Q&A: Medical Bills; Coughing
Q. My elderly mother received an outlandish bill after being in the hospital for several days. Medicare denied payment for things it normally covers and I was told that it was because she was under observation status. What is going on here?
A. The adjective Kafkaesque, inspired by the literary work of Franz Kafka, describes absurdly complex, impersonal, bizarre, or illogical situations that people can neither understand nor control-such as the current state of Medicare’s observation care.
Observation care is supposed to be used for patients who need some hospital care but not more than two nights of full hospital admittance, but it is often used for longer stays. Even though observation care is often provided in an inpatient unit, Medicare always considers it an outpatient service, which has serious financial implications. The very same services incur higher costs and lower coverage levels. When a patient is under observation, Medicare won’t even pay for normally covered routine medications, such as those for hypertension or diabetes.
It gets worse. Medicare will pay for a skilled nursing facility (SNF) or nursing home only if a patient first spends three nights in the hospital—but observation days don’t count. In one case that is part of an ongoing class-action lawsuit, a woman spent 38 days in the hospital and was still denied SNF coverage. Most people are never told that they are under this status.
So why are hospitals using this status now more than ever? In part, to avoid Medicare accusations of overcharging. Some hospitals classify up to 70% of admissions as observation status, while others hover around 10%.
Patients can’t even appeal their observation status, unlike almost all other Medicare decisions. Seema Verma, the Centers for Medicare & Medicaid Services administrator, is fully aware of the problem and wrote on Twitter, “Medicare beneficiary who requires skilled care in a nursing home? Better be admitted for at least three days in the hospital first if you want the nursing home paid for. Gov’t doesn’t always make sense. We’re listening to feedback.”
Some of that feedback is coming in the form of a class-action lawsuit that began in August. Follow the suit at https://www.medicareadvocacy.org/medicare-info/observation-status/.
Q. I cough incessantly, and nothing that my doctor has tried has given me relief. What could be causing it?
A. The most common causes of chronic cough are postnasal drip, sinusitis, asthma, gastroesophageal reflux disease (GERD), and the use of an angiotensin-converting enzyme (ACE) inhibitor. A few weeks to months of treatment, or a medication change, clears up the majority of these cases, but up to 40% of people keep coughing.
Once serious conditions such as lung cancer, pneumonia, or other pulmonary diseases are ruled out, these people are often diagnosed with cough hypersensitivity syndrome (or sensory neuropathic cough). Neuropathic pain medications, such as gabapentin and amitryptyline, help some patients, while speech therapy, behavioral cough suppression therapy, and even Botox injections in the larynx help others—but not all.
There is another simple and often overlooked treatment that may help some people. In 2011, researchers reported in the American Journal of Clinical Nutrition that vitamin B12 (cyanocobalamin) deficiency may also play a role in chronic cough. The team studied 42 patients with chronic, unexplained cough. They discovered that the 27 participants who had a B12 deficiency had a higher prevalence of laryngeal hyperresponsiveness, a thinner oropharyngeal epithelium, a lower number of myelinated nerve fibers, and a higher immunoreactive score for nerve growth factor than people with normal B12 levels.
After two months of B12 injections, patients who had been deficient in B12 experienced significantly improved symptoms. Patients who were not deficient saw no improvement.
B12 deficiency can result from a vegan diet or the use of certain medications, including colchicine, chloramphenicol, ethanol, histamine 2 receptor antagonists, metformin, and proton pump inhibitors.
If your physician is unable to help you get your cough under control, you may want to seek out the services of a dedicated cough center, such as the one at Duke Clinic Voice Center, the Mayo Clinic or the Cleveland Clinic.
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