Haydel Consulting Services LLC

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.

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.

Too many times when I speak about quality assurance, nurses can’t help but roll their eyes and sigh. To many nurses, the complicated procedures and less than timely findings of quality assurance activities are practically irrelevant to their patient care. When QA activities are relevant, they are often presented in a format that is not understood easily by clinicians who do not live in the world of Quality Assurance. And to be honest, I am not impressed with the typical quality assurance program in most agencies.

To be sure, we are great at finding deficiencies in our clinical records. We collect data for days. If every home health agency in the country pooled their data collection we could fill the National Library of Congress if the data were stored on flash drives. But usually what we do about the data falls into one of two categories. Daily we give the nurses ‘correction’ slips or some similar document so they can ‘fix’ the chart in question or we report aggregate findings at a quarterly meeting along with a complicated diagram and p values and n values and tell everyone we expect improvement by the next quarterly meeting. The meeting attendees who manage to maintain consciousness throughout the entire meeting have no idea how to go about adjusting the variables that factor into the equation without a statistics class.

It can and should be easier. Here is how QA works on Planet Julianne.

1. Do a few clinical record reviews. Write down your findings.
2. Discuss your findings with agency leadership and the staff and determine which three trends are affecting your care. There may 20 pertinent findings. But you are not that good. Focus on the big three.  Otherwise you will be busy for the rest of your career without ever accomplishing true change.
3. Bring the field staff into the QA meeting.
4. Pay very close attention to this step. ASK THE FIELD STAFF HOW THE QA TEAM CAN HELP THEM IMPROVE PERFORMANCE
5. This next step is even more important. LISTEN TO YOUR NURSES.
6. Design a simple plan. Simple as in, Problem, Plan of Action, Follow up. Leave fishbone diagrams and flow sheets to the artistically inclined. They have never hurt a QA process but other than looking good on survey, they don’t necessarily help.
7. Monitor progress – in the simplest manner possible. QA is not about data collection although you certainly can’t have QA without valid data. But if your focus is missed visits, look for missed visits. If you found no problems with timeliness of MD signatures, wait until the next quarter to look at them again. Focus, focus, focus.
8. Review findings with DON monthly.
9. At the quarter report on improvement.
10. This is another very important step. In fact, pay close attention because this is likely the most important step. IF THERE IS NO IMPROVEMENT, REALIZE THAT YOUR PLAN FAILED. YOUR NURSES DID NOT FAIL. YOU DID NOT FAIL. THE PLAN FAILED. Once you start blaming people you will lose focus and never achieve another positive result in your QA activities for the rest of your life.
11. Be willing to go back to the drawing board and try again. Being willing and able to recognize a failed plan is a huge success for anyone involved in QA activities.

Consultants like me like to go to an agency and tell everyone what worked in other agencies. Big deal. What works for your company is dependent on your staff, their talents, your problems, etc. Just as we design care plans to meet the individual needs of the patient, we should design QA activities to meet the unique needs of agencies.

So that’s my take on QA. Keep it simple. Make it work for your agency. Transform your QA staff from ‘chart police’ nobody likes into resources for the rest of the nurses. Have some fun with it.

I guarantee you success.