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

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?