Clock Driven Health Care – Why Two Midnights is Bad for Patients and Providers

Two years ago, Washington thought they developed a great “solution” known as “Two Midnights.” But the reality has been different – health care decisions based on a clock are not good for patients and providers.

Fortunately, recent changes to the Two Midnights policy were proposed by CMS. These changes partially restore a qualified providers’ ability to admit Medicare patients that don’t require a two midnight stay.

Why is this recent proposed change to the Two Midnights rule so important? As the leading network of more than 100 organizations dedicated to wellness and population health, quality and cost are important to us. We believe in the importance of treatments being driven by health care providers’ judgment and clinical standards rather than the clock.

The proposed change allows providers to work with the patient and their families and to continue their historically important leadership role in deciding the best course of care including whether a patient should be admitted to the hospital for needed care. Qualified care providers must have the ability to do the right thing – at the right time.

Without this change, patients’ care is compromised. The Two Midnights rule reduced a very complex decision – whether an individual should be admitted to the hospital – into a one-size-fits-all approach by diminishing a provider’s experience and judgment.

At the heart of this is what it means for the people that our member organizations care for on a daily basis – the patient and the consumer.

Under the Two Midnight policy, a patient would receive care based on an arbitrary time which creates uncertainty about their treatment, costs, and health. For instance, a senior who may have thought they were admitted as an inpatient, but who failed to meet the two midnight threshold, would have been left to pay unexpected higher out of pocket costs. This also creates unnecessary hardship for their family and their caregivers.

Our Medicare patients deserve better. They should know when they go to the hospital that their care providers are basing medical decisions on what’s best for them as a patient and not on a clock.

This concern about the impact of two midnights is shared across the health care system from patients to physicians and nurses to hospitals and even the Medicare Payment Advisory Commission, an independent government advisory body. The Commission voted unanimously to recommend to Congress the complete withdrawal of the Two Midnights policy. MedPAC believes the Two Midnight policy unnecessarily allowed patient care to be determined by time concerns rather than clinical realities.

Our hope, along with those of our patients and independent experts, is that CMS will safeguard the role of qualified providers and their clinical judgment as a valued component of the hospital admission process.

While CMS’s proposed change is important and the right move, it still leaves some of the uncertainty of the Two Midnights policy in place. We feel that CMS needs to remove the uncertainty and fully rescind the Two Midnights policy.


Christobel Selecky is the Chair of the Board of Directors of Population Health Alliance. 

Morning Consult