advise patients not to get treatment, if there is much chance of readmission, even when the treatment would help the patient.

So patients need to worry that advice from doctors, hospitals, or Accountable Care Organizations (ACOs) can be biased away from treatment.

Patients who want treatment can avoid being a subject of hospital penalties and hospital risk by:

1. Prevention, which includes diet (such as low salt and fat), exercise, immunizations, medicines, preventing falls. Doctor visits need to address blood pressure, cholesterol, swelling, apnea, and infections before they cause hospitalization. You can check your prescriptions for interactions at MediGuard.org
2. Avoiding admission to short term hospitals  by using prevention, urgent care centers, long term hospitals, outpatient surgery at a hospital or surgi-centers (though these can have worse outcomes, more risks, and more deaths) and other outpatient services. Patients can use Medicare's software to see if they have high readmission risk, to know if hospitals will be wary of them.
3. Dropping Part B of Medicare, if you have other insurance. "Medicare Part B is of limited value to someone already covered by a good health plan" (Center for the Study of Services, 2013). Most Medicare penalties and rankings are based on patients who have Part B, so if you drop it, your doctors know you will not affect their penalties. Medicare resists dropping Part B, and if you re-enroll later, they increase the Part B premium 10% for each year you lacked Part B, so it is a significant decision. The form to drop it is CMS-1763 (or copy); in the form part B is called "medical insurance," and part A is called "hospital insurance." Your right is established by 42CFR407.27. 14,000 people per year file this form to drop coverage (p.4 of Statement).
4. If you pay premiums for Part A Hospital Insurance you can drop it too, 42CFR406.28, but Part A is generally free. If you get Part A free, then the only way to drop it is the draconian step of refusing Social Security payments and repaying any Social Security and Part A benefits you have received. This rule was approved by the federal Circuit Court in DC in 2012 (Hall v. Sebelius); page 4 of the dissent (p.11 of the pdf file) analyzes this Social Security policy. The Supreme Court decided not to hear an appeal. Dropping part A involves the same form listed above for part B.
5. Federal retirees can opt out of Part A with fewer problems than most people. Many federal retirees lack Social Security and have federal health insurance. Even if they drop Medicare, they get charged the same as Medicare patients for hospital inpatient treatment, and for doctors who participate in Medicare (and up to 15% more by non-participating doctors). Outpatient hospital care and non-physician based care (e.g. PT, nursing homes) are not covered by this requirement for equal charges; regular Plan benefits apply. These costs are in each plan brochure, in a section titled, "When you are age 65 or over and you do not have Medicare." The limits were established by laws in the 1990s: Omnibus Budget Reconciliation Act of 1990~P.L.101-508 §7002, p.28; and of 1993~P.L.103-66 §11003, p.30.
6. Using a VA or military hospital if eligible. Members of Congress can use Walter Reed military hospital.
7. Using a specialist hospital (usually with better than average care). The following are exempt from readmission penalties: "rehabilitation hospitals and units; LTCHs [long term care hospitals]; psychiatric hospitals and units; children's hospitals; and cancer hospitals. Religious nonmedical health care institutions (RNHCIs)" 
8. Using a hospital in Puerto Rico (exempt) or Maryland (exempt, even famous hospitals like Johns Hopkins). Medicare's head office is in Maryland, so retirees and family members there do not face Medicare's readmission penalties.
9. Using a top hospital abroad; these are not covered by Medicare.
10. Using a Critical Access Hospital (small, rural, isolated, exempt, marked in "Combined list") if it has the skills you need 
11. In a US hospital, Medicare patients generally cannot pay privately: 42 U.S.C. § 1395cc(a)(1)(A)(i) says a hospital cannot charge or accept private payment "for items or services for which [an] individual is entitled to have payment made under [Medicare, Part A]" (p.16, note 9)
12. Getting a second opinion from doctors not affiliated with the hospital and not in an Accountable Care Organization
13. Arranging assisted living or caregivers and equipment at home so one can go home right after an outpatient operation and stay there successfully. Used hospital beds, bedside commodes, wheelchairs, walkers, alternating pressure pads, and caregivers are affordable. Lift chairs are expensive, but one that goes flat (A or B) will help you up and down from a sleeping position without you having to twist in and out of bed. Long term design changes can be considered whenever remodeling
14. If staying overnight at a short term hospital, consider getting it called observation, rather than being admitted. Drugs will cost more, and it will not entitle you to covered nursing home care, but the stay will also not count toward a readmission penalty.
15. Joining a Medicare Advantage plan (may promote hospice aggressively, and limited appeal rights). They are paid a flat rate per member, so they need to minimize all hospital stays and other expensive care, but they have no specific incentive to avoid readmissions.
16. If there is any ambiguity in your principal diagnosis, you can try to convince the hospital to avoid having it be one of those that have penalties (Table A).
17. Lobbying Congress to repeal or reduce the penalty

Regardless of exemptions, it is possible doctors who primarily see ordinary Medicare patients will have a habit of minimal treatment, even for managed care and private insurance patients exempt from the penalties.

B. Advocates

Patients can get a professional advocate, often a senior nurse, to advise them about recommended and alternate treatments. Some will come to the hospital to listen to doctors and advise. Others can interact with patients and doctors on Skype or Google video chat. Cost can be $60-$200 per hour, cheaper than poor health care. As long as doctors and hospitals have hidden incentives to avoid care, patients need expert advocates. (The parallel is with courts, where most people would get a lawyer, in spite of the cost.)

1. advoconnection.com has a national directory
2. nahac.memberlodge.com/ has a national directory
3. patientadvocates.com/ smaller membership
4. aphadvocates.org/ sponsors the advoconnection national directory
5. healthadvocateprograms.com/ lists training programs for patient advocates
6. billadvocates.com links specifically to help on medical bills
7. healthcarebluebook.com lists prices for many procedures
8. Consumers Union has a "Safe Patient Project" to reduce medical errors, with many stories from patients

Free telephone help will not be as effective, but it is free for the very ill from Patient Advocate Foundation on skin, breast, cervix, ovaries, prostate, and colorectal cancer, narcolepsy, heart valves, Aetna claim problems, and dealing with other insurers.