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You In?

I received an email from somebody last week who made the first valid points about The Alliance and associated groups that I have read.  Respectfully I do not agree with most of his points, but it did give me pause to consider some of my positions.  I remain firm on my position that the exclusivity of these groups and the ulterior motive of some members are reprehensible and contemptible.

That was my disclaimer.  Let me share with you one or two of his opinions that hit home.

First of all, CMS is not going to listen to any providers from any sector of the industry ‘whine’ about payment.  That much is certain whether you are the Alliance or Joe Bleaux on the street.  Fair, according to CMS is determined by the numbers.

I took the time to read the trustees report to Medicare over the weekend so you wouldn’t face that burden.  Say, Thank You, Julianne.  Most of the information was fairly useless to us as home health providers.   Some of it was so boring that I came close to tears a couple of times.  But within the report there were one or two things that are important to us as clinicians.

Here are some numbers from the report.  Stay with me.  Your only alternative is to read it yourself.

Medicare Expenditures for 2010 in Billions


Part A Part B Part D Total
Benefits 244.5 209.7 61.7 515.8

By Provider Type

Hospital 136 31.9l 168
Skilled nursing facility 26.9 26.9
Home health care 7.0 12.1 19.1
Physician fee schedule services 64.5 64.5
Private health plans (Part C) 60.7 55.2 115.9
Prescription drugs 61.7 61.7
Other 13.8 46.1 59.9

The report also said:

It is possible that healthcare providers could improve their productivity, reduce wasteful expenditures, and take other steps to keep their cost growth within the bounds imposed by the Medicare price limitations. For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains—a very challenging and uncertain prospect.

The last sentence is worthy of repeating.  “For such efforts to be successful in the long range, however, providers would have to generate and sustain unprecedented levels of productivity gains – a very challenging and uncertain prospect.”

For the home health care industry, I think it is challenge we will meet.

The next argument posed by the anonymous emailer is that the researchers and brain power in these groups was very high level.   I will begrudgingly concede that there is room for this kind of academic and intellectual examination of our industry.  But, I am a nurse and I know nurses and we are just as smart, as a whole, as any other group on the planet.  Plus we have an edge.  Nurses answer to a higher authority than any shareholders, state licensing board, policy maker organization, or even Congress.  We answer to the patient first, and then to each other.

So, down to business and I do mean business.  We sell health care for a living.  In particular, we sell nursing care and to a lesser degree, ancillary therapies.  I have used the analogy that home health agencies are like brothels in the past to illustrate that all the payor sources care about is the end product.  I was advised that some people may find my analogy offensive.  I can’t imagine why the sex industry workers would be offended but just to show my sensitive side, I will not expound on my analogy.  The point I was trying to make is that our end product is our clinical care.

In other words, CMS and Medicare HMO groups do not care who has the best accountant or even the most paid lobbyists.  They judge us by how well we perform as determined by our cost vs benefit ratio to the overall Medicare budget.

Looking at the budget numbers, the first thing you see is that the bulk of the budget goes towards hospitalizations.  Over 168 billion dollars last year was paid to hospitals from Medicare alone and I assume approximately equal percentage was paid by the Managed Care Plans in Part C. If we are competent and keep hospital rates down, we will survive.  If we are excellent and reduce overall costs to the Medicare trust, we will be golden.  They will turn to us for answers and be eager to give us the budget to care for patients.

Next number to look at is Physician costs.  Every time we provide appropriate contact to a physician for a patient already on service we reduce the total payment to physicians.  Obviously, physicians are our colleagues and we are not out to eat into their income.  But, I think even the doctors appreciate a nurse who recognizes the need for intervention and arranges for it with his assistance as opposed to interrupting his day with an unplanned patient visit.  If you keep their patient out of the hospital, you have proven your worth to them more than any expensive dinner or cute little sticky notes.

Look at the part D drug expenses.  We like drugs.  Patients like drugs.  Drugs are good things.  Nurses, in particular, are fond of drugs.  How many of you have ever wished for a Xanax or Prozac salt lick in the office.  By making a concerted effort to truly examine our patients’ medications and identify duplicate and ineffective therapy, we both improve care and reduce the risks of hospitalizations.  When we identify medications that are ‘left overs’ from an illness the patient no longer has, we save money.  We don’t do that.  I know it says that we do in the OASIS, but as an industry, there is vast amount of room for improvement.  We do not need policies or pathways to check medications.  We just need to remember to do it and address all inconsistencies.

Nursing home care is expensive.  The part of nursing home care that Medicare pays for is ‘skilled’ needs much like the skills we can and do provide in the home.  Ask yourself; is it better for the patient to be in the home or in a nursing home?   If you can provide those same skills at a lower level of expense than a skilled nursing facility or rehab hospital, you can save the Medicare system money.  Better than saving money is that you may be able to keep the patient in his or her home where life is much friendlier.

So, there is your challenge. You in?

3 Comments Post a comment
  1. Dwelia Boyce #

    I’m in!! Now if I can only get my team of nurse’s on board. I’ve been in Home Care since 2006, and since that time I’ve watch better go to worse. As a clincial supervisor,who has the opportunity to follow an epsiode from start to finish and I am disillusioned to say the least. That’s why I say I’m IN because, I really don’t know what it will take to have our field nurse to think more about the patient than the pay. There are only so many hours in a day and nurses just cut to many corners and the cost is enormous . Then to top off lazy nursing care and documentation there is a new and not so friendly electronic medical record, that was suppose to help some of these situation and make nursing more manageable. I can actually see the results from compling to what we are nurses caring about the health and welfare of the patients we serve. I am not criticizing my nurses, they do their best sometimes, with what their working with…….Anyway I’M IN

    October 10, 2011
  2. Susan #

    Three cheers.
    I got my start in home health in 1992 at a company called Kimberly QualityCare. They later were bought by Olsten who became Gentiva. Back when Bob Fusco was president of the home care side of Olsten, I was proud to work there.
    I work these days for a hospital based non-profit. And yeah, non-profit we are. But we save the hospital much more than we loose, so, we sorta win.

    I’ve never understood why they care more about our small percentage than they do the hospital’s large one, but we’ve always been the red-headed step child and like Cinderella, no one wants to take us to the ball.

    October 10, 2011
  3. Gail #

    First, as you requested, Thank you, Julianne for reading and suffering through all the gobble-de-gook to get to the meat of the issue.
    I was first of all intrigued by the discrepancy between $168 billion paid out to hospitals and our poor little $19.1 billion. Hospital care is expensive and should retain the largest percentage of the Medicare dollars. And I know that CMS is monitoring fraud and waste across the spectrum, but we (home health) look like small potatoes in comparison to the rest of the pie. It makes me wonder if the heaviest concentration of ferreting out fraud, waste, and abuse is being concentrated on the most likely offenders.
    You stated, “But, I think even the doctors appreciate a nurse who recognizes the need for intervention and arranges for it with his assistance as opposed to interrupting his day with an unplanned patient visit.” You’d think so. But, (and I’d like to hear from some other nurses in the trenches out there) we often hear, “Just send ’em to the ER. I don’t have time to fool with that.” So, since there is no transportation available, you call the ambulance and send the patient off to an expensive ER visit and hope that someone is available to come pick them up when the ER doc is finished with them. (We are considered in a rural setting.)
    We have purchased a very expensive EMR system and are still in test mode right now, but hope that this helps to fill the bill to “generate and sustain unprecedented levels of productivity gains –” We hope that this will minimize the time the nurses spend writing and open up time for actual patient care and each field nurse + office nurses will have access to pertinent information at their finger-tips without having to search the world over for one nurse’s note. When the doctor calls and wants the B/P readings from the on-call weekend nurse’s visits, I can pull it right up in the computer on my desk and give it to her without having to put her on hold for 5-10 minutes while I search through the 3 or 4 stacks of papers to find it.
    It has been asserted that nurses spend from 35-75% of their time documenting. Regulations have forced this upon them. But, “if it wasn’t charted, it was done” was the philosophy I learned in nursing school. (Thank you Miss Landry…RIP.) We can increase productivity, save money, and take care of our patients by working smarter, not harder.
    Well, this is getting long. Keep up the good work, J, and keep us on the straight and narrow.

    October 11, 2011

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