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Poor, Black People Have Worse Home Health Care Outcomes


An article came across my desk last week suggesting that Poor and Racial Minorities have Worse Home Health Care Outcomes.  If this surprises you, please stop reading and surrender your nursing license now.

If you read further, the article clarifies the Racial Minorities as Black even though the OASIS data set collects information on American Indians, Alaska Natives, Asians, Hispanic and Latinos, Native Hawaiian or Pacific Islanders as well as white patients.  So essentially, what the article is stating that if you are Black or poor, your health outcomes are worse.

Nurses know that African Americans are predisposed to certain diseases and conditions.  Hypertension and diabetes come to mind immediately. Nearly 42% of Black men and more than 45% of Black women aged 20 and older have high blood pressure.

It is the sequelae of those illnesses that disproportionately affect the black community.  This is where economics comes in and skews the healthcare received by Black people to an unacceptable degree.  Specifically, consider the following statistics:

  • Blacks are up to 2.5 times more likely to suffer a limb amputation and up to 5.6 times more likely to suffer kidney disease than other people with diabetes.
  • Strokes kill 4 times more 35 to 54-year-old black Americans than white Americans. Blacks have nearly twice the first-time stroke risk of whites
  • Cancer treatment is equally successful for all races. Yet Black men have a 40% higher cancer death rate than white men. Black women have a 20% higher cancer death rate than white women.

Additionally,

  • Black Americans are half as likely to get flu and pneumonia vaccinations as white Americans.  See last week’s blog post.

This information is obtained from an article on WebMD

There are so many reasons for these disparities that the study is almost useless to the home health industry.   So maybe the answer is to do what we always done – assess the individual needs of our patients and plan care accordingly.  But sometimes in our effort to be ‘color blind’ factors are overlooked that are closely correlated with being Black and poor in the USA.

About 24 percent of Black people cannot read past a basic level compared to 14 percent White people.  This information is not part of the OASIS dataset and probably shouldn’t be because the time and skills to assess reading ability are not available to us.  There are ways around illiteracy as most nurses know but they take time.  Take your time and be creative.  Send us an account of how your teach patients who cannot read.

Patients younger than 62 who are referred to you may have Medicaid as a primary payor.  In some states, Medicaid provides second rate health care encouraging the use of Emergency Room services when the patient is unable to wait for an appointment set in the distant future.  Medicaid approvals for some medications take time.  We can’t do anything about how the Medicaid system works but we can help the patients navigate the maze.  The truth is that we should be able to treat patients the same regardless of payor source but that ship sailed a long time ago.  If you want to be effective, you must know how the Medicaid system in your state functions.

Poverty and crime have an enduring relationship that isn’t likely to end soon.  Even though you are Wonderwomen and Supermen, you are not able to flash your badge and arrest the bad guys.  Consider the constant stress of living in a home where violent crime is common and how that might affect a patient.  When family members are addicts, patient medications may be diverted leaving a patient in pain unless they want to report a loved one to the police.  I have seen doors with multiple locks leaving me to wonder if there is an escape route in the event of a fire.

In rural areas, crime may not be a problem but the expense of getting to a physician’s office may be out of reach.   Family members may be willing to drive the patient but if they work, they might lose an entire day’s wages.  In these cases, it is possible that truly diligent assessments along with detailed reports to the physician may occasionally eliminate the need for an office visit.

Cheap food is frequently not on cardiac or diabetic diets.  Plus it adds body weight complicating pretty much every disease or condition.  The fact is that poor people eat cheap food and patients who cannot read are unable to follow that food list you gave them, anyway.

As much as we would like to, we cannot teach the world to read, fix Medicaid or reduce crime.  Driving patients to the physician’s office is impractical and basically a bad idea for reasons that would fill another blog post.  You can’t even plant a garden in their backyard to provide vegetables.

We have to look for allies.  Every agency should have a list of community services that can assist us in improving our patient’s’ chances of becoming a little more independent.   It should be reviewed regularly and distributed to all nurses.  Meals on Wheels isn’t the only service available.

We also need to realize that while outcomes are important, there are some things we cannot control.  When someone has untreated hypertension resulting in a stroke prior to admission, it is unreasonable to expect the same good outcomes that result when a patient is referred after being diagnosed with hypertension before a stroke occurs.   That doesn’t mean that we shouldn’t try our best.

The bitter pill to swallow is that our best may not be good enough.  But, it could be better.   Your personal best may be to spend an extra ten minutes with a patient so your functionally illiterate patient can understand the education you provided.  An agency may adopt a policy where breaking even financially on poor and Black patients is acceptable and schedule a few more visits.  Case managers could supplement visits with regular phone calls.  Safety for nurses and patients may be enhanced by an inservice from local law enforcement.

The value of a life is constant throughout races and economic status.  As Malcomb Forbes once said, “You can easily judge the character of a man by how he treats those who can do nothing for him.”  But you may be surprised.  The people who appear to be able to do nothing for you often do the most.

NOTE:  This is an article about African Americans.  I have used the term ‘Black’ because that is what was found in the literature and it is easier to type.  No disrespect is intended.

Guess What Happened!


3D_Influenza_blue_no_key_full_med

Image of the Flu virus courtesy of the CDC.

Guess what happened this past weekend?  The flu season officially started.  Although most people don’t like the flu season, the advent of flu season is better news than the LSU homecoming game score.  Someone should invent a vaccine for the malaise that oozes out of Tiger Stadium and infects the entire state of Louisiana when LSU loses a game deliberately stacked in their favor.  Where is Les Miles when you need him?  I’m not even sure where Troy is.

Back to the flu.  Last year’s flu season certainly wasn’t the worst we’ve seen but an estimated 71,000 flu related hospitalizations were prevented because people received the flu shot.  Is your hospitalization rate high?  Lower it with the flu vaccine.  A full 2.5 Million MD visits were prevented because people received the flu shot.  That’s about equal to the population of the state of Oregon.

We know that Medicare doesn’t give away stuff for free so have you asked why there is no charge for the vaccine?  The total number of hospitalizations for the flu each year runs about 200,000.

And yet, in home health and hospice, our hands may be tied depending state specific pharmacy laws.  In Louisiana, you have to figure that if LSU can’t beat Troy at our homecoming game, we are likely worthless against a deadly virus that kills between 3,000 and 50,000 people each year depending on the severity of the flu season.   Because most states do not allow nurses to carry medications that are not labeled for individual patients, multi-use vials are not allowed to be carried by nurses just in case a patient is in the mood for a flu shot.  While getting an order is not difficult, many nurses are not comfortable with injecting someone with the vaccine without having an emergency kit available for a possible reaction and it is impractical and wasteful to carry around a patient specific emergency kit for every flu vaccination given since it won’t be used.

According to the World Health Organization, for every 500,000 vaccinations given, someone will go into anaphylaxis (a condition causing the inability to breathe kind of like the way Louisiana residents gasped for air after Troy beat LSU on Saturday Night).

There is also a small but significant risk of coming down with Guillain-Barre’ after the flu vaccine.  Although this is one of the more undesirable effects of the vaccine, many people don’t realize that the flu causes more cases of Guillain-Barre’ than the vaccine.  So, roll the dice.  Get no vaccine and hope you don’t get the flu or get the vaccine and have a tiny chance of contracting Guillain-Barre’.  Of course, if you or your patients opt to forego the flu vaccine from your fall schedule this year and wind up sick with the flu, your chances of coming down with a pesky paralytic illness will be greater than those who didn’t get a flu shot and those that did get a flu shot combined.

So, here’s what you do.

  1. First go to the CDC Flu page.  There you will find all kinds of teaching materials for both patients and staff in multiple languages designed for various education levels.
  2. Check on your state’s regulations about the flu vaccine.  If permitted to do so, get said permission in writing.
  3. If you can’t carry flu unlabeled flu vaccine (much like LSU can’t carry a football), use this nifty widget to find out where your patients can receive a vaccine. You can even put it on your website if you want.
  4. Coordinate with your patients and physicians to get orders for patients who are truly bedbound or live in rural areas so distant that a simple trip to the drug store is out of the question.
  5. Encourage everyone in the household to get vaccinated. Leave one of those cute flyers from the CDC website taped to the refrigerator along with the list of nearby flu shot providers to reach the maximum number of family members.
  6. You can also vaccinate other Medicare beneficiaries in the household if you get orders from their physicians. (Technically, Medicare doesn’t require an order but I highly recommend that you give nobody any medication without one; especially someone you haven’t fully assessed and are unaware of their history and physical).
  7. If your agency is going to vaccinate a lot of people, consider billing for the flu shot. I have no earthly idea of how this is done but Medicare has graciously published a little info sheet for people who know what they are doing.  Note that you can only bill for patients with Part B.

The truth is that no matter what you do, the fact that Troy beat LSU cannot be changed.  But imagine if you or your patients get the flu and are too sick to do anything that takes your mind off the greatest LSU humiliation in recent history.  A situation like that could be the end zone for countless Louisiana residents.

And if you see Les Miles, tell him to come back.

Turning Point


My understanding of the events that shook my world last night is that they began before Hurricanes Katrina and Rita.   Although I am not certain of this, it seems that an investigation into Abide Home Health began prior to the storms but the evidence was washed out to sea.   I can’t say if that’s true or not but it adds a level of interest to the story knowing that the agency had a new chance to do things right and chose not to do so.

The case involved over 20 defendants, illicit sex, a dash of racism, the mother of a prominent football player (The Honey Badger), a large oil company and two Zulu Queens.  For those of you not from the South, Zulu is a Mardi Gras parade and they were Carnival Royalty. This is a big deal in New Orleans social circles.

To be sure, this case was juicy.

Imagine for a minute that you are one Lisa Crinel involved in a romantic relationship with your lawyer when a search warrant is executed relating to a fraud investigation involving your business.  Imagine if it was signed by a federal judge who was married to your lawyer.  Now imagine that you are the lawyer when Lisa Crinel files a lawsuit alleging that the lawyer ‘“never informed Ms. Crinel that it was a conflict of interest for him to represent her and her company while carrying on an extramarital affair with her….”   Yes, indeed.  How else could she have known?  I’m betting the judge was unaware of the affair when she signed the search warrant because it didn’t include a cavity search.

For some people, Medicare fraud isn’t enough.  The original press release from the US attorney’s office in Eastern Louisiana alleges that Lisa Crinel created false documentation to support claims for two employees and her daughter so that they could collect money from the funds provided by BP to compensate real victims of the Deepwater Horizon oil spill.  Classy.

Moving right along, Ms. Crinel had already lost 1M to the feds who seized her property even before she was indicted.  This was interpreted by Lisa Crinel as being racially motivated because they did not seize the property of another Medicare defendant accused of the same crime.    I believe there is a possibility that something, other than race motivated that decision.  Could there have been a previous overpayment?  How strong were her ties to the community?  I have to admit, a beach in a country without extradition might have appealed to me if I were in that position.   I sincerely hope that federal investigators did not simply seize her property and bank accounts with no good reason prior to the indictment because in spite of mountains of evidence, Ms. Crinel was innocent until proven guilty.

The Turning Point

In October of 2015, Lisa Crinel woke up with a newly calibrated moral compass.  In exchange for a lighter sentence of no more than 8 years and an agreement from the Assistant US Attorney that all felony charges be dropped against her daughter who served as CEO, she pleaded guilty.  She explained her decision, ‘because I am in fact guilty, and because I did not want to put the government through the unnecessary expense and trouble of proving this in court. I also pled guilty because I understand that accepting responsibility for the wrongs that I have done is the first step toward correcting them.”

Of course, she also agreed to provide the prosecutors with any truthful cooperation in any way she could.  According to Ms. Crinel, this was a genuine personal turning point for her, not just a legal one.  Yes.  That’s what she said.

The Sad Part

Last night, four doctors were convicted of multiple counts of Medicare fraud.  The longest possible sentence I saw was 170 years although the sentencing date has not been set. yet.  Are they guilty?  I think they are.  I still don’t know all of the details but the Feds don’t lose.   They knew this case was their’s for the winning when they took it on.  They turn away far more cases than they accept and the do not indict until they are certain they have a case.

Of the four, I know one mainly through his office staff.  I know that he was with his grandson who was receiving chemo when his office was raided.  I do not believe this was an accident because I’ve heard too many other stories about the feds arriving when the targets of their investigation were least available.  I have followed behind this doctor and another and read their clinic and hospital documentation for years.  The truth is that they are razor sharp physicians who are responsive to their patients and the nurses who call them for orders.

They are basically good men.

So, what happened? One doc received $3,500.00 a month from the agency – $1,000.00 more than would be allowed by law assuming he worked for the paycheck.  None of the doctors were poor and they all made more money than most people reading this blog.

My anger towards the owner of the agency is what I hang on to while these questions still linger.  Lisa Crinel owned Abide Home Health.  Her daughter was the CEO.  They wrote and signed checks that went to physicians.  They paid a physician’s wife an inflated salary so that her husband would refer patients.

Did the docs approach her asking for a Medical Director position?  I bet they were approached by Lisa Crinel.  And what they saw was a successful business woman in New Orleans – an economic nightmare since the storms in 2006.  They saw someone who had overcome the odds and lived well.  They signed orders because she or her agents asked.  Did they trust that the orders were legitimate?

Did they get a little greedy rationalizing that the dollar amount of money may be technically fraud but they deserved it?

These physicians could not have realized they were risking what may amount to life sentences for the relatively small amount of money they received.  But that doesn’t matter.  The standard isn’t what you know but rather what a reasonable person in the same position has the responsibility to know.

Lisa Crinel had the jewels and cash paid for by the proceeds of the fraud.  She was a New Orleans socialite; queen of Zulu.  She was a leader of the community and she lead dozens of her followers to the jailhouse.  While the physicians earned most of their money providing care to patients, she stole all her money by committing fraud.  And when she ran out of lawyers available for affairs and the BP scheme fell flat and nobody would believe that her African American heritage was the reason the feds were picking on her, she turned on the very people she recruited to participate in her fraud scheme.  I’m not sure I have any respect for her.

And New Orleans has lost two great physicians and two more that may or may not be great.  I’m not disagreeing with the verdict but I still find it sad.   The jury found them guilty and I trust the jury.  But they are guilty of fraud; not of being scumbags who systematically scheme to steal as much as they can from the government.   Sometimes good people break the law.

New Automated Denials Coming Soon


Today’s post is written by John M. Reisinger, CPA (TN Licensed) of Innovative Financial Solutions for Home Health Publisher of the Home Health Care Resource Planner.  His contact information follows this post.

John sent the following out in an email this morning so some of you may have already seen it but it is important enough that reading it twice is a good idea.  It speaks to a new way that agencies can be denied without a lot of trouble.  There are links to supporting information an this needs to be shared with your entire agency.

Dear Clients:

 The CMS Medicare Learning Network (MLN) released a new article on March 24 regarding the denial of payment when a Claim is submitted when there is no (required) corresponding assessment in their system.  This will have an effective date of April 1, 2017; so this is something that you want all your billers to be on top of, as well as those that manage the OASIS submission process.  (Julianne’s note:  often the OASIS is submitted but not included with ADR information when a recertification falls in the prior episode.  Be sure that the person compiling the ADR knows to go back and retrieve the recert OASIS.)

Title:  Denial of Home Health Payments When  Required Patient Assessment Is Not Received – Additional Information

PROVIDER TYPE AFFECTED

This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.

PROVIDER ACTION NEEDED

In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.

BACKGROUND

Don’t cost yourself money by not paying attention to the details.  This has always been a requirement under PPS, just a loosely (if at all) enforced regulation.  That is changing effective April 1st.  Now is not the time to worry about the ‘way we have always done it’, now is the time to start doing it ‘the way it should be done’.  Hopefully your software has systems in place to identify these instances when they occur, and your billers have an understanding of how to verify what is appropriate to be billed and what is not yet ready and why (and have processes in place to share that information with you immediately).

In fact, everyone should now be moving to and focusing on ‘the way it should be done’ in all aspects of their operations instead of the‘way we have always done it’, because if things we did in the past were so good, we wouldn’t be having the troubling relationship that we currently have with CMS, MedPac, Congress, et al, that we do have.

Respectfully,

John

www.ifsforhomehealth.com

http://www.linkedin.com/in/johnmreisingercpa
mailto:jreisinger@ifsforhomehealth.com
Ph. # (813) 994-1147
Fax # (866) 547-8553

 

MedPac’s Report to Congress


What is MedPac and why should you care?

Before I answer that question, I will admit that for years I thought MedPac was a Political Action Committee – you know, those huge organizations that use political contributions to try to win favor from lawmakers.  I was wrong.  Oops.  Or maybe it was just a bad name for the committee.

MedPac is a committee created pursuant to the Balanced Budget Act of 1997.  They are tasked with presenting information and recommendations to congress each year on payment to providers from Medicare.  There are eleven commissioners with impressive titles and yet they seem to know very little about the home health industry and show very little interest in learning.  I bet they are boring cocktail party guests if this lack of curiosity is pervasive.  Just yesterday, they posted their March report which, as always, includes chapter about Home Health payments.

It is a long and boring document so please allow me to share with you the highlights.  Here’s the big one.

MedPac recommends another five percent reduction to your payment and the elimination of therapy as a contributor to payment as we know it.

To support their position, various factoids taken out of context are posited as evidence.  They note, for instance, that most beneficiaries can leave the home to go to the doctor and yet, Medicare does not provide any incentives for beneficiaries to receive services elsewhere.

Just to be clear, a trip to the physician for an elderly patient with congestive heart failure, COPD, a surgical wound, a recent CVA, etc. is necessary on occasion.  In terms of difficulty, getting a cat to the vet is probably easier (although to their credit, Medicare beneficiaries don’t howl).  It can take the better part of a morning to help the patient bathe and dress.  Getting into the car is like directing an elderly person through a Cirque du Soleil rehearsal and upon arrival at the doctor’s office you might find that helping them out of the car makes getting into the car seem like child’s play.  Of course, all of this must be repeated in reverse after the office visit and elderly people who are confined to the home are often eager to have a meal out somewhere since they’ve already endured the torture associated with automotive travel.  Everyone is exhausted after the outing but it is worth it.  The patient gets medical care and the family spends some time providing their loved one with a good meal and company.  Passing a good time is not always easy.  MedPac doesn’t quite get that.

Having said that, lives would be in danger if this was a twice weekly occurrence and not just the patient’s life.  Even if a family had the will to survive such an ordeal several times a month, where would they take a patient for medication and diet teaching?  Does MedPac believe it would be less expensive to send a patient to the ER for IV medications?  About the only alternative I can think of is a skilled nursing unit or rehab facility that costs more and deprives the patient of the comforts of their home.

Patients requiring therapy often do go to outpatient therapy as suggested by MedPac, upon discharge from home health once the patient is no longer homebound.   We should not have to be the ones to inform MedPac of how this works.

The report talks about a 2015 CMS review of home care services that revealed that almost 60 percent of claims were missing information that satisfied Medicare criteria.  The report does not address all in the information sent to their contractors that is lost so neither will I.  I could but I won’t.  What’s important is the time frame of the report which resulted in an expansion of Medical review and the Preclaims Review Process.  MedPac uses cost report data that doesn’t not include the added expense of being under scrutiny or having to participate in the PCR process.  There are no home health leprechauns who put together charts and ensure that all the right pieces are put together so that the chart can be sent to the Medicare contractor that requested it. Paid employees do this work.

Another thought that occurs to me unbidden, as I hate to be unkind, is that when 60 percent of claims are found to be lacking one or more elements of documentation that satisfies Medicare requirements, maybe the problem is with the reviewer.  Maybe there should be more education available to providers.  Hell, I’d be happy if there were a number I could call and ask a question.  (CGS is excepted from this last comment.  Lately, I’ve been calling them for questions even though most of my clients bill Palmetto GBA).

There is so much more in this report that illustrates with utter clarity how little insight MedPac has into our industry but the therapy issue really gets under my skin like scabies.  MedPac believes the increase in therapy is not justified in the very same report that notes that hospitalizations in home health patients has decreased from 28.8 percent down to 25.4 percent.

Another way of saying that is that an increase in therapy visits coincided with a decrease in hospitalizations.  Even I know that correlation does not equal causation but MedPac presents no hard numbers to demonstrate that the lower hospital rates are not related to increased therapy although they speculate a little.

So, MedPac wants home health to take another hit.  Bully for them.

Back to the original question:  What is MedPac and why you should care?  The first part of that question has been answered.  More info is on their website if you are still curious.  The second answer is that this information is prepared for the US congress.  Unless they hear other points of view, our industry will continue to die a slow death by strangulation.  Our state and national associations have lawyers and lobbyists who can construct arguments with greater legal authority than most of us and I have no doubt that they will.  But if I were a senator or a representative (fat chance of that ever happening), I would want to hear directly from the people affected by these proposed cuts.  So, take a few minutes and let your congressmen know how very myopic and well, stupid this report is and suggest they put it in the recycle bin.  There’s no point in killing trees, too.

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