CMS UPDATES:
Observation and
the 2-Midnight Rule
Society of Cardiovascular Patient Care
18th Congress – San Antonio, Texas
Michael A. Ross MD FACEP
Professor of Emergency Medicine
Emory University School of Medicine
Medical Director – Observation Medicine
Atlanta, Georgia
Disclosure of Commercial Relationships:
• Nature of Relationship Name of Commercial Entity
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Advisory Board
Consultant
Employee
Board Member
Shareholder
Speaker’s Bureau
Patents
• Other Relationships
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CMS Technical Advisory Panel: AMI,
HF, pneumonia
Past CMS APC Advisory Panelist
Chair – Visits and Observation
Subcommittee
Co-chair, Mission Lifeline Atlanta,
AHA
Objectives:
• A. Past: Understand the background and history of
observation services and the 2-Midnight Rule
• B. Present: Know the “Two Midnight Rule” and how it relates
to observation medicine
• C. Future: Know current and future CMS policy issues
regarding Observation Services and the 2-Midnight Rule
The Anatomy and Physiology
of Medicare . . .
• U.S. Government:
• Senate
• House of Representatives
• Executive Branch
• Cabinets
• Secretary of State, etc
• Secretary of Health and Human Services
Emory University 4
• Judicial Branch
• Legislative Branch:
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Assistant Secretary for Health
Public Health Service
Office of the Surgeon General
Public Health Service Commissioned Corps
Assistant Secretary for Preparedness and Response
Office of the Assistant Secretary for Preparedness and Response
Biomedical Advanced Research and Development Authority
Assistant Secretary for Legislation
Assistant Secretary for Planning and Evaluation
Assistant Secretary for Administration
Assistant Secretary for Public Affairs
Assistant Secretary for Financial Resources
Office of the Inspector General
Administration for Children and Families
Administration on Aging
Agency for Healthcare Research and Quality
Agency for Toxic Substances and Disease Registry
Centers for Disease Control and Prevention
Centers for Medicare and Medicaid Services
Food and Drug Administration
Health Resources and Services Administration
Indian Health Service
National Institutes of Health
Substance Abuse and Mental Health Services Administration
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DHHS:
Center for Medicare and
Medicaid Services
• Employs approximately 4,100 employees:
• Hubert H. Humphrey Building in Washington, D.C.
• 10 regional offices
• Various field offices located throughout the United States.
• The head of the CMS is appointed by the president and
confirmed by the Senate.
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• 2,700 are located at its headquarters in Baltimore
• The remaining employees are located in:
Regional Offices
• Region I – Boston, Massachusetts
• Connecticut, Massachusetts, Maine, New Hampshire, Rhode Island and Vermont.
• Region II – New York City, New York
• New Jersey, New York, as well as the U.S. Virgin Islands and Puerto Rico.
• Region III – Philadelphia, Pennsylvania
• Delaware, Maryland, Pennsylvania, Virginia, West Virginia and the District of Columbia.
• Region IV – Atlanta, Georgia
• Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina and
Tennessee.
• Region V – Chicago, Illinois
• Illinois, Indiana, Michigan, Minnesota, Ohio and Wisconsin.
• Region VI – Dallas, Texas
• Arkansas, Louisiana, New Mexico, Oklahoma and Texas.
• Region VII – Kansas City, Missouri
• Iowa, Kansas, Missouri, and Nebraska.
• Region VIII – Denver, Colorado
• Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming.
• Region IX – San Francisco, California
• Arizona, California, Hawaii, Nevada, the Territories of American Samoa, Guam, and the
Commonwealth of the Northern Mariana Islands.
• Region X – Seattle, Washington
• Alaska, Idaho, Oregon, and Washington
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Medicare
Medicaid
State Children’s Health Insurance Program (SCHIP)
Clinical Laboratory Improvement Amendments (CLIA)
Health Insurance Portability and Accountability Act (HIPA) of
1996
Note: Medicare eligibility is determined by the Social Security
Administration
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Medicare administers:
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Part A: Hospital Insurance - 1966
Part B: Medical Insurance
Part C: Medicare Advantage plans
Part D: Prescription drug plans
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Medicare Parts
Part A: Hospital Insurance
• Part A covers inpatient hospital stays, including
semiprivate room, food, and tests.
• Part A — For each benefit period, a beneficiary will
pay:
How much???
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• Definition of an inpatient – to be discussed
Part A: Hospital Insurance
• Part A covers inpatient hospital stays, including semiprivate room,
food, and tests.
• Part A — For each benefit period, a beneficiary will pay:
• A Part A deductible of $1,216 (in 2014) for a hospital stay of 1–60 days.
• A $304 per day co-pay (in 2014) for days 61–90 of a hospital stay.
• A $592 per day co-pay (in 2014) for days 91–150 of a hospital stay, as part of their limited
Lifetime Reserve Days.
• All costs for each day beyond 150 days[33]
• Coinsurance for a Skilled Nursing Facility is $144.50 per day (in 2012) for
days 21 through 100 for each benefit period.
• A blood deductible of the first 3 pints of blood needed in a calendar year,
unless replaced. There is a 3 pint blood deductible for both Part A and Part B,
and these separate deductibles do not overlap.
• Covers hospice benefits
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• Definition of an inpatient – to be discussed
Part A: Rehab or Skilled Nursing
Facility (SNF) payment
1.
A preceding hospital stay must be at least three days as an
inpatient, three midnights, not counting the discharge date.
2.
The nursing home stay must be for something diagnosed during
the hospital stay or for the main cause of hospital stay.
3.
If the patient is not receiving rehabilitation but has some other
ailment that requires skilled nursing supervision then the nursing
home stay would be covered.
4.
The care being rendered by the nursing home must be skilled.
•
Medicare part A does not pay stays which only provide custodial, nonskilled, or long-term care activities, including activities of daily living
(ADL) such as personal hygiene, cooking, cleaning, etc.
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• The Four “IF”s:
• Medicare will take back hospital inpatient payments and far
more, 4 to 18 times the initial payment, if an above-average
number of patients from the hospital are readmitted within 30
days.
• These readmission penalties apply after some of the most
common treatments: pneumonia, heart failure, heart attack,
COPD, knee replacement, hip replacement
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Hospital Inpatient
Readmission Penalties . . .
Medicare Contractors
• MAC: Medicare Administrative Contractors
• RAC: Recovery Audit Contractors
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Outpatient hospital procedures and visits
Physician and nursing services
X-rays
Laboratory and diagnostic tests
Influenza and pneumonia vaccinations
Blood transfusions
Renal dialysis
Limited ambulance transportation
Immunosuppressive drugs for organ transplant recipients
Chemotherapy
Hormonal treatments such as lupron
Other outpatient medical treatments administered in a doctor's
office.
13. Medication administered by the physician during an office visit
14. Durable Medical Equipment
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Medicare Part B coverage
includes:
Medicare Part B - deductible
• Exceptions – Medicare pays:
• Most lab services – 100%
• Outpatient mental health services – 55% (planned trending
toward 20% over several years)
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• For “covered” services - After a beneficiary meets the yearly
deductible of $140.00, they will be required to pay a coinsurance of 20%
Medicare payment issues:
Inpatient vs. Outpatient
Outpatient: ED or Obs
• 20% copayment for all
unpackaged services
• Time does NOT count
toward SNF
• Self administered drugs
NOT covered
Inpatient
• Single copayment for MSDRG ($1,216)
• Time counts toward 3-day
SNF benefit
• Self administered drugs
included
Where to find Medicare Part B
coverage criteria:
• National Coverage Determinations (NCD)
• at the national level
• multi-state area managed by a specific regional Medicare
Part B contractor
• Other sources:
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CMS Internet-Only Manuals (IOM)
The Code of Federal Regulations (CFR)
The Social Security Act
The Federal Register
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• Local Coverage Determinations (LCD)
Medicare rule making process:
• Proposed Rule (Federal Register)
• Open comment period
• Public / stakeholder organizations
• HOP (Hospital Outpatient Panel)
• Med Pac
• Closed comment period
• Final Rule (Federal Register)
• Program Memorandum
• Hospital Manual
• CMS website
• Implementation date
The 2-MN Rule: How did we get here???
1983:
DRGs
“Houston, we have a problem”. . .
• The Problem:
• Patients that are “too sick to go home,
but do not meet inpatient admission
criteria”
• The Solution: CMS created a “fix”:
• Observation Services
20
DEFINITION: OBSERVATION
Observation services are those services furnished on a hospital's
premises, including use of a bed and periodic monitoring by nursing or
other staff, which are reasonable and necessary to evaluate an
outpatient's condition or determine the need for a possible admission
as an inpatient...
... Such services are covered only when provided by order of a physician or
another individual authorized by State licensure law and hospital bylaws
to admit patients to the hospital or to order outpatient tests. . .
. . . Observation services usually do not exceed one day. Some patients,
however, may require a second day of outpatient observation services.
Observation services exceeding 48 hours will be denied.
Observation services history:
as the Pendulum swings. . .
• 1984 – The creation of observation services (unstructured)
• Pendulum swings to observation
• Hospitals over-use for all outpatient surgeries
• Pendulum swings to admission
• 2003 – CMS starts paying observation for only 3 conditions with
many stipulations
• Slight rise in obs
• 2007 – CMS removes stipulations, starts paying for all obs
conditions, interqual grows, RAC and readmission penalties grow
• Pendulum swings to observation
• 2012 – CMS redefines inpatient: the 2-MN rule
• Decrease prolonged observation and RAC audits?
• Impact on observation services?
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• 2000 – CMS stopped paying separately for observation
CMS Payment Policy for Observation Services
- APC 8009 (effective 2014)
• Requirements:
• Physician order and documentation supporting the need for
observation
• Preceding (packaged) HOSPITAL visit: any of the following
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Clinic visit (HCPCS code G0463)
Type A ED visit - level 4 or 5 (HCPCS code 99284; 99285)
Type B ED visit – level 5 (HCPCS code G0384)
Critical care (CPT code 99291)
• Minimum of 8 hours of observation:
• “observation services of substantial duration”
• HCPCS code G0378 X 8 or more
• No associated “T-status” procedure on the same or preceding day
• Surgery or procedures
• 2014 APC 8009 Payment Amount = $1,357
• 2014 APC 99285 amount = $ 456
Growth in observation services
• 2007 – 2009: Observation Services
• 34% rise in Medicare ratio of observation to inpatient stays (Feng,
Health Affairs, 2012; 31:6 1251-1259)
Reasons for growth in OS:
1. Return to baseline – observation policy changes
• 2000 - OS Elimination
• 2003 - 3 conditions with restrictions
• 2007 - No restrictions, all conditions
2.
3.
4.
5.
Shift from inpatient to outpatient – independent of OS
RAC audit pressures – 80% targeted status issues
Re-admission pressures – stiff penalties
Admission criteria confusion
• CMS criteria – legally binding, simple, intuitive (not used)
• RAC criteria – often commercial criteria (i.e. Interqual)
• Issues – a “book”, complex, poor evidence basis for several
conditions (musculoskeletal pain in the elderly)
Trends in observation services
• 2007 – 2009: length of stay creep (Feng, Health Affairs, 2012; 31:6 1251-1259)
• >24 hours = 50%
• >48 hours = 10%
Reasons for LOS creep . . .
• Patient selection: A growing pool of patients that did not meet
Interqual criteria
• Hospital fears – RAC and readmissions
• Setting – type 4 setting
B. The Present: OIG Reports
• Driven by concerns: To clarify
• Use of observation, long outpatient, and
short inpatient services
• Copayments for OS vs DRG
• Impact of these services on SNF benefit
• Issues with 2-midnight rule
• Scope of improper payments for all the
above
2012 Medicare Data: OBS, LOPS, and SIPS
• OBS: Observation volumes - 2.1 million:
• 1.5 million Obs => home
• 0.6 million Obs => Inpatient
• 78% began in the ED; 9% from cath lab/OR
• LOPS: Non-observation outpatient volumes:
• 1.4 million Long OP stays
• SIPS: Short Inpatient Stays ( <2 nights)
• 1.1 million SIPs
• Case mix was similar across all three groups!
• Total = 4.6 million claims
Does observation cost Medicare
less? YES!!! – almost 3 times less
• Over all:
• SIPS = $5.9 BILLION
• Obs = $2.6 BILLION
• By case:
• SIPS = $5,142 per case
• Obs = $1,741 per case
• Variation between conditions, however all favor observation
over inpatient
Does observation cost patients
more? NO!!!
• Average inpatient copay is almost twice as much as obs
• Observation copay is less than inpatient 94% of the time
• Average SIPS copayment = $725
• Average Obs copayment = $401
• 51% had self admin Rx costs = $528
• 6% (n=84K) paid more than IP deductible
• 0.2% (n=3K) paid more than 2X IP deductible
• By condition:
• IP more for 12/14 (359-$572 more)
• IP less for 2/14: Stent ($817) and circulatory disorder ($359)
• Policy question:
• Do you compromise the 94% for the 6%?
• How to address the copayment issue?
SNF Breakdown:
• 3 days, but less than 3 IP days
• Received SNF services
• Medicare paid (inappropriately)
= 617,702
= 25,245 (4%)
= 23,148 (92%)
• Medicare payment = $255M
• Ave patient copay = $2,735
• Medicare did NOT pay
• Ave patient copay
= 2,097 (8%)
= $10,503
• Bottom Line:
• SNF patients at risk represent 0.6% of whole group
IS THIS REALLY TRUE????
• 100% of 2009 Medicare inpatient and
outpatient claims:
• >1 million observation visits
• 2.9% (29,324) discharged to a SNF
• 62% came from the SNF
• 8% came from a NH
• 26% (7,537) came from community (at
risk)
• 0.75% (7,537) with SNF benefit at risk
• NOTE: OIG (above) reported that CMS
still paid 92% of these (inappropriately).
Is observation hiding
readmissions? - NO
For all Medicare beneficiaries: 2007-2012
• IP admits/ben fell 4.3%
• IP re-admits/ben fell 6.8%
• Obs visits/ben increased 11%
• Obs “re-admits”/ben increase 3.7%
• In absolute numbers:
• Observation did not come close to
accounting for the decline in readmissions
Is observation hiding readmissions? - NO
Pressure on CMS to do something
B. PRESENT: IPPS 2 Midnight Rule
From the “clock” to the “calendar”
• Written to:
• Provide a clear “Benchmark” to physicians for determining the
appropriateness of an inpatient admission.
• Decrease prolonged observation stays
• Decrease admission denials and RAC audits
• Timing:
•
•
•
•
Final rule out
Implementation date: October 1, 2013
Audit and educate period (MAC)
Final enforcement (RAC) – April 1, 2015
OLD INPATIENT DEFINITION:
Hospital Manual: Chapter II - Coverage of Hospital Services
210. COVERED INPATIENT HOSPITAL SERVICES. Page 21.3/Rev. 525, 01-89
An inpatient is a person who has been admitted to a hospital for bed occupancy for
purposes of receiving inpatient hospital services. Generally a person is considered an
inpatient if formally admitted as an inpatient . . .
. . . with the expectation that he will remain at least overnight
and occupy a bed even though it later develops that he can
be discharged or transferred to another hospital and
does not actually use a hospital bed overnight.
The physician should use a 24-hour period as a benchmark,
i.e., he or she should order admission for patients who are
expected to need hospital care for 24 hours or more, and
treat other patients on an outpatient basis.
However, the decision to admit a patient is a complex medical judgment
which can be made only after the physician has considered a number of
factors, including the patient's medical history and current medical needs,
the types of facilities available to inpatients and to outpatients, the
hospital's bylaws and admissions policies, and the relative appropriateness
of treatment in each setting.
NEW INPATIENT DEFINITION
• A 2-midnight benchmark: FOR DOCTORS
• An inpatient is expected to stay in the hospital at least two
midnights:
• 24 hours and 1 minute, or 47 hours and 59 minutes
• “Clock” starts at triage
• Outpatient time (ED or observation) counts
• Inpatient stays < 2-MN not paid as an inpatient
• except death, transfer, AMA, etc
• A 2-midnight presumption: FOR REVIEWERS
• If a patient met benchmark criteria, the admission will not be
scrutinized by reviewers (RAC, MAC, etc)
Under the Final Rule, CMS codified the definition of an inpatient admission
at 42 C.F.R. § 412.3. An inpatient admission is appropriate and payable
under Medicare Part A when:
• ORDER: The patient is formally admitted to the hospital pursuant to an
order for inpatient admission by a physician or other qualified
practitioner eligible to admit;
• The order is present in the medical record and is supported by the
physician admission and progress notes; and
• CERTIFICATION: The physician certifies the services are required to be
provided on an inpatient basis, and the certification must include:
• The order for inpatient admission;
• A documented reason for the inpatient hospitalization for either inpatient medical
treatment or diagnostic study, or special or unusual services for cost outlier cases; and
• A statement that the inpatient hospital services were provided in accordance with new
section 42 C.F.R. §412.3 (i.e., the order).
Asserts the authority of Medicare policy over
commercial tools:
CMS Open Door Forum: IPPS and 2-midnight rule
August 15, 2013
http://downloads.cms.gov/media/audio/081513InpHosAdm2MidnightProvSODF.mp3
George Mills: George Mills, Director, Provider Compliance
Group, Medicare Staff
“InterQual and Milliman are just tools, they are not
Medicare policy; the RACs and MACs and CERT use them, but
they are not definitive on Medicare rules and regulations and
coverage decisions (Medicare rules) are what is definitive, not the
InterQual or Milliman.”
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OP ordered
(obs) (obs)
Outpatient
Midnight #1
Discharge before
MN #2 likely?
+
Maintain OP
status.
−
Admit as IP
(generally)
Discharge before
MN #3 likely?
−
Maintain IP status
+
+
Midnight #2
IP criteria met
amd 2MN
benchmark?
−
Convert to OP
status (code 44)
Midnight #3
Maintain IP status
• OBSERVATION
PATIENTS:
• If a patient is not going to be
discharged before second
midnight – admit on second
day (don’t wait until third day).
• Avoid IP conversion then
discharge (abuse?) risk
• Avoid risking 3 day SNF
benefit
• MAC and RACs will target
patients for review for
inpatient stays of 0-1 days
IPPS and the 2MN Rule
• May 15th, 2014: IPPS Proposed Rule
• “Solicitation of comments on an alternative
payment methodology under the Medicare
program for short inpatient stays”
• “Discussion of the process for submitting
exceptions to the 2-midnight benchmark”
• August 19th, 2014: IPPS Final Rule
• Summary of comments
• No change in short inpatient payment policy
OPPS and the 2MN Rule
• July 14, 2014: OPPS Proposed Rule
• No meaningful change in the structure of
payment for APC 8009 “Extended Assessment and Management”
(observation)
• Proposed 2015 payment = $1,287
• 2-MN rule: Proposed revision of the
requirements for “physician certification”
of inpatient admission under the 2-MN rule
• Remove the requirement except for cases
that are “outliers” – whose length of day is
expected to go beyond 20 days.
Reflections on the 2-MN Rule:
• Unintended consequences of the 2-MN Rule – Procedural
cases:
• Not the intent of the 2-MN rule as stated
• Big financial impact on hospitals
• Beneficiary Impact with deductibles markedly increase
• Example: EP Procedure from $1,068 to $6,224
• Is it a solution, or a symptom?
• Solution –
• Simplifies and reasserts the authority of CMS inpatient criteria
• Prolonged outpatient stays – should decrease SNF, RAC issues
• Symptom – “6-24 hour patients”
• Observation services – does it address their needs adequately?
• Unresolved issues – SNF, self administered meds, site of service
C. FUTURE: U.S. Health Care - 2014
Health care costs . . .
Patient co-pays are increasing
2013 Kiaser EmployerHealthBenefitsSurvey:
http://kff.org/private-insurance/report/2013-employer-health-benefits/
“Hospitalized but Not Admitted”
Sheehy AM et al. JAMA IM 2013
• Retrospective observational cohort study
• Setting: Type 4 (No type 1 obs unit)
• 566 bed Academic Medical Center (U. Wisc)
• Time frame:36 months
• Population: Hospitalized patients
• 43,853 patients
• 10.4% for “observation”
• Mean LOS = 33.3 hours (17% over 48 hours)
• Medical patients = 41.1 hours
• More medical, elderly, and female patients
• Hospital Margin = LOSS of $331 per case
• Conclusion: “. . . observation status”
• Are they missing something???
Variations in Observation Services
– Wright, Hockenberry
• Hospital characteristics are associated with the duration of
observation services
• Prolonged observation services increase patient costs
Vankatesh A, Suter L; HSR Aug 2014, 1083-1087
Observation Service Settings:
52
Condition / Year / Author
N
Primary Outcome
1. Syncope / 14 / Sun *
124
↓ admissions and LOS
2. Chest Pain / 10 / Miller *
110
↓ Cost (stress MRI)
3. Atrial Fib / 08 / Decker
153
↑ conversion to sinus
4. TIA / 07 / Ross
149
↓ LOS and cost
5. Syncope / 04 / Shen
103
↑ established diagnosis, ↓ admissions
6. Asthma / 97 / McDermot
222
↓ admissions, no relapse ↑
7. Chest Pain / 98 / Farkouh
424
No difference cardiac events
8. Chest Pain / 97 / Roberts
165
↓ LOS and cost
9. Chest Pain / 96 / Gomez
100
↓ LOS and cost
*Added since published after this review
ALOS Trend across State and Nation
ED volumes
OS Volumes
OS LOS >8hr (average)
% OS >24hr
% OS >36hr
% OS >48hr
% OS >72hr
OS=>IP admit rate
Emory/Grady
(Type 1 units)
185,901
7,199
17.2 hr
10.4%
0.1%
0.1 %
0%
13.1%
Georgia
(HCUP 2010)
4,194,602
162,375
27.2 hr
42.8%
23.0%
6.7%
1.5%
17.8%
National
(NHAMCS 2009-10)
133 million
1,216,000 **
22.3 hr
29.0%
14.9%
6.9%
0.9%
23.2%
54
• U.S. Savings Potential from Type 1 Units:
• Observation patients -
$950 Million / year
• 38% shorter stays
• 44% lower admit rates
• Short Inpatients -
$8.5 Billion / year
• 11.7% of all admissions
• Savings potential – ED visits vs ED admissions:
• Avoided ED visits =
• Avoided ED admits =
• Relative savings =
(avoided: admits vs ED visits)
$2.3-3.4 Billion/yr
$5.5-8.5 Billion/yr
2.4-2.5 times greater
•
•
•
•
•
Observation Paradox . . .
Consider E&M services:
E/M Service:
Clinic Visits
Emergency (99281-5)
Critical Care
Inpatient Services
• Observation Services
(99217-20, 99234-6)
Service Location:
Clinics
Emergency Departments
Critical Care Units
Inpatient Beds
2/3 of U.S. hospitals:
Anywhere in the hospital???
56
ACEP 2015 OPPS Proposal to
CMS regarding observation
• CMS should ask hospitals to report the “site of service” for
observation patients (in a dedicated unit or not)
• Apply time in observation to the SNF 3-day stay
• Cover self administered medications
• We agree - Remove the certification requirement from the 2MN rule
Summary
• To understand current 2-MN rule and observation policy
issues, one needs to know their history
• The 2-MN rule is a big change that will better define and value
observation services
• Like other E/M services, CMS needs to recognize the setting in
which observation services occur.
• If you don’t have an observation unit, you have a problem!
References:
•
•
•
•
•
•
•
•
•
•
Office of Inspector General. 2013. “Memorandum Report: Hospitals’ Use of Observation Stays and Short Inpatient
Stays for Medicare Beneficiaries, OEI-02-12- 00040.”Washington, DC [accessed on September 10, 2013]. Available
at http://oig.hhs.gov/oei/reports/oei-02-12-00040.asp
Feng Z, Jung HY, Wright B, Mor V. The origin and disposition of Medicare observation stays; Medical Care; 2014,
article in press
Ross MA, Aurora T, Graff L, Suri P, O’Malley R, Ojo A, Bohan S, Clark C. State of the Art: Emergency Department
Observation Units. Critical Pathways in Cardiology 2012;11: 128–138
Sheehy A, Graf B, Gangireddy S, et al. Hospitalized but not admitted: characteristics of patients with “observation
status” at an academic center. JAMA Intern Med. 2013;173(21):1991-8. doi: 10.1001/jamainternmed.2013.8185.
Wright, B., H.-Y. Jung, Z. Feng, and V. Mor. 2014. “Hospital, Patient, and Local Health System Characteristics
Associated with the Prevalence and Duration of Observation Care.” Health Services Research 49 (4): 1088–1107.
Hockenberry JM, Mutter R, Barrett M, Parlato J, Ross MA Factors associated with prolonged observation services
stays and the impact of long stays on patient cost. Health Services Research. Dec 2013. 1-17
Ross MA, Hockenberry JM, Mutter R, Wheatley M, Pitts S. Protocol-Driven Emergency Department Observation
Units Offer Savings, Shorter Stays, And Reduced Admissions. Health Affairs. Pub pending, 2013 Dec; 32(12):21492156
Venkatesh, A. K., B. P. Geisler, J. J. G. Chambers, C. W. Baugh, J. S. Bohan, and J. D. Schuur. 2011. “Use of
Observation Care in US Emergency Departments, 2001 to 2008.” PLoS ONE 6 (9): e24326.
Baugh, C.W., A. K.Venkatesh, J. A. Hilton, P. A. Samuel, J. D. Schuur, and J. S. Bohan. 2012. “Making Greater Use of
Dedicated Hospital Observation Units for Many Short-Stay Patients Could Save $3.1 Billion a Year.” Health Affairs
31 (10):2314–23.
Venkatesh, A. K . Suter LG. 2014. Observation “Services” and Observation “Care” – One Word Can Mean a World of
Difference. Health Services Research 49 (4): 1083–1087.