This chapter discusses some of the history and issues of observation as related to the Centers for Medicare and Medicaid (CMS). The CMS definition of observation is given. When a physician orders that a patient be placed under observation, the patient’s status is that of an outpatient. Recovery Audit Contractors (RACs) hired by CMS may retroactively review medical records and deny admissions. Over the years, the number of observation cases and hours in observation has increased. The “outpatient” status prevents Medicare beneficiaries from accessing their Part A benefit for a stay at a skilled facility (SNF) covered by Medicare, and self-administered medication costs during the observation stay are not covered. Medicare beneficiaries took the battle to the courtroom. A class action lawsuit was filed in 2011 by seven Medicare patients and their families, later joined by seven more plaintiffs, against the Department of Health and Human Services (HHS). However, a federal judge ruled against the lawsuit. In 2014, the US Senate held a committee hearing on the impact of Medicare observation. Congress passed the Notice Act which became law in 2015, which lead to CMS developing the Medicare Outpatient Observation Notice (MOON).

A 7-year-old girl visited the outpatient clinic because of difficulty walking. She had never managed to run properly, and experienced frequent falls ever since she began walking independently at the age of 18 months. Jumping was not possible, and when stepping up or down, she needed support below her arms. There was no fluctuation of symptoms during the day, but she had suffered from periods that could last several weeks in which using the stairs was completely impossible. She was unable to blow up a balloon and her speech was slow and poorly articulated. There were no complaints about chewing or swallowing. She had a healthy non-identical twin sister and the family history was unremarkable.

The impact of climate change on the distribution of fish stocks and other marine species is a pervasive problem that causes governance issues and threatens the rule of law for the oceans. Fish moving across static jurisdictional and management boundaries may become unregulated and risk being overexploited. Shifting fish stocks threaten the certainty, predictability and stability of the international fisheries legal framework, and undermine conservation and management measures by coastal States and regional fisheries organisations, impeding sustainable exploitation and conservation of global fish stocks. This chapter assesses whether and to what extent the international legal framework adequately places an obligation upon States to adapt to the complexities caused by MLRs shifting their location, to maintain the rule of law. It assesses whether the key principles and obligations under the international framework are fit for purpose to address these issues. It indicates that there is a general obligation on States, either individually or collectively, to adapt the management of marine living resources to the effects of climate change. It concludes with potential solutions which may strengthen an adaptive response.