Cherry Picking
Every year my mother picks cherries. She doesn’t think twice about climbing on
a ladder and reaching over the fence to the neighbor’s tree and picking all the cherries she can reach. She read somewhere that fruit that fell from a neighbor’s tree into her yard is legally hers. She insists she is merely assisting the cherries to fall gently to the ground on her side of the fence where they were going to fall anyway. Then when she gets enough cherries, she fills two big glass containers and pours vodka over them to make Cherry Bounce. I really don’t have a problem with that because my Mama is over 80 and if the worst thing she ever does is make Cherry Bounce with cherries of questionable origin, I think I can live with that.
Cherry Picking patients is another story all together. I am not a lawyer so I will not speak to the legalities of it, if there are any. I am not an ordained minister (if you don’t count the free certificate I ordered off the web just to see if I could) so I cannot offer you moral advice. I am, however, a long time participant of home health in various capacities at various companies and I assure you that I recognize sleaze when I see it.
We all know the agencies who visit patients right up until their benefits run out. In Louisiana, Medicaid patients are seen by one set of agencies in the first part of the year and another set of agencies in the last part of the year. We know of agencies who refuse expensive wound care patients and low paying Medicaid in other states. Proving it would be difficult but I cannot count the number of times that I have been in a client’s agency and a referral came from a discharge planner or doctor’s office reporting they had tried two or three other agencies before they could find someone to accept the patient.
Nurses, excluding the DON, often don’t have much of a choice over setting policies in an agency but we do have the responsibility to advocate for our patients. We can insist on timely discharges and responsible frequencies so that a patient will get the care that they need.
We can also insist that visits be increased when needed regardless of the cost to the agency. It is never appropriate for a financial person to bully a nurse into writing a care plan that doesn’t meet the needs of the patient. It is also not a financial decision to determine if a patient is ready for discharge or needs to be recertified.
Before I start interagency wars, I have experienced that good agencies often have some conflict between the clinical and financial departments. I see agencies thrive when both sides are firm in their positions and each side knows when to relent or compromise. As a nurse, I think every patient needs daily visits and the most expensive wound care products. As a businesswoman, I realize that nobody gets care if the agency cannot stay afloat. It is only when clinicians and ‘money dudes’ have mutual respect for each other that solutions benefiting both the agency and the patient are regularly discovered.
If you are competing against an agency who never compromises with the clinicians and consistently refuses care to expensive patients or low paying patients because of ‘staffing’ shortages, document each event that comes to your attention. If they occur repeatedly, send the information along to your state survey office. They have every right in the world to determine if the agency had sufficient staff for other referrals that day.
If you receive a referral that has been refused by other agencies for financial reasons, ask for the next referral as well. My friend, Ed Lakin, a Marketing Consultant says that too often we forget to ask for business. The referral source can always say no but at least you have made known that you are open to more referrals. (And I do mean, ‘ask’ and only after you have accepted the patient in order avoid the appearance of an inappropriate arrangement where you are bartering with patients.)
When physicians who are Medical Directors of other agencies only refer money pit patients to you to protect their interests, document your concerns. If it happens repeatedly, diplomatically confront him. Smile sweetly and be courteous while you let him know you believe he is behaving in a manner that is an embarrassment to his profession. Do not use those words.
I like making money. I love business. I work all the time to help my clients increase their margins. There are countless ways that it can be done but none of them involve being sleazy.
Sometimes, doing the right thing costs money. When a patient requires care, it will likely be provided. There is always a nurse who can be talked into seeing a patient with real needs. The question is which provider will lose money on the patient?
Hopefully, the same provider who is able to accept and admit high dollar patients will take a hit now and then. If not, the agency that does admit the patient is without a doubt the better agency. Of course, their outcomes may not reflect it because costly patients often are at higher risk for hospitalizations and since their competition only admits high profit patients, it stands to reason that their patients will have better outcomes.
If you have any solutions to this issue, please share them below or email us. It frustrates me when I see this happen and I get paid regardless. I cannot imagine the frustration agencies experience on a daily basis. All of my solutions usually result in long discussions with lawyers and tailors measuring for prison scrubs. Help your fellow agencies out here and provide some ideas that do not jeopardize licenses, marriages or freedom.
