“Two Kinds of Hospital Patients: Admitted, and Not”

Over a year ago (June 22, 2012), the New York Times covered the topic of how someone with Medicare can be a patient in the hospital but not be an “admitted patient.” 

They’ve picked up the topic again this week probably because on October 1st a new Medicare policy took effect.  The new policy is:

“When a physician expects a patient’s stay to include at least two midnights, that person is an inpatient whose care is covered under Medicare Part A, which pays for hospitals. If it doesn’t last two midnights, Medicare expects the person to be an outpatient, and Part B, which pays for doctors, takes over.”  Apparently there is unanimity in disliking this new policy, which Johns Hopkins calls the “Cinderella Rule.”

The 2012 article refers to this Medicare publication –

“Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!”

Here’s a link to this week’s article:  (Note that some of the comments are worth checking out)


The New Old Age: Caring and Coping
Two Kinds of Hospital Patients: Admitted, and Not
New York Times
By Paula Span
October 29, 2013, 12:01 pm


Where’s That Advance Care Directive? (NYT, 10-17-13)

Many people have completed advance care directives (healthcare power-of-attorney, living will, POLST, Five Wishes, etc.) but, as this New York Times article points out, they haven’t distributed copies to the right people and they don’t have a copy available when needed.  The article notes that often these ACDs are at lawyers’ offices or in safe deposit boxes.

Between the article and the comments on the article, this advice was given as to whom to distribute copies of your ACDs:

  • primary care physician
  • other physicians including neurologist and cardiologist
  • individuals named as healthcare decision-maker
  • additional family members and friends

The author says:  “The more copies there are in circulation, the better the odds that one will materialize at the hospital when you need it.”

One of the comments had this useful advice from an attorney:  “I also tell clients to enter the names and numbers of their agents/proxies into their cell phones under an entry entited ICE== in case of emergency.  EMTs look for ICE numbers as well.”

Speaking of EMTs…  One local support group member handed his wife’s living will to the EMTs, who came to their home after he dialed 911 as his wife had fallen.  This is not a form that the EMTs can do anything with.  The only form that should be handed to EMTs is the POLST, which stands for Physician Orders for Life-Sustaining Treatment.  For lots of good info on the POLST, see capolst.org.

Other comments contained advice on where to place copies:

  • On the refrigerator door
  • If not on the refrigerator door, then put note on refrigerator door telling EMTs where the copy can be found, maybe near a bed or on the back of a door.
  • “Put a copy of it in the glove box of your automobiles, and ask your named health care agents to do the same.”
  • “If your health care agent is likely to take an airplane to your home destination, ask him/her to put a copy in his/her luggage.”
  • Save copies electronically in various places – Google Drive (and give access to others), Dropbox (and give access to others), on a smartphone, with a service, on a USB drive.

One other worthwhile suggestion — if you are wanting the ACD of a family member, ask them to give you their completed ACD as a Christmas gift.

Here’s a link to the full article:


The New Old Age: Caring and Coping
The New York Times
Where’s That Advance Care Directive?
By Paula Span
October 17, 2013, 6:00 am


My Life as a Caregiver (Dr. Nancy Snyderman, AARP Mag, Oct/Nov 2013)

This short article by Nancy Snyderman, MD — a medical expert on NBC News — was in the recent issue of AARP The Magazine. Here are a few things I picked up from the article:

* She says: “Perhaps the most important lesson I learned in all of this is how little we plan for the inevitable crises — and how much we all need help.”

* “Caregivers tend to patients an average of 20 hours each week, but many would agree that it often feels like more.”

* About half of all caregivers have a full-time job in addition to caregiving responsibilities.

Here’s a link to the article by Dr. Snyderman:


My Life as a Caregiver
‘When my father fell ill, I put my own life and health on hold to save his. It wasn’t easy’
AARP The Magazine,
by Nancy L. Snyderman, M.D.
October/November 2013



Advice About Assisted Living for Aging Relatives (NYT, 10-16-13)

The New York Times ran part one of a question-and-answer article on assisted living and other living arrangements for seniors.  It seems that senior living options are very location-specific so I’m not sure of the value of this general article.  But see what you think!

I did find value in the first commenter’s nine suggestions.  The first commenter, Kay, said she had seen a parent through dementia and three years in seven different care settings.  Her suggestions include:

1. Buy long term care insurance for yourself, now. This kind of care is expensive.

2. Your parent failed to do #1, and also failed to be wealthy? Your options are extremely limited. Examine your state’s Medicaid program carefully. Pay someone to serve as a consultant, if need be.

2a. Is your parent a veteran? This saved our bacon. Our state runs veterans homes, and the tariff at one of these was low enough (I assume with a DoD offset) that my parent could afford it. It took his whole pension, but didn’t impact us. That said, those places were often in distant, rural areas (they were anchors of the local economy, and placed there to be so), and so were hard for us to get to for visiting. Not to mention his friends.

3. Does your aging relative have dementia of some type? Most facilities are designed to care for the physically frail, not the physically OK but mentally frail. Locked units would drive a sane person crazy. With more Boomers aging, hopefully we can find a better solution.

4. Look into any state benefits for the disabled. Our state has a program that provides a caregiver for ADL’s if the recipient is disabled (and probably poor enough). Anything that can keep you in your own home is cheaper.

5. Group homes, if your relative would be happy with that option, are a more affordable and humane choice. (We’re talking a suburban house where each bedroom has a resident, and there are at most two caregivers present. This only works for people with relatively few needs.)

6. Most facilities of any type are heavily populated by women. If your relative is a man, he might totally hate this. Mine did.

7. Even in the best of places (nursing homes especially), staffed by the most loving caregivers, there is no substitute for family. You need to visit as often as possible. Did your relative run out of toothpaste? Is the clothing in his/her closet actually his? This can be a real problem if you live far away.

8. Be prepared emotionally for the disagreements between siblings regarding the care of a parent. This tore our family apart in a way that nothing else even approached. (And, no, it wasn’t about money.)

9. Investigate places in more rural parts of your area. They might be just enough cheaper that you can afford them. But, the drive will be long.

Next Wednesday part two of this article will appear.

Here’s a link to part one of the article:


Ask an Expert
Advice About Assisted Living for Aging Relatives, Part 1
By The New York Times
Published: October 16, 2013


“The Logistics of Death: What to Do When Someone Dies”

Michael Krasny, host of Forum, a radio program on KQED, focused on the logistics of death in a 52-minute long program on Monday, 10-14-13.  One guest was attorney Scott Taylor Smith, author of the new book “When Someone Dies: The Practical Guide to the Logistics of Death.”

Scott Taylor Smith said that as soon as his mother died, the questions began, despite his grief.  First, what mortuary did he intend to use?  Second, the mortuary wanted to know how many death certificates he wanted.  (His suggested answer is take the number of credit cards someone has and multiply by two.  That’s how many death certificates you may need.)

He suggests that you write the obituary and plan the memorial before the person dies.  For his mother, the family wanted to have a celebratory event.  This meant that they waited 6 months after her death before having the celebration.

Scott Taylor Smith talks about conflict in his family over the use of morphine for his mother.

Another guest was Jim Mitchell, an estate lawyer with Coblentz, Patch, Duffy & Bass in San Francisco.  He talked about probate and revocable trusts.  He was asked the downside of setting up a trust; his reply – “attorney’s fees.”  He discussed “permanent” estate tax legislation.

Jim Mitchell talked about two powers of attorney documents:  medical and financial.  He recommends consulting with an attorney on these documents but noted that they are available online.

A couple of the callers mentioned the POLST form.  This form must be signed by someone’s MD.  See capolst.org.

You can find an audio recording here:


I looked over the comments, gleaning one resource and one suggestion:

* everplans.com:  “articles, tips, and checklists to help people with everything from who to call first to how to choose a casket to what the various religious traditions are”

* “Death Certificates are expensive, as well as awkward to obtain. Good News: you can actually request that the various agencies, institutions, et cetera which require presentation of theses documents RETURN them to you (include a SASE with a note. Almost all of them will do so. The really only need to see (and then copy) same. The only exceptions for me were real estate-related (mortgage-holders). Even Social Security returned the certificate. I “recycled” several of them, and in doing, saved myself a lot of money, time and effort.”