Not Much Left to Say
March 18, 2010
So, my cousin, Frank died yesterday. He spent almost a month in ICU with ARDS subsequent to H1N1. It was not a good time for our family and there really isn’t much good to say. But that isn’t to say that there is nothing good to say.
My cousin’s son, FJ who is 25 years old and now the man of the family, called me yesterday when my cousin’s doctors were running out of treatment options. It was a dire situation and he knew it and it all came down to the familiar waiting game. As we waited, FJ told me that the whole experience had given him a lot to think about and that he was thinking about changing his major to nursing.
There are several nurses in our family but FJ has never really seen us at work. Before this week, he never really considered nursing as a career. He honestly doesn’t know the difference between Levophed and sudofed. But somewhere along the way, the ICU nurses at the Baton Rouge General inspired FJ to at least think about growing up to be just like them.
This is easy to imagine when a patient in a dire situation is admitted and through heroics, the nurses save lives and restore a patient to good health. That obviously didn’t happen.
It says so much more that a team of nurses was able to care for a very complicated patient without losing sight of their number one priority of being compassionate to both the patient and the family.
Imagine doing your job so well that even when the outcome is not desired, a family member decides to be just like you.
The medical care my cousin received from numerous doctors was amazing. For this I am eternally grateful. But I am not ‘one of them’. I am a nurse, though and I was damn proud to be ‘one of us’ as the nurses gave my cousin every chance to live while at the same time, letting Frank die with dignity. What an amazing accomplishment. I am so proud.
As all of us go through the motions of our jobs, we should remember that we never know when someone will be looking towards us for inspiration. We need more nurses who go into the field because they are impressed by our ability to care for patients rather than our starting salary. We need nurses who realize that good nursing care is not always heroic and dramatic but is important in ways not seen on TV. We need nurses who remember that patients come with families and we cannot care for a patient without caring for the family.
If I Were a Recovery Audit Contractor
March 4, 2010
If I were a Recovery Audit Contractor, I know pretty much exactly how I would choose my targets for review. After all, we know that that the RACs can use statistical information from electronic sources to select agencies to review. By looking at aberrancies in data, I would choose the following triggers to guide me in my work:
- High case mix weights. This is pretty much a given since agencies with very low case mix weights may be under-billing.
- High therapy utilization. Nothing brings up a case mix weight more than therapy! Prior to 2008, there were many patients who needed 10 or 11 visits to meet the therapy threshold. Now the same patient might be assessed as needing seven or 14 visits! Very few patients receive 12 visits anymore.
- I would look for a lot of technical stuff. If I wanted to prove a diagnosis wasn’t appropriate, I would have a lot of clinical record review to get through. Then, when I adjusted the case mix weight based on diagnosis coding, I might find a couple of hundred dollars. On the other hand, if a physician didn’t date his or her signature, I get back the entire HHRG.
- All things being equal, I would choose agencies with very long lengths of stay. While it is true that a Medicare Beneficiary is entitled to unlimited episodes of home health as long as they have a qualifying need, documentation tends to become stale after a while. Homebound status is a little more difficult to discern by clinical record review but when I am reviewing clinical records, I can’t help but wonder about patients with multiple missed visit reports.
Does this mean that you should avoid patients who need therapy and have a high case mix weight. I do not see that as a valid answer. But when time is limited and you must pick and choose clinical records to review for completeness, these are the types of patients I would choose. I would also keep all these factors in mind at case conference. Front end protection in a RAC situation is most certainly better than trying to address problems after the record has been requested.
If you have comments or questions, please post below or email them. If you have any other ideas of what you would do if you were a RAC auditor, please share!
Nothing Special
March 1, 2010
It has been a long couple of weeks for me! Sometime in the middle of feeling overwhelmed, it occurred to me that I am living the life of many of our patient’s families.
My Aunt fell and broke her hip last week. My uncle, her husband is suffering from some sort of dementia and is unable to care for her. Because they live in a rural area, her surgery took place an hour north of their home and my uncle was unable to stay with her. Fortunately, my cousins drove him back and forth to visit.
Meanwhile, another cousin was admitted to the hospital in Baton Rouge. He is in ICU with a diagnosis of ARDS although no one can figure out the underlying cause. Needless to say, our family is spread thin, we are trying to make decisions and give advice long distance and we all feel inadequate because we are not able to be in two places at once.
What occurred to me over the weekend is how common this experience really is. How many times have you been into a patient’s home and learned of another relative either nearby or away that was also gravely ill. There is nothing special or unique about being pulled in multiple directions when more than one relative is ill.
And we have it made compared to many of our patients. This branch of our family tree includes many nurses and two physicians. All of us have cars and the ability to take time off work without worrying about being able to eat or pay bills at the end of the month. We are so much more fortunate than many of our patients and their families.
I know that I would forgive myself if I forgot to make a trip to the drug store or misunderstood some directions that a home health nurse gave me. I see my cousins who are not in the health care field try to make sense of all the information and how easily they become confused. Nurses and other health care providers spend years learning the vocabulary of our industry. What about the teachers and electricians?
And so when we are dealing with family members who are hopelessly non-compliant, I wonder if we are always fair with them? The fatigue of being vigilant all night long for a patient with a broken hip is exhausting. Waiting rooms are not a place to get rest.
Maybe in those first few visits when a patient returns from the hospital we should focus on teaching ONLY what is necessary and eliminating opportunities for confusion. Maybe we should focus on doing more than teaching. Implementing fall precautions with the permission of family members (lifting throw rugs, providing for adequate lighting, etc.) may be more effective than instructing someone who hasn’t slept well in several weeks. A simple phone call to follow up on medication compliance in those first few days may prevent serious complications due to the forgetfulness of fatigued family members.
It has only been a week since all this happened. I have a great family that’s actually pretty big. All of my family members have stepped up to the plate in this stressful time. And we are tired! My attitude towards seemingly non-compliant family members has changed tremendously. I hope you learn a little from my experience and that you keep it in mind both when taking care of patients and in your personal lives.
If you have any questions or comments, please email them or leave them in the box below.
Updated House Version of Health Care Reform Bill
February 22, 2010
The White House has revised its proposed health care bill and released a very favorable summary for all to read. I must admit there are improvements in this version but many lingering questions keep coming to my mind. Please help me to understand if you can.
One of the president’s selling points is that there will be no more ‘discrimination’ against people with preexisting illnesses or conditions. My question concerns the definition of risk adjustment versus discrimination. It is a hard question. Is it fair to people with preexisting illnesses to be excluded from inexpensive insurance? Conversely, is it fair for healthy young Americans to pay premiums for the chronically ill? I wish I knew the answer to this ethical dilemma but I do know that risk adjustment is not synonymous with discrimination.
The option for a national plan has been removed from the current plan. This proposed plan focuses instead on affordability of health insurance. Again, this is a difficult question for me. How many uninsured Americans are simply gambling that they will not become ill? My personal cable services bill is in excess of 150.00/month and I do not have many premium channels. More people have cable TV services than health insurance though. After all, who wants to bet that they will become gravely ill? Go to any casino and you will see the eternal optimism of the American gambler even though we know the odds are in favor of the house. Most of us don’t like to face this fact until we have to and that is when health insurance becomes extremely expensive. And yet, I am not allowed to drive without insurance. I wonder what would happen if health insurance became mandatory?
And just because I am feeling controversial today, I think it is interesting that unearned income will also be subject to Hospital Insurance taxes in the same way that earned income is. This looks really good on paper but when you stop to think about it, it is the elderly and a handful of very wealthy folks who have a significant amount of unearned income. My own parents live off of ‘their retirement’ – interest (unearned income) from investments made while they were actively employed and contributing to Medicare. Help me out here. Is this fair?
Since I am complaining about so much, let me point out that I really like the idea of adding funding to community health centers in underserved areas. I mean, it’s only fair since I am quite vocal about what I don’t like.
There is a lot of talk about reducing fraud and abuse in the current bill. There was also a lot of talk about reducing fraud and abuse in the BBA97. And yet, in case you haven’t noticed, we still have fraud and abuse. Oops.
My point is that all of us – certainly anyone interested enough in home health to be reading this knows fraudulent providers are out there. Most of us can name one or more. And yet, if we know about them, why don’t the feds? Isn’t fraud and abuse a concern that should be currently being met with overwhelming diligence even without any new legislation being offered? I must admit the collusion of the IRS and CMS is an interesting twist. In our office we complete a lot of CMS paperwork. It would astound you to know how many social security numbers we submit to CMS. Pretty much anyone who runs, manages, owns more than five percent of a provider or just happens to be a consultant gets their SSN submitted to CMS. Being able to cross reference databases on the assumption that fraudulent providers are also prone to tax evasion might provide us all with some entertainment in the future.
There is a provision for smiting people who sell Medicare or Medicaid numbers for the purposes of fraudulent billing. I must be mistaken because I thought that was covered under HIPAA and the new Red Flags rule. And just to set your anxieties aside, the limitations on what can be reviewed by MACs prior to payment (ADRs) have been relaxed.
There is so much more that confuses but the one issue that has truly caught me off guard is the closure of the tax loophole for biocellulistic fuels. Folks, we will no longer be able to manufacture black liquor as produced by the Kraft technique and get a tax credit. Please, please, please, somebody tell me what that means, why it is in a health care reform bill and why I should care.
If you have any questions, I suggest that you send them to the whitehouse.gov website. On the other hand if you have any answers, clarifications or comments, please post below or email us.
Cat Ears
January 19, 2010
Did you know that cats have 32 muscles in each ear? Surely you will agree with me that this information is fascinating. But as interesting as that tidbit of information is, can you really say that it is useful outside of a small circle of academics?
That’s the way a lot of the information we collect in home health is – useless out of context. We obsess about visits per episode. We want to know what our competitors are doing or what the national average is. We want to know what other people are doing with case mix weights. All of this information is useless unless it is viewed in context.
Take visits per episode, for example. I have clients that admit a lot of post op ortho patients. And I have other clients who have very few therapy patients. I have yet another client who sees a lot of psychiatric patients. To use a standard number of visits per episode for the purposes of comparison is absurd. This is not to say that you don’t need to know how many visits per episode you are providing but this information must be reviewed with your payment and cost information.
Another area we obsess about is productivity. How many visits per day are nurses doing? In other words, are my nurses more or less productive than yours and how can I get them to do more visits? Like visits per episode, there are so many unique variables inside individual agencies that it is ridiculous to take a single number for comparison without putting it into the context of the agency. How are the nurses paid? Are they salary, per hour or per visit? How many miles are logged in each week for the nurses? Is most of the driving done on an interstate or on back roads and in some cases cold, icy mountain roads?
Costs per visit can be calculated so many ways that unless you have a heart to heart with your accountant, you may never know what your true cost per visit is. Furthermore, is it appropriate to use your actual Medicare cost per visit when considering outliers or fee for service private pay home health? A good Medicare accountant is one who can not only help you make these decisions but who can explain in plain English what your numbers mean so that you can make information driven decisions.
I love numbers. But numbers are like power tools. As useful as they are, they can be equally as dangerous in the wrong hands.
But if you’re just in the mood for something interesting, try this. The word, ‘almost’ is the longest word in the English language in which all the letters are in alphabetical order.
If you have any questions about what your numbers mean or if you know any other completely useless but interesting facts, please post below or email them to us.
