Tuesday, April 1, 2014

Two Midnight Rule: What Do You Expect?

What happens when government takes over health care?  You get dozens of bureaucratic horrors like the "two midnight" rule for Medicare.  What is the two midnight rule?  It is rule CMS 1599-F.
This new, Obamacare-forced rule specified that a hospital stay can only be paid for by Medicare insurance if that stay “(1) expects the beneficiary to require a stay that crosses at least two midnights and (2) admits the beneficiary to the hospital based upon that expectation.”
In the American Spectator, Jeffrey Lord does a fine job of playing the Democratic Party helpless victims game, telling the story of one Frank Alfisi, who died because he needed to be admitted to hospital to get a kidney dialysis.  A dialysis doesn't need a two day stay, so Medicare wouldn't cover it and the hospital wouldn't perform the dialysis.  Alfisi was too sick for a regular dialysis.

So President Obama killed Frank Alfisi.

On the contrary, this is what you get when you put the government in charge of things.

This is what you get when you pretend that the government can act like a compassionate daughter, like Frank's daughter Amy.

This is what happens when you believe politicians that say that they care about people.

This is what happens when people buy health insurance and assume that it takes care of everything.

The fact is that all institutions, from government to insurance companies to hospitals, run on rules.  The rules are arbitrary.  The rules say that we will do stuff for you if you the facts say one thing, and we won't do it if they say another.

Of course our modern world is drenched in institutions like this, starting with the rule of abstract principles.  Everything is subject to the tyranny of rules and principles.

In fact, of course, life is a lot messier than the rules and the abstract principles pretend.  You see it in the assumptions of Newtonian mechanics, that it is dealing with point particles and frictionless motion.

And you see it in the assumptions of 1,000 page bills to reform the whole health care system.

There are two things that can overcome the rules.

One of them is money.  If you have the money, you can tell the hospital: screw the rules; I'll pay for the admission and the dialysis.  Unfortunately for Frank Alfisi he had already spent all his money caring for his deceased wife in her terminal illness.

The other thing is love.  You can say: I don't mind what it costs, we are going to stump up the cash for dear old Dad.

But in our degenerate age we prefer to re-enact the helpless victim as poster boy melodrama.  We ask, with TV cameras rolling, how "they" could be so heartless as to deny care to Frank or to deny coverage to Betty.  Everyone knows their role, from tough reporter to tearful relative, and plays it to perfection.

Some of the better modern thinkers have recognized the problems with the modern age of reason.  They recognize that instrumental reason is mechanical, that institutions based on modern reason act "strategically," that you can't make an omelette without breaking eggs.  That something else is needed, something other than systems and bureaucracies.

The modern era has been going for about 200-500 years, depending on your taste.  It's long past time for anyone to be shocked by the heartlessness of modernity.  We should all recognize that modern governments and insurance companies and hospitals are purely "strategic" institutions.

If you don't want to fall between the cracks you need a Plan B.  Otherwise the "two midnight" rule or its close bureaucratic relative is going to get you.

1 comment:

  1. I bow to no one in my abhorrence of gov't involvement in medicine. It has been a disaster for medicine in the US for decades and it's only getting worse. However the '2 midnite rule' may not be quite the bugaboo you portray it to be. I can't speak to the specifics of the case you mentioned; I suspect someone misinterpreted the rule however. Where I practice it is commonplace to bring patients into the hospital for one 'midnite' for care that may include dialysis and many other treatments. It's called 'observation',not an 'admission', and the hospital doesn't get paid as much (and certainly strives to maximize as legitimately as possible those who are officially 'admitted' for '2 midnites' rather than in 'observation'. The '2 midnite' rule actually has made life a bit easier for we physicians at our hospital; we're no longer trying to please 'bean counters' to justify whether someone is an 'admission' vs an 'observation'; all we need to do is say we think the patient is going to stay 2 midnites. Even if they end up only staying one all we need to do is document that we were surprised that they improved that fast. Of course 'the devil's in the details': we don't know yet how this is all going to work out; if it ends up costing Medicare a lot more money, I suspect the 'bean counters' will come back and say 'you shouldn't have said this patient would stay 2 midnites' or something like that. So far, so good, but gov't involvement in medicine doesn't end well...