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Posts tagged ‘home health care’

Schooling Me

Last week, I wrote about a study that revealed an astonishing fact:  Poor, Black people have worse home health outcomes.   I surmised that we really didn’t have time to do a full literacy assessment; nor did we have the skills to do so.  Oops.  A reader, Kyandra commented that there is a Single Question Literacy assessment and that prompted a day long journey into Health Literacy on the internet.  Some of the information I found truly was surprising – and frankly, embarrassing to us as a nation.

The statistics are wide and varied.  One study estimates that one in three adults does not have the literacy skills to understand written health materials. Most health materials are written at an 8th grade level but the average reading level of adults is closer to the 5th grade level.  Older Americans (i.e. Medicare Beneficiaries) are more likely to be unable to read or comprehend written materials.  Accidents happen, hospitalizations increase and preventative care decreases with an increase in health literacy skills that are basic or less than basic.

Should health literacy statistics bore you, know that effective January 1, you are mandated to have a working knowledge and use it.

From the new Conditions of Participation:

The agency must provide information about rights and responsibilities verbally and in writing in a manner the patient can understand. There must be documentation that the agency has complied in the chart.

This is not new.  It has always been a part of the Civil Rights Act section 504 which applies to all government contractors (yes, you are a government contractor ever since your agency entered into a provider agreement with CMS).  Now it is part of the CoPs.

Finally, patients and/or their families have sued successfully when they were unable to understand consents or other forms given to them.  Judges think that a patient who cannot understand the information cannot give informed consent.  I agree.

During my rambling search, I found one video by the AMA that explains the problem much better than I do and also offers solutions.  If I ran an agency, I would play this video at a mandatory inservice for all employees.

After watching the video, consider using a single question literacy screen that has been proven to be fairly accurate in determining health literacy in adults as suggested by Kyandra.

 “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”

  1. never
  2. Rarely
  3. Sometimes
  4. Often
  5. Always

Although the assessment is determined to be only moderately effective in research, there’s a good chance that a patient admitting to having difficulty reading medical instructions needs more than a standard teaching guide and I’m pretty sure that creative nurses will be able to accommodate those needs.

Nicole White from Chicago commented that she used a sheet of paper handed to her patients.  It had several goals written in a font similar to that found on medication bottles.  She asked them to choose a couple of goals they would like to achieve.  If they couldn’t read the sheet, she asked if she could fetch their reading glasses from another room.  She assessed patient specific goals, vision and literacy without adding time to her assessment.

Nobody is in a better position to dance around problems with literacy than home health employees.  We are in the homes where patients are typically more comfortable.  We get to the know the patients (which may suggest the need for a second screening after a few visits).  We may have more than one person to teach and we can truly give the patient our full attention watching for indications that they are not understanding.  And we can solicit questions.

Agencies can lower hospitalizations, prevent medication and other errors, save a life or two, comply with the new CoP’s, reduce risk and save Medicare millions of dollars when they take health literacy seriously.  And it only costs the time it takes to play a YouTube video and let your nurses and therapists loose to find creative, patient specific solutions.  If nurses can devise a plan to use pool noodles in their care, I’m pretty sure they can use those same skills to meet the needs of their patients.

Please share how you work with patients with limited English proficiency or literacy skills by commenting below or emailing me.

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.

The Z-Factor

Nurses have been trained to not bother physicians, especially referral sources with petty concerns. But, there is a balance between irritating a physician to the point that your competitors gain a new referral source and responsible patient care. If you have to choose, go for responsible patient care.

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THE Formula

The formula for making money in home health is simple.  Take the number of patients you have and multiply it by the average payment and you can get a pretty good idea of what your revenue will be.  I don’t think you need a degree in higher mathematics to figure that out.  What I have trouble conveying to certain people is how the census influences the average revenue.  The significant decrease in later episodes is enough to make a sane person think twice about holding onto patients who have met their goals but sanity doesn’t seem to be our strong point at times. 

Luckily for me, Palmetto GBA has simplified the explanation for me.  Here are some numbers that PGBA sent to one provider as an explanation for why they were undergoing a probe audit.

Length of Stay in Days


It would seem that this particular provider has an average length of stay close to a thousand days but Louisiana in general is closer to 400 (that is not a typo) and all PGBA states are just over the 200 mark.  More than half of the agency’s patient are on service longer than 975 days. 

Based upon these numbers, one would think that the provider who received this letter was paid a whole lot more than they should have been, right?  After all, their patients were on service for twice as long as most Louisiana patients and three times as long as the average of all patients in the states that PGBA serves as a MAC.  But, you would be wrong.  Otherwise, I would not be writing this post.  Here is the reality in dollars and cents.

Disbursement per Beneficiary


Suddenly the tops of the bars are a little closer together.  The blue provider is only making slightly more per patient than agencies with a shorter length of stay and about 2K greater than all PGBA states.

So, if your strategy for increasing your census is to hold onto patients until they die, or quite possibly you die, you may want to re-visit that strategy.  Everything else aside, the agency in blue is now burdened with the extra expense and stress of getting records ready for review by Palmetto GBA.  In agencies with a large number of later episodes, the average HHRG will come up simply by discharging patients who are on service for longer than they need to be.

Keep one other thing in mind as you look at these numbers.  The PPS system results in higher reimbursement for some occurrences in the later episodes offsetting this natural decline in payment.  Patients who have surgical incisions in later episodes or a need for therapy actually pay much higher than the average.  What this means is that patients who truly do require extra services because of a new diagnosis or event will generate the revenue required to take care of them. 

The original formula still works but in order to succeed agencies need to understand how the numbers affect each other and aggressively pursue new admissions as the only way to build census.  Holding onto patients apparently costs the agencies more than it does the payor source but it won’t stop them from coming after you if your numbers produce a graph such as this.

If you have received a copy of a similar letter from PGBA, I would very much like to see a copy of it.  You can delete your agency information or you can be assured that I would never disclose your identity. 

Don’t forget to register for the Food, Football and Fun event.  Your nurses will come away with the tools your agency needs to survive the scrutiny that is apparently our fate this year.

Note: The blue numbers have altered insignificantly so that a provider’s actual data was not posted in a blog.

Attention: Bill Borne, CEO Amedisys, Inc.

Dear Bill:

I read with great horror a Reuters feed in the Baltimore Sun  this morning in which you made a statement to the effect that you along with Louisiana Home Care Group and Gentiva think it might be a good idea to accelerate the pending payment cuts to Home Health Providers.  You are on record as saying that such acceleration would give you the opportunity to exploit the ensuing financial devastation of smaller, privately held agencies with the ultimate goal of purchasing up to 53 percent of them.  You made an extremely salient point that is no fun to wake up and see your stock prices plummet and spoke of a strategy that involves sudden death to MY clients to possibly lift an overhang on the stocks.

I worked with you when you picked up shifts at the Baton Rouge General CICU 20 years ago.  I went to work for Amedisys Corporate when we were the proud owners of 5 provider numbers.  I was there when Amedisys got kicked off NASDAQ because of insufficient cash and Assets.  And I was there when the small fish bought the big fish, Columbia.  To be honest, up until this morning, this has always been a source of pride for me.  I learned a lot at Amedisys and I am grateful for the opportunity to have worked for you.

So, riddle me this, Bill.  Did Reuters somehow misquote you?  Were your words taken out of context?  Did you forget to run your opinion by your PR department?  Because let me assure you that I am so not impressed.

The industry as a whole is facing serious challenges but my clients are more than capable of handling them unless the three largest publicly traded home health care companies put pressure on CMS to hurt them.  It seems like you want CMS to lower the cost of acquisitions for you.  What a brilliant idea.  I want CMS to make being stupid a diagnosis that adds to the payment for a patient so you can be admitted and treated by one of my clients.

Make no mistake, if I believed that the Amedisys way is the best way to take care of patients, I would be out there brokering deals with my current clients right now.  But that isn’t the case as the numbers show.   The graphs below show a couple of my clients’ performance in comparison to Amedisys and LHC in areas where you coexist.    I limited the comparison to hospitalization rates because reducing hospitalizations is the greatest benefit offered to patients, families, communities and our payor sources.

Baton Rouge, Louisiana Hospitalization Rates

Houma, Louisiana Hospitalization Rates

Birmingham, AL Hospitalization Rates

I assure there are many more examples but my goal is not to say that my clients outperform you and leave you in the dust.  In the interest of transparency, I also have clients with a much higher hospitalization rate.  My purpose here is to illustrate that my clients are more than capable of holding their own against the ‘big boys’ in our industry in the only outcome that really counts – hospitalizations.

Of course, there are more than numbers to consider.  My clients hire a lot of nurses that have previously worked at Amedisys or LHC.  While I appreciate your need for standardization for management purposes, it is frequent that Directors of Nursing and Administrators are merely figureheads on paper that are given job descriptions resembling recipes.  This approach limits creativity and the ability of the nursing staff to take into consideration the particular strengths and weaknesses of their field staff.  When the most important decision they make all day is whether or not they should call Corporate it is unreasonable to expect them to be able to gracefully deal with more serious challenges like federal investigations, etc.

I can’t help but notice that your personal annual compensation package is greater than the annual revenues of many of my clients.

William Borne/Chief Executive Officer

2006 2007 2008 2009 2010
1,350,758 3,669,021 4,381,190 3,247,024 2,185,698

I do not begrudge your wealth.  The way I figure it, Bill, is that as smart as you are, you are not smarter than me.  Ergo, if you can do so well then so can I.  I would feel worse if you were chronically broke after working so hard and I do recognize the fact that you worked very hard.

What I find so offensive is that you used to be a CEO of a company that took care of sick people in their homes.  What pisses me off is that I remember when you were a nurse.

Unless you were seriously misquoted, it would seem that somewhere along the way you have evolved into just another corporate fuck-up motivated by greed and stock prices.  I feel like holding a funeral for the Bill I held in such high esteem for so long.  I hope you always remember that victory at the expense of others is a merciless taskmaster.  It is an honorable aspiration to do grow your organization by giving superior care.  It is pathetic that you prefer to build your organization by wishing harm to your competitors.  Little boys kill ants in jest but the ants die earnestly.  The ants in your world are my clients and countless other smaller providers just like them and I work just as hard for them as I ever worked for you.  Consider that.

You may not know this but my office is now less than a mile from your corporate headquarters.  It is next to the first Corporate Building that you and I worked at together on South Sherwood.  I am upstairs in suite 300 and would love to give you an opportunity to clarify your outrageous statements.  Call me at 225-253-4876 if you want to schedule a time to talk or email me a response.