Could UnitedHealth Group’s Woes Ultimately Result in Improvements?

By Juliet Ugarte Hopkins, MD, ACPA-C

In the last seven months, UnitedHealth Group (UHG) has been racked by devastating events, from the massive cyberattack on Change Healthcare in October to the murder of UnitedHealthcare’s (UHC’s) CEO, Brian Thompson, in December. 

At the end of last month, after reporting a weaker-than-expected first quarter (despite posting $6.3 billion in profit during the same timeframe), UHG stock plummeted by more than 22 percent, faster than any drop seen by the company in the last 25 years. 

UHG’s CEO at the time, Andrew Witty, associated the poor performance with beneficiaries – especially those within their Medicare Advantage (MA) plans – utilizing more medical services than expected. This comment truly (and possibly, inadvertently) illustrated the point that health insurance companies make more money for their shareholders when their beneficiaries don’t seek out or receive healthcare services.

This comes as no surprise to case managers everywhere who try and secure skilled nursing facility (SNF) or inpatient rehabilitation facility (IRF) care for hospitalized patients and repetitively face stalling tactics (and ultimately, denials).

Then, on May 13, UHG stock dropped again, this time by more than 16 percent, in the hours after Witty abruptly resigned “for personal reasons.” Despite multiple lawsuits and threatened actions by private, state, and federal agencies across the country, UHG has been a longtime dominant force related to revenue cycle, provider staffing, utilization, and managed and commercial health insurance plans.

The owner of Aetna, CVS Health, as well as Humana have also seen recent declines in their profitability, but to a lesser extent than that of UHG. This is likely a reflection of what historically has served UHG so well in the past – a profound presence in healthcare across the country.

Last year alone, UHG acquired or created over 250 subsidiaries, including acute surgery centers, home care companies, and pharmacies. The thousands and thousands of new beneficiaries that came along with these subsidiaries – many of whom are covered by UHC’s managed Medicare plans – possibly led to the unanticipated increase in costs of medical services. 

On May 15, UHG stock plunged yet again, by more than 15 percent, after the Wall Street Journal reported the U.S. Department of Justice (DOJ) has been conducting a criminal investigation since last summer into possible Medicare fraud carried out by UHG’s Medicare Advantage arm of the business. This is in addition to a DOJ civil investigation announced at the start of the year, looking into the possibility of UHG inappropriately assigning more significant diagnoses to beneficiaries to obtain larger or extra payments from Medicare.

While an official announcement from the DOJ has not yet been made, considering that UHG stock is down almost 50 percent since the start of 2025 and has lost over $300 billion of its $600 billion market value in one month, it’s clear recent events have taken their toll on the company and are not a simple blip on the radar. Since the road toward the astronomical profitability UHG has enjoyed in prior years was paved with narrow medical care access for beneficiaries, what could these recent events mean for hospitals and the patients they serve? Increased scrutiny of the medical necessity of emergency department care or hospitalizations? Escalated denials related to out-of-hospital continuation of care at SNFs, access to home nursing and therapy services, or coverage of medications and durable medical equipment (DME)?

Unfortunately, it’s very possible that beneficiaries and the health systems serving them will experience most of these frustrations.

On the other hand, should hospitals dare to dream that positive changes are on the horizon, concerning their dealings with UHC? In an effort of good faith, might UHC throttle back their aggressive tactics, involving an overwhelm-and-overcome strategy related to denials, and put less emphasis on shareholder dividends and more on patient care? 

While a possibility, it appears less likely now, given that Witty was quickly replaced by former UHG CEO Stephen Hemsley, who ran the organization from 2006–2017. 

References:

1. What UnitedHealth’s Stock Drop Reveals About Medicare Advantage, N. Adam Brown, MD, MBA, MedPage Today, April 29, 2025 

2. UnitedHealth Group Reports Third Quarter 2024 Results, BusinessWire, October 15, 2024

3. UnitedHealthcare stock takes massive hit after earning forecast cut, Fox 9 KMSP and Associated Press, April 17, 2025

4. UnitedHealth Group stock tumbles; Andrew Witty steps down as group CEO, Martin Baccardax, The Street, May 13, 2025

5. UnitedHealth Group shares plunge 13% on report of DOJ probe into possible Medicare fraud, Annika Kim Constantino, CNBC, May 15, 2025

6. UnitedHealth Responds to Fraud Investigation Report: ‘Deeply Irresponsible’, Newsweek, May 15, 2025

Navigating the Two-Midnight Rule with Medicare Advantage

By Tiffany Ferguson, LMSW, CMAC, ACM

In its Contract Year 2026 Medicare Advantage and Part D Final Rule (CMS-4208-F), the Centers for Medicare & Medicaid Services (CMS) addressed ongoing confusion about how Medicare Advantage (MA) plans apply inpatient criteria, specifically the “two-midnight rule” and how this interacts with appeal processes through the Independent Review Entity (IRE).

Layered deep in the seventh provision to clarify terminology regarding inpatient level of care, which primarily surrounds clarification of concurrent status changes and notice requirements for MA plans to patients, you will find a question from a key commenter who raised concerns about the disconnect between the two-midnight presumption used in traditional Medicare and the flexibility afforded to MA plans in denying inpatient claims.

The concern focused on the patient experience: beneficiaries are often admitted under an inpatient order, only to learn later that their stay has been reclassified as outpatient or observation, despite receiving the same level of hospital care. This results in potential financial liability and confusion, particularly when coverage status changes mid-stay.

Despite the gains that many hospitals felt regarding MA final rule 4201, this appears to be an interesting clarification regarding the difference between the two-midnight presumption verse the two-midnight benchmark.

CMS clarified that while the rule strengthens various enrollee protections, it does not extend the two-midnight presumption to MA plans. The presumption, which deems inpatient admissions crossing two midnights as appropriate for Part A payment, was designed as a safeguard for traditional Medicare post-payment reviews conducted by Recovery Audit Contractors (RACs) or Quality Improvement Organizations (QIOs). The response then went on to say that this ruling is not a universal standard and does not bind MA organizations.

MA plans, however, are required to follow the inpatient admission criteria outlined in 42 CFR §412.3, commonly referred to as the “two-midnight benchmark.” This means that if a physician expects the patient to require hospital care spanning at least two midnights and formally admits the patient as such, the criteria for inpatient coverage may be met assuming the documentation supports medical necessity.

Importantly, CMS emphasized that if the IRE overturns an MA denial and determines that the inpatient admission meets criteria under §412.3, MA plans must honor the IRE’s decision and effectuate payment.

Although the two-midnight presumption remains outside the MA scope, CMS has taken other steps in the final rule to reduce patient and provider burden. These include stronger notice requirements for communication tools from MA plans to ensure level of care changes are communicated timely to patients, clarification on when MA beneficiary financial liability is triggered, and limitations on retroactive reclassification of previously approved inpatient stays.

To safeguard against the two-midnight benchmarking allowance for MA plans, the burden of proof will remain on providers to ensure thorough documentation surrounding intentions for admission, and the clinical rationale for inpatient care.

CMS Suspends Eight MIPS Improvement Activities for 2025

By Tiffany Ferguson, LMSW, CMAC, ACM

In early May, the Centers for Medicare & Medicaid Services (CMS) announced the suspension of eight improvement activities under the Merit-Based Incentive Payment System (MIPS) for the 2025 performance year.

The notice stated that “this decision aligns with the Improvement Activities Suspension Policy finalized in the CY 2021 Physician Fee Schedule (PFS) Final Rule (86 FR 65465),” and it can be seen as a precursor to their potential removal in future rulemaking.

MIPS, a key component of the CMS Quality Payment Program (QPP), requires eligible clinicians to report across four performance categories: quality, cost, promoting interoperability, and improvement activities. The improvement activities category specifically aims to encourage practice-level enhancements that support patient engagement, access to care, and population health.

For 2025, CMS is suspending the following eight activities:

1. IA_AHE_5: MIPS Eligible Clinician Leadership in Clinical Trials or Community-Based Participatory Research (CBPR);

2. IA_AHE_8: Create and Implement an Anti-Racism Plan;

3. IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols;

4. IA_AHE_11: Create and Implement a Plan to Improve Care for LGBTQ+ Patients;

5. IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health;

6. IA_PM_6: Use of Toolsets or Other Resources to Close Health and Health Care Inequities Across Communities;

7. IA_ERP_3: COVID-19 Clinical Data Reporting with or without Clinical Trial; and

8. IA_PM_26: Vaccine Achievement for Practice Staff: COVID-19, Influenza, and Hepatitis B.

While these activities are no longer available for selection in 2025, clinicians who have already completed or are in the process of completing them may still attest and receive credit. CMS has stated that all related QPP resources, including guides, factsheets, and the “Explore Measures and Activities” tool are currently being updated to reflect these suspensions. However, as of this report, nothing is available on the QPP website.

The rationale for these changes has not been elaborated on, but the move is expected to stir debate, particularly given that several of the suspended activities focus on health equity, social determinants of health (SDoH), and pandemic-related responses. CMS had previously emphasized these areas as high-priority in the wake of COVID-19 and ongoing efforts to reduce health disparities; however there is clearly a political shift in focus with the current administration.

Clinicians and practices participating in MIPS are advised to consult the updated 2025 Improvement Activities Inventory to identify alternative activities that align with their practice capabilities and patient population needs. The inventory remains a critical tool for guiding MIPS compliance and maximizing performance scores, which directly influence Medicare payment adjustments.

This suspension reflects an evolving policy landscape within CMS as the agency continues to balance an emphasis on regulatory burden reduction with the promotion of value-based care.

Per the news brief, additional updates and proposals are anticipated in future rulemaking cycles.

Leveraging the QIO for Patient-Level Appeals Under MA Final Rule

By Tiffany Ferguson, LMSW, CMAC, ACM

The finalized Medicare Advantage (MA) Rule 4208 includes important clarifications of enrollees’ rights to appeal denied inpatient stays. In my casual reading for clarification on another topic, I noticed this statement on page 175:

“We note that similar policies exist for other types of coverage denials. For example, after an MA organization determines that covered inpatient care is no longer necessary, the enrollee may file an expedited appeal of the discharge decision to the QIO (Quality Improvement Organization). If the QIO upholds the MA organization’s decision, and the enrollee has left the hospital, in accordance with § 422.622(g)(2), the enrollee may continue their appeal to the ALJ (administrative law judge), Departmental Appeals Board (DAB), and ultimately, Federal court (if other conditions are met).”

Specifically, under 42 CFR §422.622, MA enrollees may initiate an expedited appeal through the QIO when their plan determines that continued inpatient care is no longer necessary. This marks a critical shift in the landscape for hospitals and case management teams, especially as they grapple with increasingly aggressive denial practices from MA plans for continued stay hospitalizations – particularly for those untimely authorizations and post-acute denials. There have been increasing reports of MA organizations not only denying continued inpatient hospital days, but simultaneously delaying or denying authorizations for medically necessary post-acute care placements.

Traditionally, hospitals have issued the Important Message from Medicare (IMM) only in the parameters of the physician-expected and initiated discharge, in a similar construct to guidance for Medicare fee-for-service (FFS) beneficiaries. However, MA enrollees have distinct rights under §422.622 that differ from the FFS model. According to the regulation and operational guidance, once an MA organization issues a formal denial of continued hospital coverage, hospitals are responsible for informing patients of their right to request immediate QIO review, even if the patient remains hospitalized.

The guidance specifically states that “an enrollee has a right to request an immediate review by the QIO when an MA organization or hospital (acting directly or through its utilization committee), with physician concurrence, determines that inpatient care is no longer necessary.” Note that this statement does not cite all hospital care services, but specifically inpatient hospital services. 

Thus, the IMM should be provided alongside the MA plan’s denial notice, and case management/utilization review (CM/UR) teams should actively engage patients regarding their expedited appeal options. If the patient elects to appeal, they may contact the QIO directly, triggering an expedited review. Under section (c), the Centers for Medicare & Medicaid Services (CMS) confirms that the burden of proof is on the MA organization to prove to the QIO why the patient discharge is the correct decision, either on the basis of medical necessity or based on other Medicare coverage policies.

This process introduces several operational changes that CM/UR teams may want to consider. Once a notice of continued non-coverage is received from the MA plan, UM/CM teams will want to convene immediately, review with the attending for concurrence, and provide notice of denial to the patient with the IMM. This will notify the patient of their appeal rights to the QIO, and should the patient elect to appeal, the QIO would review to either support continued stay approval from the MA plan or push for timely authorization and support for needed post-acute placement.

By embedding the QIO appeal process earlier, when the denial is issued, rather than at discharge, hospitals can better protect patients, address financial inequalities regarding inpatient services, and challenge inappropriate payer behaviors that compromise safe discharge planning.

CMS Proposes Key Updates to TEAM Under IPPS Proposed Rule

By Tiffany Ferguson, LMSW, CMAC, ACM

In the FY 2026 Inpatient Prospective Payment System (IPPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) announced updates to the Transforming Episode Accountability Model (TEAM); discussed in prior articles, this is a new mandatory alternative payment model scheduled to start January 1, 2026. TEAM will run through December 31, 2030, and will test whether an episode-based payment approach tied to quality metrics can reduce Medicare expenditures while maintaining or improving care quality for beneficiaries.

TEAM will focus on five surgical episode categories: Coronary Artery Bypass Graft (CABG) surgery, lower extremity joint replacement, major bowel procedures, surgical hip/femur fractures, and spinal fusion. In the FY 2026 proposed rule, CMS has introduced several key modifications designed to adjust TEAM’s structure ahead of its performance start date. The changes include:

• Limited Deferment Period: Certain hospitals may be granted a temporary deferment from TEAM participation based on specific criteria such as new hospitals, purchased-acquired hospital, or data adjustments through the program period that would put a particular hospital in the program qualifying core-based statistical area.

• Track 2 Eligibility Alignment: Hospitals designated as Medicare Dependent Hospitals (MDH) will have participation eligibility linked to the expiration of the MDH program itself. Per the proposed ruling there are about 25 hospitals that are MDH and in TEAM.  21 of those are Track 2 eligible for being either a safety net, rural community, or sole community hospital.

• Finalized Quality Measures: The addition of the Information Transfer Patient Reported Outcome-based Performance Measure (Information Transfer PRO-PM) aims to strengthen patient-reported outcome tracking.

• Neutral Quality Measure Submission Option: TEAM participants who submit insufficient or low volumes of data will now receive a neutral quality measure score, proposed as essentially a score of 50 from 1-100, to avoid being penalized.

• Target Price Construction for Coding Changes: A recommendation has been proposed to adjust target pricing structures when procedural coding changes occur during the model period. CMS will also reconstruct the normalization factor and prospective trend factor used in financial benchmarks throughout the program period.

• Shift in Calculations: TEAM will replace the Area Deprivation Index (ADI) with the Community Deprivation Index (CDI) which is consistent with the ACO REACH model calculations.

• HCC lookback period: CMS proposes a similar adjustment to lessons learned from the bundled payment program to adjust the lookback period for Hierarchical Condition Codes (HCCs) to 180 days, instead of 90, with HCC v28.

• Removal of Health Equity: The updated ruling has removed any mandatory and voluntary data tracking and reporting for health-related social needs or health equity data.

• Adjustment of labels from gender to sex: For data reported, TEAMS participants will be required to submit the binary sex labels of surgical patients, rather than the previous term of gender.

• SNF 3-Day Waiver expanded to include swing beds: The ruling proposes including the SNF 3-day waiver for TEAM members to SNFs that meet the CMS Star rating requirements of 3 stars or better. The proposal noted that swing beds are being considered for this waiver, thus patients in TEAM will be eligible to transfer to a swing bed under the waiver program.

• Removal of the Decarbonization Initiative: CMS has also withdrawn the proposed Decarbonization and Resilience Initiative from the model.

Additionally, CMS is seeking public comment (but not proposing changes yet) regarding Indian Health Service (IHS) hospital outpatient episodes, low-volume hospitals, the use of standardized prices and reconciliation amounts, and primary care service referral requirements.

Through these updates, CMS aims to strengthen TEAM’s focus on driving quality improvement and cost reduction across surgical episodes. The proposed ruling describes these revised changes as a continued effort to promote fairness in performance assessment, and ensure a more seamless transition for hospitals into value-based payment models.

Hospitals impacted by TEAM should carefully review these proposed changes and consider submitting comments before the final rule is issued.

Understanding the First Steps To Address Custodial Hospitalizations

By Juliet Ugarte Hopkins, MD, ACPA-C

Custodial or social hospitalizations have been a long-standing issue within acute care hospitals. 

These patients generally arrive to the Emergency Department (ED) with vague or even no acute complaints. 

Following initial work-up, it’s clear they don’t medically require hospitalization but deficits in their day-to-day needs or the ability to care for themselves remain unsolved. As such, there is significant concern by the medical team and often, the patient themselves, that there is no safe path forward to ensure the patient’s well-being.

Some hospitals have Herculean initiatives and well-staffed teams focused on finding alternative modalities of care or placement out of the ED; but even they are unable to avoid hospitalization in every case. Every day, scores of patients across the country enter inpatient hospital beds for what amounts to custodial care. 

Assistance with ambulation, transfers, and activities of daily living (ADLs), administration of medications, and delivery of meals are all available in the hospital setting but don’t require the hospital to take place. Absent a perfect world with strong and all-encompassing support systems for these individuals who need assistance to safely live their lives, hospitals are the social safety net. 

Much has been written and discussed about this topic, including how to address or mitigate the problem. In fact, I and fellow MedLearn Media Talk Ten Tuesday panelist, Tiffany Ferguson, presented at the American College of Physician Advisors’ National Physician Advisor Conference recently about this very topic. But what often gets overlooked are the very first steps hospitals need to take when considering solutions. 

These initial steps seem incredibly simple but can be astonishingly complex, involving multiple teams to participate and ensure success – case identification and data collection.

In theoretical discussion, custodial cases seem easily identifiable. In reality, clarity wanes when medical staff are faced with providing care to dozens of patients over the course of a shift and are intimately aware of these patients’ profound limitations. 

Does that extremely debilitated, practically cachectic, 90-year-old man who hasn’t yet been able to take his medications without dropping a pill or two, really not need hospital care? What about the 42-year-old woman with severe developmental delays who was brought to the ED because her elderly parents simply can’t manage her transfers, toileting, and bathing any longer? 

What were the parents supposed to do?

Targeted discussion and education delivered to nurses, physicians, social workers, and case managers should focus on identifying the difference between no other available option to provide patient care, and care which can only be provided in the hospital. Emphasizing robust identification of these patients will allow the health system to effectively investigate augmentation of or collaboration with outpatient services and community support. 

Point out that when these patients are effectively cared for outside of the hospital setting, more hospital beds will be available for those who truly require them for their acute medical needs. 

Identification is one aspect, but collection of the data is another. Do you have modalities to capture different scenarios or discharge barriers in your electronic medical record? Who can enter this information, and is it simple for them to do so? 

If only case managers have this tracking tool access, how does the message get passed along when a nurse, social worker, or physician suspects a patient’s hospitalization is custodial in nature? Ultimately, who is reviewing the data and making sense of it all, providing recommendations of action? 

Patients who are hospitalized solely for custodial or social reasons should be classified as Outpatient or Outpatient in a Bed. They do not have need for Observation services, and their lack of need for care which can only take place in the hospital setting creates ineligibility for Inpatient status (regardless of how many days they are in a hospital bed before an outpatient care plan is established and the patient is discharged). 

However, what if a patient who is hospitalized for custodial reasons, then develops a condition which requires hospital care or investigation? In this instance, adding Observation services, at least, would be appropriate. But if your hospital’s method of identifying and tracking custodial cases involves designation of Outpatient status at discharge, these patients would be lost due to the addition of Observation services to the claim. 

This could be remedied by adding a different designator in your electronic health record which is independent of patient status and even allows tracking of days associated with cases which become custodial following a justified medical or surgical hospitalization. Since this is a situation to which case managers would be most attuned, application of this type of identifier by this team might make the most sense. 

However, they should not carry this mantle alone, which brings us back to education for physicians, bedside nurses, and others to participate in prompt identification.

Routine review of collected cases by a physician advisor should involve sorting into categorization types, payors, and length of time custodial care was provided. Categorization types might include the following:

1. Assistance with ADLs

2. Assistance with transfers/ambulation

3. Family no longer willing/able to care for patient

4. Facility no longer able to care for patient

5. Guardianship/other legal challenge

6. Unhoused

Collaboration with members of the hospital’s revenue cycle team can then assign a financial impact to these cases based on the cost of services provided without reimbursement. Additionally, retrospective review of the hospital’s ED boarding numbers and potentially lengthened throughput during days when there were high levels of custodial patients occupying hospital beds can provide more clarity to the overall impact of these cases to the hospital’s ability to function at its highest level for the surrounding community.

Support for development of comprehensive and effective processes will be realized only when the scope and impact of custodial hospitalizations is made clear to your hospital’s leadership. 

Before expending effort into how to address this issue, focus first on synthesizing a clear picture of the challenges and impacts.

Significant Changes to Medicare Readmission Reduction Program

By Tiffany Ferguson, LMSW, CMAC, ACM

In the FY 2026 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) proposed rule, the Centers for Medicare & Medicaid Services (CMS) introduced significant updates to the Hospital Readmissions Reduction Program (HRRP).

CMS is proposing five major changes to the HRRP that will have significant impact on how hospitals and health systems manage and address readmissions. If these proposed changes are finalized, important adjustments will be needed toward readmission avoidance strategies. 

The proposed changes include the following:

1. Inclusion of Medicare Advantage Data: Historically, HRRP has assessed readmission rates using data from only Medicare Fee-for-Service (FFS) beneficiaries. In a notable shift, CMS proposes to refine all six readmission measures to include patients enrolled in Medicare Advantage (MA). The IPPS ruling stated that this will provide a more comprehensive view of hospital performance across the full spectrum of Medicare beneficiaries and aligns with CMS’s broader goal of data harmonization.

2. Removal of COVID-19 Exclusions: CMS previously excluded patients with a COVID-19 diagnosis from the denominator of the readmission measures to account for pandemic-related disruptions. CMS now proposes to remove this exclusion across all six measures.

3. Shortening the Applicable Period: CMS proposes to reduce the applicable data collection period for readmission measures from three years to two years.

4. Revised DRG Payment Adjustment Formula: In conjunction with the inclusion of MA data, CMS proposes to modify the diagnosis-related group (DRG) payment ratios used in the HRRP payment adjustment formula. These modifications are intended to ensure the payment penalty calculations accurately reflect the expanded patient population and the varying costs associated with MA versus FFS enrollees.

5. Clarification of the Extraordinary Circumstances Exception (ECE) Policy: CMS seeks to update and codify the ECE policy, clarifying that the agency retains discretion to grant exceptions based on hospital-submitted requests. This adjustment (listed throughout the proposed ruling in many of the changes) aims to streamline administrative processes and increase transparency for hospitals impacted by extraordinary circumstances such as natural disasters or other systemic disruptions.

HRRP & MA Readmission Denials

There is a clear emerging tension between how hospital performance is measured under the HRRP in the proposed ruling and how MA plans are rated under the Medicare Star Ratings system. It appears that for now, hospitals are going to be caught with a potential double penalty, while MA plans appear unscathed.

As discussed in previous articles, under the current HEDIS data submission requirements, MA plans are not obligated to report all hospital readmissions. Because HEDIS measures rely on self-reported paid claims, MA plans are only required to submit data for readmissions they have approved for payment. Consequently, denied or bundled claims are excluded from the MA Star Rating calculations, potentially underrepresenting true readmission rate.

This creates a regulatory disconnect, as hospitals will now be held financially accountable for readmissions of MA patients as part of the HRRP.  Hospitals will also see no relief from the existing denials related to readmissions from MA plans. Thus, hospitals could be denied payment on a readmission from an MA plan and also have to report this as a readmission under the HRRP.  Yet the MA plans face no parallel accountability for these same readmissions.

While the FY 2026 IPPS proposed rule reflects a commitment to equal accountability across Medicare populations, true parity will remain elusive until CMS imposes comparable transparency and quality reporting requirements on MA plans.

As it stands, the burden of readmission accountability remains disproportionately shouldered by hospitals.

The Undoing of SDoH Reporting

By Tiffany Ferguson, LMSW, CMAC, ACM

In a sweeping policy shift, the Centers for Medicare & Medicaid Services (CMS) has proposed significant rollbacks to Social Determinants of Health (SDoH) and equity-related reporting requirements across the Inpatient Prospective Payment System (IPPS), Inpatient Rehabilitation Facility (IRF), and Long-Term Care Hospital (LTCH) settings.

Released April 11, drastic changes were introduced. Per the CMS email brief, the fiscal year (FY) 2026 proposed rules reflect the CMS alignment with Executive Order 14192, “Unleashing American Prosperity Through Deregulation,” which prioritizes the reduction of administrative burden and private-sector compliance costs.

Under the FY 2026 IPPS proposed rule, CMS has announced its intent to remove four key measures from the Hospital Inpatient Quality Reporting (IQR) Program beginning with the Calendar Year (CY) 2024 reporting period/FY 2026 payment determination:

1. Hospital Commitment to Health Equity – This was a structural measure to evaluate a hospital’s leadership, training, data collection, and community partnerships to advance health equity.

2. COVID-19 Vaccination Coverage Among Healthcare Personnel – This measure captured frontline worker vaccination rates and was considered a critical post-pandemic accountability tool.

3. Screening for Social Drivers of Health – Introduced to assess whether hospitals are actively identifying patient challenges related to housing, food, transportation, and utilities.

4. Screen Positive Rate for Social Drivers of Health – A complementary measure to quantify the proportion of patients screening positive for social needs.

The elimination of these measures marks a notable retreat from the CMS prior emphasis on collecting actionable data to address health disparities and improve care planning based on non-medical risk factors.

CMS is also proposing similar rollbacks in post-acute care settings through changes to the IRF and LTCH Quality Reporting Programs (QRPs), which currently require standardized data collection on patients’ social needs.

In IRFs, CMS proposes to eliminate four SDoH Standardized Patient Assessment Data Elements (SPADEs) from the IRF-Patient Assessment Instrument (PAI), effective in FY 2028. These include data fields for living situation, food, and utilities. These elements were designed to inform discharge planning and improve care coordination for medically and socially complex patients. Under the proposed ruling, however, these will no longer be required fields.

In LTCHs, CMS proposes parallel removals. Beginning in FY 2028, LTCHs will no longer be required to report living situation (R0310), the two items for Food (R0320A and R0320B), and the one item regarding utilities (R0330).

These proposed changes, while framed as efforts to reduce provider burden, represent a broader retreat from embedding SDoH and health equity into federal quality and payment programs. The argument listed in the FY 2025 IPPS ruling, discusses the burden of training, data collection, and patients’ answering these same questions across multiple healthcare facilities.  However, since FY 2026 was the payment determination period, it is unclear if any benefit will be awarded to all the health systems that have been actively collecting this data and have ingrained this into daily workflows. 

Instead of SDoH, CMS is requesting ‘Consideration for Future Years in the Hospital IQR program- request for information (RFI): Well-Being and Nutrition’.

CMS’s regulatory realignment signifies the growing tension between administrative simplification and the drive for more equitable, data-informed care delivery. At this time, it does not appear that the SDoH z-codes have been adjusted, however the link provided in the proposed ruling to review coding changes appears to not be working.

Although it is clear that hospitals and health systems did have increased burden with the SDoH questions, removal of these requirements does not eliminate the presence of SDoH risk factors and its impact on patient health outcomes.

Public comment is open regarding the proposed ruling.

How Can the Discharge Lounge Concept Work?

By Tiffany Ferguson, LMSW, CMAC, ACM

In a follow-up to last week’s article about when discharge lounges do not work, I thought I would elaborate today on when the concept can provide efficient relief for capacity issues.

Although the focus has historically been on the back-end process, moving patients out of their hospital rooms to alleviate congestion at the front, there is evidence supporting their effectiveness when discharge lounges assist not only hospital units, but also emergency departments (ED), and operate by a “pull” system rather than a “push” system.

ED overcrowding remains a significant challenge for hospitals across the country, leading to prolonged patient wait times, decreased patient satisfaction, and increased strain on medical staff. Implementing discharge lounges for patients who are stabilized but need to wrap up the logistics of returning home has proven effective in enhancing patient flow and alleviating ED congestion.

In a “push” system, hospital units or ED staff send patients to the discharge lounge when they deem them ready, based on a long list of eligibility criteria. This can lead to inefficiencies and underutilization. In contrast, a “pull” system actively identifies and relocates patients who meet discharge criteria, optimizing patient movement and improving throughput.

Hospitals that have successfully implemented a pull system employ dedicated discharge teams that proactively seek out patients eligible for discharge, ensuring a steady flow of patients to the lounge. These teams coordinate with unit nurses, physicians, and case managers to identify and transition patients efficiently. This approach prevents bottlenecks in the ED and bedded units, ensuring that beds are available for incoming patients who require immediate care.

Case Examples

Montefiore Health System implemented a discharge lounge that serves approximately 678 patients per month, or about 22 patients per day. Montefiore reports that their discharge lounge is six times more effective than other lounges, largely due to its role in serving both hospital units and the emergency department. Their system moves patients efficiently by proactively pulling them from bedded units and the ED, rather than waiting for units to push patients to the lounge (Montefiore, 2024).

The University of Alabama at Birmingham (UAB) Hospital has also refined its discharge lounge operations over time. Initially, it accommodated only four patients a day, but by 2022, it averaged 20 patients daily. The key to this improvement was a dedicated discharge team that actively pulled patients from the units, ensuring a smooth transition to the lounge and reducing overall hospital congestion.

Repurposing discharge lounges to support ED throughput and create a better environment for patients who have completed their ED evaluation, but require additional logistics such as obtaining medications, follow-up referrals, education, support appointments, or coordinating transportation can significantly alleviate ED congestion. A pull system ensures that discharge-ready patients are efficiently relocated, freeing up critical ED and inpatient resources. By focusing on active patient identification and proactive support to facilitate the discharge process, hospitals can optimize resource utilization, improve patient experiences, and enhance overall operational efficiency.

References

Montefiore Einstein (2024). Montefiore Discharge Lounge Offers Stress- Free Transition from Hospital to Home While Saving 10,000+ Bed Hours. Retrieved from Montefiore Discharge Lounge Offers Stress-Free Transition from Hospital to Home While Saving 10,000+ Bed Hours | Update | Montefiore Einstein Now

UAB Medicine News (2022) Nursing leaders created patient discharge lounge to reduce ED boarding time. Retrieved from Nursing leaders create patient discharge lounge to reduce ED boarding time

Case Managers Can Play Crucial Role in Emergency Department

By Kelly Bilodeau

More than 139 million patients come through the doors of U.S. hospital emergency departments (ED) every year, and many move into inpatient hospital beds. “About 70% of patient hospital admissions go through the ED,” said Marie Stinebuck, MBA, MSN, ACM, COO at Phoenix Medical Management Inc. 

ED case managers can serve as gatekeepers for this high-traffic entry point, ensuring accurate status determinations, preventing unnecessary readmissions, and helping to keep as many inpatient beds open as possible.

The right services for the right patient

Not everyone who arrives at the ED needs to be there or meets the medical criteria required for inpatient admission. Some individuals come in because the patient and/or the family need custodial, not medical support, Stinebuck said. An ED case manager can offer patients more appropriate alternatives. Depending on the patient’s needs, this may include referrals for community services, medical support, or placement resources if home care is not a viable option.

The ED case manager can also intercept potentially avoidable readmissions. Patients discharged from the hospital sometimes reappear in the ED within 30 days for problems that don’t warrant another inpatient admission. “Most electronic medical records have a readmission flag,” Stinebuck said. So, when these patients arrive in the ED, it triggers a notification to the case manager, who can quickly interview and assess the patient. Often, patients come back because of logistical problems that are manageable without a hospital stay—they couldn’t fill a prescription or missed an appointment with the primary care doctor. In other cases, a readmission is unavoidable, but the case manager can decrease or prevent future return visits by creating complex care plans for high-risk patients, including those with substance use disorders or behavioral health challenges, Stinebuck said.

While managing high-risk patient populations is a crucial part of an ED case manager’s role, they must also verify that patients are assigned correctly as inpatients or outpatients with observation services. UR reviews at admission can help ensure the patient receives the right level of care.

Establishing an ED case management program

To begin an ED case management program, assess your existing processes to determine when case management services are most needed, Stinebuck said. Look at the number of ED admits, identify peak hours in the ED, and monitor for high-utilizing patients and inpatient readmissions. Peak ED hours don’t always match 9 a.m. to 5 p.m. schedules. A case management shift could be most beneficial from 10 a.m. to 6:30 p.m., 4:30 p.m. to midnight, or 10 a.m. to 10 p.m. Depending on your community and patient population, you may or may not need an overnight case manager.

“If you want to set up a new program, start during your peak hours, knowing that you're going to get the biggest bang for your buck,” Stinebuck said. Ideally, you should have one case manager for every 30 patients.

In a busy ED that sees 60 to 70 patients at a time, you may need to assign more than one case manager with overlapping shifts to meet demand.

Understanding your patient demographics can also help you determine who is best for this ED case management role, a nurse or a social worker. “If you’re a trauma facility with a high homeless population or drug seekers, social workers have training to deal with this social complexity and psychosocial components and are a better fit in the role than a nurse.” Stinebuck said.

An ED case manager must work closely with ED providers to be effective. “Staff members in the ED really need to have a good understanding of what that case manager does and the support they can offer,” Stinebuck said. Ultimately, a well-structured program can help hospitals manage the large and unpredictable flow of patients entering through one of its busiest departments and help keep hospital beds open for the people who need them the most.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

Addressing The SDoH in The Emergency Department

By Tiffany Ferguson, LMSW, CMAC, ACM

A recent qualitative study published in the Journal of the American Medical Association (JAMA) explored the implementation of social determinants of health (SDoH) screening in U.S. emergency departments (EDs). The study aimed to identify the main themes that arose with the process of screening, documentation, and addressing SDoH concerns in this setting. 

Researchers conducted in-depth interviews with leaders from 27 EDs across urban, rural, academic, and community settings who reported screening for SDoH. These participants, predominantly female (66.7 percent), held various leadership roles, including chairpersons and medical, nursing, or operation directors. The interviews, conducted between April and September 2023, were conducted with the goal of gathering insights into current practices and challenges related to adverse SDoH screening responses and subsequent referral processes.

Not surprisingly, the study found significant variability in how EDs screen for and document SDoH factors. This inconsistency reflects the absence of standardized protocols, leading to diverse approaches in identifying and recording patients’ social needs. The article noted that some ED leaders expressed doubts about the effectiveness of screening – and referring patients to services within the ED environment. The most significant concern was centered around the ED’s capacity to address these identified social needs effectively, given its primary focus on acute medical care. The findings go on to identify challenges related to lack of resources, staffing, and time to conduct screenings and facilitate appropriate referrals. These limitations hinder the ED’s ability to address patients’ social needs comprehensively. However, like a notion explored in the survey, the question remains: is the ED the best place to address these needs? Identifying issues and conducting follow-up do not have to happen at the same time if there is nothing urgent. Outside of personal safety, the questions surrounding the SDoH are not recent nuances to care; they are longstanding issues that patients have been facing.

The study did provide some recommendations:

They suggested revisiting the screening tools to align better with the fast-paced ED environment. They suggested involving ED personnel in the design and implementation process to ensure that the tools and workflows are practical and contextually appropriate. Finally, they requested employing additional staff, particularly social workers, to focus on the screening results to help alleviate the burden on medical staffs. Social workers are also skilled in identifying community resources and supporting patients and clinical staff with the moral distress that unmet SDoH needs create in a healthcare environment. Finally, they recommended aligning more with community resources and existing non-ED SDoH initiatives to facilitate effective referrals and patient support needs. 

As we consider the continued requirements for SDoH screening in hospital outpatient departments, such as EDs, it is essential to consider key questions:

1. Does the patient want assistance with their unmet needs? 

2. Is the patient already working with an agency or organization to address their unmet needs?

Given that these questions are being asked across nearly every healthcare setting, many patients may already be engaged with available services to address their SDoH concerns.

This study is commendable for emphasizing that resolving positive SDoH screenings does not necessarily need to occur in the ED, particularly if it does not impact the immediate medical care being provided. A potential approach could involve establishing post-ED outreach, where case managers and/or community health workers follow up with patients who screen positive, providing resources and referrals. If a patient’s needs are more complex, they could then be escalated to a social worker for further support.

Implementing SDoH screening in U.S. EDs presents both challenges and opportunities. While there is variability in current practices and skepticism about the utility of such screenings, targeted strategies such as improving screening tools, involving ED staff in process design, improving staffing models to address needs and requirements, and enhancing community collaborations can improve the effectiveness of these initiatives.

When Is a Hospital Delay Okay?

By Juliet Ugarte Hopkins, MD, ACPA-C

There are few perfect things in this world, and hospital operations are not one of them. While multitudes of individuals – clinical and non-clinical – work diligently to carry out the most efficient and effective processes to provide patient care, often, their efforts fall short.

Many of these shortcomings are related to staffing and the availability of services on weekends and evenings. “Differentials” in pay for these time periods often apply to employees needed to carry out these services across the spectrum, from environmental service technicians to surgical nurses. This can lead to decisions by hospital leadership to cut back on testing, imaging, procedures, and surgeries outside of “banker’s hours.”

These kinds of delays should be a focus of your utilization management team’s assessment of avoidable days. While different from the patient who is medically ready for discharge but still waiting for a skilled nursing facility bed to open up, they are still delays. A patient might medically require a cardiac catheterization before he can be safely cleared to discharge home, but the delay in procedure on a Saturday and Sunday until it can be performed on Monday has nothing to do with the patient’s condition. The delay is due to the hospital’s lack of resources over the weekend. 

These avoidable days should not only be captured by reason – for example, EEG, PICC line placement, upper endoscopy, etc. – but also include the average financial impact. What cost did the hospital incur by caring for that patient an additional two days while waiting for a nuclear stress test? Or, in the case of a patient in outpatient status, how many observation hours were erroneously billed or written off because the hospital doesn’t perform MRIs after 4 p.m.? In order to present a strong case supporting increased availability of services, you must have data showing the impacts to length of stay, bed availability, and cost.

Are there any delays in imaging, testing, or procedure that can be medically justified? Absolutely! Examples include a brittle diabetic who’s quick to develop significant hypoglycemia during bowel prep before a colonoscopy, leading to a slower cleanout with close titration of IV fluids with dextrose – or an anticoagulated patient who requires time off their medication before proceeding with a surgical procedure to avoid excessive bleeding. Both of these instances are medically justified, and as such, should be documented in detail by the clinician to clearly support the medical need of the delay. Without such documentation, there is a risk auditors will assume a capacity or timing delay instead. 

As with other scenarios involving documentation, it’s incredibly easy for a physician to overlook these specifics involving medically necessary delays, because at face value, they seem to be obvious and relatively inconsequential. Case and utilization review nurses should keep an eye out for these potential omissions as they review patient charts and inquire either the attending physician or physician advisor when clarification is required. Similarly, physician advisors should track commonly missed documentation related to specific situations and create standardized education for hospitalist, cardiology, GI, and surgical groups.

Finally, an insidious factor contributing to avoidable days related to service delays involves testing, imaging, and procedures that are not required. While grossly unnecessary services are likely uncommon, if you look closely, you’ll probably find quite a few situations where the services did not have to take place during the hospitalization, and instead could have been scheduled in the outpatient setting following discharge. Convenience for the patient or patient’s caregiver is often a major factor, but poor accessibility and availability of outpatient services is another. These issues should also be investigated when found to be leading to avoidable days, as outpatient solutions could positively impact inpatient lengths of stay.

Warning: Significant Changes at CMS Innovation Center

By Tiffany Ferguson, LMSW, CMAC, ACM

On March 12, The Centers for Medicare & Medicaid Services (CMS) Innovation Center announced significant changes to its model portfolio to better align with its “statutory obligations and strategic goals,” noting that it will “protect taxpayers and enhance the health of Americans by focusing on models that demonstrate cost savings and improved quality of care.”

This initiative involves the early termination of underperforming models, modifications to existing models, and the discontinuation of planned initiatives. CMS reported that these changes will result in taxpayer savings of nearly $750 million; however, the math seems a little unclear.

The CMS Innovation Center was established under the Patient Protection and Affordable Care Act to develop and test innovative payment and service delivery models. These models aim to reduce expenditures within Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while ensuring high-quality care.

However, after a recent assessment, CMS determined that some models were not delivering sufficient cost savings or quality improvements. As a result, the agency has decided to conclude certain models by the end of 2025 and modify others to align with its long-term objectives.

As part of the realignment, CMS will terminate the following models ahead of their original end dates:

• Maryland Total Cost of Care (2019–2026): This program will move over to the AHEAD program, so while listed as a termination and cost savings, this really looks like a change in title and official move to the AHEAD program, which already lists Maryland as part of Cohort 1.

• Primary Care First (2021–2026): Focused on enhancing primary care services to improve patient care and reduce Medicare expenditures.

• End-Stage Renal Disease (ESRD) Treatment Choices (2021–2027): Encouraged increased use of home dialysis and kidney transplants for ESRD patients; CMS will propose its termination through rulemaking, so more to come on if this will be discontinued, but it is officially on alert.

• Making Care Primary (2024–2034): Intended to strengthen primary care services and build upon previous initiatives, but will end prematurely. This program focused on incorporating health-related social needs into primary care infrastructure for risk stratification.

CMS also mentioned that it is evaluating potential adjustments to the Integrated Care for Kids (2020–2026) model, which may include reducing the scope of awards or implementing structural changes to better align with strategic goals. This model operates in seven states and is an integrated approach for physical and behavioral health services.

The announcement also cited that CMS will no longer move forward with the following initiatives:

• Medicare $2 Drug List: This initiative aimed to provide certain generic drugs to Medicare beneficiaries at a $2 price point.

• Accelerating Clinical Evidence: Designed to incentivize drug manufacturers to complete confirmatory trials for drugs receiving accelerated approval.

The limited briefing did state that CMS will provide guidance and technical assistance to affected participants to ensure a smooth transition and continuity of care for beneficiaries.

Although new programs have yet to be offered, CMS stated that they are shifting their strategy to emphasize preventive care, patient empowerment, and competition within the healthcare system.

Study Shows Higher Infant Mortality Rates for States with Abortion Bans

By Tiffany Ferguson, LMSW, CMAC, ACM

The political movement to restrict abortion access following the U.S. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade, has been quite active.

This ruling granted states the authority to regulate abortion without federal oversight, leading to a wave of restrictive laws, including total bans and six-week gestational limits. A recent study published in the Journal of the American Medical Association (JAMA) by Dr. Alison Gemmill, titled US Abortion Bans and Infant Mortality, examines a potential consequence related to the abortion bans in more restrictive states, specifically pertaining to infant mortality rates.

The study conducted a population-based, cross-sectional analysis using national statistics data from 2012 through 2023. The focus was on 14 states that enacted either total abortion bans or restrictions at six weeks of gestation. These states were Alabama, Arkansas, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, and West Virginia.

By comparing observed infant mortality rates post-ban with expected rates, based on historical trends, the researchers assessed the impact of these restrictive policies on neonatal and infant health outcomes.

The study found a statistically significant increase in infant mortality rates in states with restrictive abortion laws. Specially, there was an overall rise in infant mortality in these states, from an expected 5.93 per 1,000 live births to an observed 6.26 per 1,000 live births, which represents a 5.6-percent rise, or 478 excess infant deaths.

The study also found that Black infants experienced the largest increase in mortality rates compared to their non-black demographic groups. Finally, the study also found that the deaths due to congenital anomalies rose by 10.87 percent, from 1.24 per l,000 live births to 1.37.

The findings of this study suggest that restrictive abortion laws may have unintended negative consequences on maternal and infant health. Many public health experts argued that abortion restrictions would lead to an increase in high-risk pregnancies.

Without the option to terminate nonviable or medically complex pregnancies, this study confirms the unintended consequences that have led to more infants being born with severe health conditions – and a concerning increase in infant mortality rates.

Case Management Corner: CMS Notice May Create Hurdles

By Kelly Bilodeau

As of February 14, hospitals have a new CMS notification to contend with. But unlike the Medicare Outpatient Observation Notice (MOON) or the Important Message from Medicare, the Medicare Change of Status Notice (MCSN) might not be as easy to automate and could create operational challenges, said Sara Williams, MSN, RN, ACM-RN, vice president of clinical strategy at Phoenix.

CMS created the notification to let Medicare patients know that they can appeal if a doctor admits them as an inpatient, but later downgrades them to observation services. Patients sued CMS for the right to challenge these reassignments, which can lead to significant out-of-pocket costs. Patients with only Part A Medicare coverage shifted from inpatient to observation may be on the hook for the entire hospital stay if they do not also have supplemental coverage. Patients with Part A and B may not meet the three-day qualifying inpatient stay needed to unlock Medicare coverage for a subsequent skilled nursing facility stay, which may force them to forgo care or to pay out-of-pocket.  

Challenges ahead

While the decision was a welcome one for patients, Williams said, the MCSN is likely to present some hurdles for hospitals. “Operationalizing this is going to be a challenge,” she said. For one, the notice only applies to a sliver of Medicare patients, including Medicare Part A patients who were downgraded from inpatient status to outpatient with observation services and does not address patients with Medicare Part A whose status changes to OP, such as patients undergoing elective procedures. It also applies to Medicare Part A and B beneficiaries receiving observation services who are still in the hospital three days or more after the original inpatient order. The notice is only issued after they meet this criterion.

Because of these constraints, hospitals can’t establish a pre-set list of patients to receive the MCSN and may need to weed through individual cases to determine when it applies— leaving more opportunity for lapses. CMS requires staff members to give patients the notice “as soon as possible,” but no later than four hours before discharge. It will be important for hospitals to look for innovative strategies to use technology to alert staff to patients who should receive this notice.

Before the MCSN, the hospital would give a downgraded patient a MOON or a Condition Code 44 letter, Williams said. While some suggest substituting the MCSN for the Condition Code 44, questions linger because neither CMS nor the Quality Improvement Organizations (QIOs) have offered specific guidance. “My recommendation is to continue their current patient process and to provide this notice in addition,” Williams said.

Preparing for retroactive appeals

Hospital Health Information Management Departments will also need to field requests related to retroactive status change appeals because the court approved them in cases extending back to January 1, 2009. As a result, hospitals will also need a process to ensure patients can obtain related records, which will be an additional challenge. “Make sure that internal teams are educated to understand what these requests are and why,” Williams said.

While the new appeal process could benefit patients, Williams said it might not always hit the mark. For example, the notice requirement doesn’t apply to patients reassigned to outpatient status, just observation, which could limit appeal rights for surgical patients who commonly run into trouble with these status changes. If a surgical patient with only Part A coverage came into the hospital for inpatient surgery and the doctor reassigned them to outpatient status, they would have no coverage and can’t appeal the decision, Williams said.

However, this outpatient/observation distinction can also allow facilities to avoid the notification requirement in some situations, Williams said. “If you have a Condition Code 44 patient who is being discharged within an hour, instead of making them outpatient with observation services, it's safer to just make them an outpatient,” she said. The facility can’t bill for the observation hours anyway because the stay is under the eight-hour threshold, and they aren’t required to provide the MCSN.  

Strategies for compliance

When the notification is required, hospitals should ensure that they comply with CMS specifications, which include:

·       Incorporating an unaltered notification into the electronic medical record system

·       Including the expiration date and a general phone number that the patient can use to contact the QIO

If staff members deliver the notification to a patient representative, they should establish a process to document verbal and/or written receipt.

Ultimately, while this new notification is well-intentioned, CMS and hospitals still need to iron out some kinks and overcome logistical hurdles to achieve its intended goal.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

Gaining a Better Understanding of Social Workers

By Tiffany Ferguson, LMSW, CMAC, ACM

March is Social Work month, a time to recognize the contributions of my fellow social workers in various fields, particularly healthcare.

Social workers play a crucial role in ensuring that patients receive not only medical treatment, but also psychosocial support, and that our healthcare providers receive clarity regarding social barriers our patients face.

The field of medical social work owes much to Ida Cannon, who is recognized as the first medical social worker. In the early 20th century, Cannon revolutionized the integration of social work into healthcare by establishing the first medical social work department at Mass General in 1912. It was Ida and her Medical Director, Dr. Richard Cabot, who believed that the integration of social considerations in medical care would “make medical care effective” and “cure consumption”. She believed that addressing the social and emotional needs of patients was just as important as treating their physical ailments.

Through her advocacy and inclusion of social services work in healthcare settings, Cannon laid the foundation for modern healthcare social work, emphasizing patient-centered care and interdisciplinary collaboration.

Healthcare social workers often assist patients in facing life-altering diagnoses, chronic illnesses, or terminal conditions. They offer counseling and emotional support to help patients, and their families cope with stress, anxiety, and grief. It is often the social worker who is guiding the patient and family through difficult decisions and addressing social complexities.

With the additional need to address the social determinants of health (SDoH) in the acute-care setting, social workers help coordinate care by connecting patients with community resources, arranging post-acute transitional care services, and ensuring a smooth transition from the hospital. Their involvement reduces hospital readmissions and enhances patients’ overall well-being.

Starting with our foundational leaders such as Jane Addams and Ida Cannon, social workers recognize that health outcomes are influenced by more than just medical care. Economic stability, access to nutritious food, safe housing, and social support all play a role in a person’s health. The inclusion and consideration of social risk factors is ingrained in our social work clinical training, ensuring a comprehensive approach to patient care.

Social workers are present in hospitals, hospice care, rehabilitation centers, mental health clinics, skilled nursing homes, home health, and among other settings. In a 2017 study (Steketee, Ross & Watchman) looking at three decades of studies on the outcomes of social workers and patient health outcomes across 16 studies, they found that “social work services had positive benefits for both health and economic outcomes for vulnerable adults, children, pregnant women, and older adults.

The quality of the research was higher when social workers were leaders of the health services rather than members of a team.”

I am likely biased, but I believe that social workers are an indispensable part of the healthcare system, providing holistic support to patients. Their work is a testament to the profound impact that compassion, advocacy, and social responsibility can have on individuals and communities alike.

Maternal Deaths are Down – For Everyone Except African Americans

By Tiffany Ferguson, LMSW, CMAC, ACM

The Centers for Disease Control and Prevention (CDC) released its updated stats report in February 2025 on maternal mortality in the United States for 2023, revealing both some positive trends, but also some persistent disparities.

The CDC defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Maternal mortality rates are calculated as the number of maternal deaths per 100,000 live births.

The overall maternal mortality rate decreased to 18.6 deaths per 100,000 live births in 2023, down from 22.3 in 2022. This decline represents a reduction from 817 maternal deaths in 2022 to 669 in 2023.

Despite this overall improvement, significant racial disparities remain. The maternal mortality rate for non-Hispanic Black women was 50.3 deaths per 100,000 live births in 2023, which is significantly higher than the rates for non-Hispanic white women (14.5), Hispanic women (12.4), and non-Hispanic Asian women (10.7).

While the decrease in mortality rates for non-Hispanic white and Hispanic women between 2022 and 2023 was statistically significant, the observed decreases for non-Hispanic Asian women and the increase for non-Hispanic Black women were not statistically significant.

A recent article from Axios, with reference back to a 2023 article, centers on a study published in The Lancet which found that Black women in areas with greater access to maternal healthcare still face disproportionately higher risks of maternal mortality, compared to white women living in underserved areas.

The study uses the U.S. Maternal Vulnerability Index, a system that assigns a score from 0 to 100 to each state and county, with lower scores indicating lower vulnerability to adverse maternal health outcomes. By analyzing data from 13 million births of Black and white women aged 10–44, researchers found that even in less vulnerable areas, Black women remained at higher risk of maternal mortality than white women residing in more vulnerable locations.

See maternal mortality rate, by race and Hispanic origin: United States, 2022 and 2023, here.

Age also continues to play a critical role in maternal mortality. In 2023, women 40 and older experienced a maternal mortality rate of 59.8 deaths per 100,000 live births, nearly five times higher than the rate for women younger than 25, which stood at 12.5. However, this rate is at a significant decrease from 2022, when it was 87.1.

In summary, while the overall decline in maternal mortality rates in 2023 is a positive development, the persistent and significant disparities among different racial and age groups, particularly Black women and women over 40, demonstrate the value in utilizing targeted intervention strategies.

HHS Returns to a Binary System for Gender Definitions

By Tiffany Ferguson, LMSW, CMAC, ACM

The U.S. Department of Health and Human Services (HHS) recently announced policy changes in response to President Trump’s executive order aimed at gender classifications and restricting gender-affirming care for minors.

These actions are a 180-degree change from the Biden Administration, which had previously expanded policies and rights for transgender and non-binary individuals, after the Supreme Court’s ruling in Bostock v. Clayton County (2020).

In alignment with Executive Order 14168, titled “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government,” HHS issued guidance establishing strict sex-based definitions for gender classifications. According to this guidance, sex is defined as an immutable biological characteristic, categorizing individuals strictly as male or female.

The definitions specify that a female is “a person whose reproductive system is designed to produce eggs,” while a male is “a person whose reproductive system is designed to produce sperm.” This move aims to influence policies across various federal agencies, ensuring that distinctions based on these definitions are recognized and enforced.

Newly confirmed HHS Secretary Robert F. Kennedy Jr. emphasized in a press release the administration’s commitment to what it terms “biological truth,” stating that “this administration is bringing back common sense and restoring biological truth to the federal government.” The guidance also includes definitions for terms such as woman, man, girl, boy, mother, and father, all rooted in biological characteristics.

In conjunction with Executive Order 14187, “Protecting Children from Chemical and Surgical Mutilation,” HHS is implementing policies to prohibit federal support for gender-transition treatments for individuals under 19. This includes withholding federal funding from medical institutions that provide surgeries, hormone therapies, puberty blockers, and other gender-affirming treatments to minors.

Furthering the administration’s agenda, Executive Order 14201, “Keeping Men Out of Women’s Sports,” directs HHS to implement policies ensuring that athletic competitions are segregated based on the newly established biological definitions of sex. This order aims to prevent transgender women and girls from participating in female sports categories, a move proponents argue is necessary to maintain fairness in women’s athletics.

As these policies begin to take effect, the nation remains deeply divided over issues of gender identity, medical autonomy, and the role of government in personal healthcare decisions. The current administrative actions are dramatically different than the prior HHS philosophy. This will likely end up with further legal proceedings over discrimination protections and restricted access to healthcare for transgender individuals, particularly youths. 

When Discharge Orders No Longer Signify Patient Discharge

By Juliet B. Ugarte Hopkins, MD, ACPA-C

As with many other physicians of a certain age, I had the opportunity to practice patient care in both the worlds of paper and electronic charting.  Granted, as a pediatric hospitalist working in a busy, near-tertiary care center with little (purposeful) exposure to utilization management or clinical documentation integrity, my focus then on how my charting impacted other areas of hospital functioning – such as with revenue cycle – was extremely minimal.  This being the case, I hope I am afforded some leniency with my viewpoint that one big difference between the two worlds – paper and electronic – is utilization for processes outside of frank communication between members of the care team. 

On paper, History and Physicals, Progress Notes, Operative Notes, and Discharge Summaries allowed doctors, nurses, physical therapists, pharmacists, etc. to inform each other about what was happening with the patient during the hospitalization.  When paper charting moved to electronic, suddenly those same notes were utilized not only for communication, but also to track quality measures, create claims for the hospital to bill services, and support Diagnosis-Related Group categorization. 

A similar situation happened with placement of orders.  On paper, when a physician wrote the current date and time followed by, “Discharge patient,” this informed the bedside nurse that the process for patient discharge out of the hospital could be undertaken.  Whether the patient was leaving the hospital for home, a rehabilitation facility, or another hospital for a higher level of care, did not matter.  Ultimately, the order’s message was that the patient was ready to leave the hospital that day. 

Just as multi-level connections to hospital operations became tied to documentation, the same happened with placement of clinician orders.  Electronic Health Records (EHR) often evolved to utilize an order for patient discharge to equate an end to hospital billing for the hospital encounter on the calendar day and time the discharge order was placed.  As such, when a discharge order is placed other than on the day when a patient leaves the hospital, this can lead to under-reporting the patient’s length of stay, misidentification of bed availability, and prevent the hospital from understanding where potential opportunities lie buried within categories of avoidable days (days in which patients remain hospitalized without medical necessity).

When a hospital inadvertently makes a connection like this in the EHR it can usually be quickly identified and addressed.  However, when a health system is contracted with an employed group of physicians who are directed by entities outside hospital leadership to follow a specific process, things can get dicey.  Add in an association with a commercial or managed payor and the conflict increases even more.

Such a situation has recently been reported by a number of hospitals and health systems across the country.  Employed hospitalists are being told by their leaders that when a patient is medically ready for discharge, even if they do not have a safe discharge plan in place and hospital services will continue to be provided, including daily physician rounding, an order for discharge should be placed.  This can include a situation where the patient no longer requires hospital care but requires transfer to an Inpatient Rehabilitation Facility (IRF) or other Skilled Nursing Facility (SNF), however there are not yet any accepting location with open beds.  Another situation could involve a patient who is clinically ready to discharge from the hospital with an outpatient plan for prolonged IV antibiotic therapy but who does not yet have outpatient nursing services established to monitor the peripherally inserted central catheter (PICC) in the home setting.

When an order for discharge is used in these instances, it puts the hospital and medical team – especially the nursing staff – in a situation of having to elucidate when a discharge order should be acted on or ignored.  This is a major patient safety issue, as order intent should always be clear and uniform to those reviewing them and carrying them out.  Granted, there IS significant utility in identifying when a patient is medically ready for discharge from the hospital and when the patient actually leaves the hospital.  However, placing a discharge order is not the way to do it.  In at least one EHR system, there is a “Medically Ready for Discharge” identification feature which can be utilized by clinicians, nursing, or case/utilization managers within the record to make the distinction.  Then, when everything is in place for the patient to truly leave the hospital building, a discharge order is placed.

Review of Centers for Medicare and Medicaid Services (CMS) rule uncovers other points which clearly make placement of a discharge order erroneous in these instances.  Per the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart C, 412.42 (bolding added):

“The hospital (acting directly or through its utilization review committee) determines that the beneficiary no longer requires inpatient hospital care. (The phrase “inpatient hospital care” includes cases where a beneficiary needs a SNF level of care, but, under Medicare criteria, a SNF-level bed is not available. This also means that a hospital may find that a patient awaiting SNF placement no longer requires inpatient hospital care because either a SNF-level bed has become available or the patient no longer requires SNF-level care.)” 

Because of this, a Medicare patient who begins their hospitalization in justifiable Inpatient status and is medically ready for discharge on the third hospital day but does NOT leave on that day because they require SNF placement and there are no available beds, will have three Inpatient midnights pass on the fourth hospital day allowing for use of their Part A SNF benefit.  If a discharge order is placed on hospital day three and the billing is captured as a two-day encounter (not including the “day of discharge” identified by the calendar day the discharge order is placed), the patient will not be able to access their SNF benefit, as demonstrated in the Code of Federal Regulations excerpt, above.

Then, there are issues related to the Important Message from Medicare (IM) and a beneficiary’s rights to appeal their discharge.  As seen in Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 405, Subpart J, 405.1206 (bolding added):

“(a) Beneficiary's right to an expedited determination by the QIO [Quality Improvement Organization]. A beneficiary has a right to request an expedited determination by the QIO when a hospital (acting directly or through its utilization review committee), with physician concurrence, determines that inpatient care is no longer necessary.

....

(c) Burden of proof. When a beneficiary (or his or her representative, if applicable) requests an expedited determination by a QIO, the burden of proof rests with the hospital to demonstrate that discharge is the correct decision, either on the basis of medical necessity, or based on other Medicare coverage policies. Consistent with paragraph (e)(2) of this section, the hospital should supply any and all information that a QIO requires to sustain the hospital's discharge determination.

(d) Procedures the QIO must follow.

(1) When the QIO receives the request for an expedited determination under paragraph (b)(1) of this section, it must immediately notify the hospital that a request for an expedited determination has been made.

(2) The QIO determines whether the hospital delivered valid notice consistent with § 405.1205(b)(3).

(3) The QIO examines the medical and other records that pertain to the services in dispute.

(4) The QIO must solicit the views of the beneficiary (or the beneficiary's representative) who requested the expedited determination.

(5) The QIO must provide an opportunity for the hospital to explain why the discharge is appropriate.”

If a Medicare or Medicare Advantage patient is given an IM due to placement of a discharge order and the patient appeals to the QIO, what will be hospital’s response when the QIO asks for documentation related to how discharge of the patient is appropriate when in actuality...discharge is NOT appropriate due to lack of an out-of-hospital plan of care?  This is further complicated by verbiage found within the IM itself (bolding added):

“Your Right to Appeal Your Hospital Discharge:

•   You have the right to an immediate, independent medical review (appeal) of the decision to discharge you from the hospital.  If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles).

•   If you choose to appeal, the independent reviewer will ask for your opinion.  The reviewer also will look at your medical records and/or other relevant information.  You do not have to prepare anything in writing, but you have the right to do so if you wish. 

•   If you choose to appeal, you and the reviewer will each receive a copy of a detailed explanation about why your covered hospital stay should not continue.  You will receive this detailed notice only after you request an appeal.”

Just like a clinician would not order, “Dilaudid 2 mg IV Q4 PRN severe pain” if they do not intend for the patient to ever receive the medication, clinicians should not order to “Discharge patient” if they do not intend for the patient to leave the hospital that day.  If aiming to identify the difference between a patient remaining hospitalized with medical necessity versus those who remain hospitalized due to non-medical barriers, there are other ways this can be accomplished. 

One final note – in instances where Medicare patients are medically ready for discharge from the hospital AND either have a discharge plan or are failing to agree with a safe discharge plan and they intend to appeal their discharge, the discharge order should remain while the appeal to the QIO takes place and until the QIO determination is made.

Freezing DEI: What does this mean in terms of healthcare?

By Tiffany Ferguson, LMSW, CMAC, ACM

President Donald Trump recently issued an executive order titled “Ending Radical and Wasteful Government DEI Programs and Preferencing,” aiming to dismantle diversity, equity, and inclusion (DEI) initiatives within federal agencies.

This directive mandates the termination of all DEI-related policies, programs, preferences, and activities. The order also requires agencies to report on all DEI and “environmental justice” positions to the Office of Management and Budget (OMB) within 60 days.

This order has since created considerable confusion between the broadness of the executive order and the general terms in DEI.  For reference, DEI is defined as “the state of having a diverse group of participants as well as policies and norms that are equitable and inclusive. ” This includes racial and ethnic groups, gender, sexual orientation, people with disabilities, religious groups, age groups, and socioeconomic status. 

The executive order’s broad and sweeping language has led to confusion among federal agencies, contractors, and communities as they work to interpret and implement the directive. The requirement for agencies to enumerate and report all DEI-related positions, contractors, and federal grant funding has contributed to some fear and chaos, as stakeholders attempt to understand the full scope of the order’s implications. This uncertainty has resulted in a chilling effect, with some agencies and organizations preemptively halting or dismantling DEI initiatives to avoid potential non-compliance.

For instance, the Department of Health and Human Services (HHS) has been directed to cease all DEI-related activities, resulting in the suspension of programs aimed at reducing health disparities among underserved communities. Furthermore, the Food and Drug Administration (FDA) has quietly rolled back DEI initiatives, raising concerns about underrepresentation in clinical trials and the potential impact on healthcare outcomes.

Some consequences of this confusion and freeze have been recently reported in specific healthcare communities which operate with small margins.  Specifically, Community health centers in rural and underserved areas, especially those serving marginalized populations, have been notably affected. For instance, clinics in Virginia and West Virginia have faced closures or staff layoffs due to challenges in accessing essential federal funding following the implementation of the executive order.

These clinics have been forced to reduce services or shut down entirely, impacting access to primary care for approximately 400,000 patients.

In recent weeks, specifically grants supporting HIV prevention initiatives and services tailored for transgender individuals have been terminated. This has halted services and created confusion for health centers that provide HIV prevention and care for transgender patients leading to new legal challenges for future continued care. 

President Trump’s executive order to end DEI programs represents a significant policy shift from the prior administration.  It is unclear of the full effects of what will happen to these programs and who will be considered inclusive in the DEI freeze, since all federal health communications from the Centers for Disease Control and Prevention (CDC), FDA, and the National Institute of Health (NIH) were halted until the beginning of this month, leading to additional confusion.

While many argue this will eliminate wasteful spending in the federal government, others are fearful that this will undermine years of effort in working towards addressing systemic inequalities and supporting marginalized communities.