Re: Proposed Revision of Important Message from Medicare - Form CMS-R-193 (OMB #0938-0692), 67 Federal Register 9743, March 4, 2002

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Thursday, April 4th 2002

Ms. Allison Eydt
Office of Management and Budget
Human Resources and Housing Branch
New Executive Office Building, Room 10235
725 17th Street, NW
Washington D.C. 20503

Dear Ms. Eydt:

On behalf of our nearly 5,000 member hospitals, health systems, networks, and other providers of care, the American Hospital Association (AHA) welcomes this opportunity to provide the Office of Management and Budget (OMB) with our comments, concerns, and suggestions on the proposed revisions to the Important Message (IM) from Medicare.

America's hospitals want beneficiaries to know their rights as hospital patients. In the early 1970s, hospitals were the first to voluntarily provide to all patients a statement of their rights. More recently, we have appreciated efforts by the Centers for Medicare and Medicaid Services (CMS) to reduce the number of notices and simplify the language used to advise beneficiaries of their Medicare appeal rights. Our focus group research with hospital patients and their families, including Medicare beneficiaries, clearly reinforces the need to present information in plain language and in a manner that provides easy access to more detailed information as it is needed.

While the new IM notice is more clearly written and less alarming than its predecessor, several practical issues remain regarding how the notice will be administered. In addition, cosmetic changes do not adequately address the huge increase in administrative burden hospitals would bear if duplicative notices for every Medicare patient are required. In short, the overall approach still does not create an easily understood and workable process for beneficiaries and hospitals.

AHA recommends that OMB postpone approval of the proposal until CMS engages the hospital community in a meaningful consultation process that addresses practical operational issues. We would gladly help organize such an effort.

We were surprised to read in the March 4 Federal Register notice CMS' assertion that the AHA had given its "unofficial agreement" to the new approach in discussions between CMS, AHA and
the New Jersey Hospital Association. That discussion was incidental to a meeting on another
issue, lasted about 10 minutes and occurred without the benefit of prior notice or any written description of the proposal - only a two-minute verbal description. The discussion was neither thorough nor conclusive. We merely indicated that simplification of the process and reduction in burden would be welcomed by hospitals. This does not constitute the level of consultation needed, and it certainly did not result in our agreement with the proposal.

Duplicative Notices
Section 1866(a)(M) of the Social Security Act requires hospitals to provide to Medicare beneficiaries, upon admission, a written statement explaining the individual's rights. The proposal retains the requirement to provide the notice at admission, but then judges that ineffective by requiring that it be given again at discharge. The statute does not require this.

AHA recommends that the provision of a second notice be reserved for those occasions when the patient questions their readiness for discharge, which is the current practice under the Medicare fee-for-service (FFS) program, or when the patient and/or physician disagree with a Medicare+Choice plan's decision to end coverage for acute inpatient care.

Timing of IM at Discharge
Under the current revision of the process, hospitals would be required to provide the IM to each patient on the day before discharge. This approach continues to ignore how hospital discharge decisions are made. As early in an admission as possible, an estimated discharge date is determined to support discharge planning. Whether a patient is discharged on that date or not is determined by their physician, based on daily rounds and on the patient's progress. Throughout this process, physicians, nurses and discharge planners talk to patients and families about the expected discharge date and adjustments that need to be made as circumstances change. But the discharge date is confirmed only after the physician has deemed that the patient has achieved the necessary level of clinical stability and recovery. This is made official in the physician's written discharge order, which typically is completed the morning of the discharge. Until then, hospital staff cannot establish a certain discharge date. Requiring an IM to be provided after a confirmed discharge decision but a day before actual discharge automatically and unnecessarily would add a day to each of the nearly 12 million Medicare hospital inpatient admissions every year.

The purpose of providing notice at discharge needs to be clarified. If it is to notify the beneficiary of his or her appeal rights, that has already occurred at admission, and the average six-day length of a hospital admission leaves little time to lose the information. If the purpose is to ensure that beneficiaries have advance notice of their expected discharge so they and their families can be ready, that is accomplished by the discharge planning process, already required by Medicare. If the purpose is to notify beneficiaries about when they become financially liable if they stay beyond the point that they need acute inpatient care, then the notice should be reserved for those limited occasions when the hospital needs to establish that liability.

AHA recommends that the proposal reflect a clear purpose for the discharge notice, and that hospitals be given greater flexibility in their timing.

Underestimate of Burden
The CMS asserts that the revised IM form and the methodology for administering it are "much less burdensome." We believe, however, that the revised methodology, while an improvement, falls short of the paperwork and burden reduction claims made by CMS. The burden estimate of an average of $1,777 per hospital per year grossly understates reality. The estimate suffers from a variety of flaws, including:

  • The analysis of the requirement to provide the notice at or near the time of admission assumes only a marginal (and, hence, ignored) burden on the basis that hospitals are allowed to administer the notice through the use of clipboards, posters, handouts, etc. However, to ensure that patients are actually made aware of the notice, and to respond to patient questions about the notice, hospital staff time will be required - time that is a calculable cost, just like the cost is calculated for the presentation of the IM prior to the patient's discharge. This does not include the cost of clipboards, posters, and handouts.

  • The estimate of burden for administering the notice at the time of discharge fails to include certain personnel and materials costs. Staff time will be required to prepare the IM in the event that a hospital elects to customize it with the patient's name and discharge date (as outlined in the CMS instructions). In addition, the estimate assumes that 90 percent of the notices provided at discharge will be delivered and explained by clerical staff (at a pay rate of $10/hour) in two minutes per admission. This assumption is not valid. Clerical staff is generally not available on patient care floors (even if they were, the average pay rate is closer to $12/hour). They also are not available around the clock. This function will likely have to be performed by nurses and social workers whose pay rate is closer to $25/hour. Furthermore, it is inconceivable that staff will be able to deliver a notice in two minutes; patients and families are very likely to ask about it; even if they don't, two minutes does not even cover the time it takes to walk to a patient's room. Staff time will also be required to copy and file forms on which a patient's signature is obtained. Also, the forms themselves represent a cost to the hospital that is not acknowledged in the government's estimate. While in isolation this cost may seem insubstantial, in reality it is layered atop many other paperwork burdens and costs imposed on hospitals by Medicare.

The AHA appreciates the Administration's efforts to work through the operational issues posed by the myriad of paperwork requirements under Medicare. We are committed to working with CMS to identify practical solutions to practical problems, while ensuring that Medicare beneficiaries remain well served.

Again, thank you for the opportunity to submit these comments. If you have questions regarding our comments, please contact me; Carmela Coyle, senior vice president for policy at (202) 626-2266; or Ellen Pryga, director of policy development, at (202) 626-2267 or


Rick Pollack
Executive Vice President


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