Thanks to Medicare changes...My Job Was Just Eliminated

[TheCommuter, BSN, RN]

I wouldn't completely blame your job loss on 'ObamaCare.' The changes to the Medicare reimbursement structure were developed in 2002 under a different presidential administration.

The movement to link Medicare reimbursement to HCAHPS had clearly gained momentum in 2005-2007.....several years before President Obama entered office and many years before his healthcare reform bill had been signed into law.

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalHCAHPS.html

Beginning in 2002, CMS partnered with the Agency for Healthcare Research and Quality (AHRQ), another agency in the federal Department of Health and Human Services, to develop and test the HCAHPS survey. AHRQ carried out a rigorous scientific process, including a public call for measures; review of literature; cognitive interviews; consumer focus groups; stakeholder input; a three-state pilot test; extensive psychometric analyses; consumer testing; and numerous small-scale field tests. During this process, CMS provided three opportunities for the public to comment on HCAHPS, and responded to well over one thousand comments.

In May 2005, the HCAHPS survey was endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and research and quality organizations. In December 2005, the federal Office of Management and Budget gave its final approval for the national implementation of HCAHPS for public reporting purposes. CMS implemented the HCAHPS survey in October 2006, and the first public reporting of HCAHPS results occurred in March 2008. The survey, its methodology and the results it produces are in the public domain.

Hospitals implement HCAHPS under the auspices of the Hospital Quality Alliance (HQA), a private/public partnership that includes major hospital and medical associations, consumer groups, measurement and accrediting bodies, government, and other groups that share an interest in improving hospital quality. The HQA has endorsed HCAHPS.

The enactment of the Deficit Reduction Act of 2005 created an additional incentive for acute care hospitals to participate in HCAHPS. Since July 2007, hospitals subject to the Inpatient Prospective Payment System (IPPS) annual payment update provisions ("subsection (d) hospitals") must collect and submit HCAHPS data in order to receive their full IPPS annual payment update. IPPS hospitals that fail to publicly report the required quality measures, which include the HCAHPS survey, may receive an annual payment update that is reduced by 2.0 percentage points. Non-IPPS hospitals, such as Critical Access Hospitals, may voluntarily participate in HCAHPS.

The Patient Protection and Affordable Care Act of 2010 (P.L. 111-148) includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program, beginning with discharges in October 2012.

[CDUBBYA]

November is coming up soon so you can repay the favor. The cuts from reform always happen but this time these cuts are diminishing the quality of care and turning hospitals into a "cattle herding" operation. Get them in then get them out as soon as possible to reduce cost. NO MATTER HOW SICK THEY ARE! Let's see if one of the BIG WHEELS in the white house let that happen to their family members? They probably would is what is sad.......

It was Tuesday, 3:20 PM. The phone on my desk rang and I saw the extension was "1961"...

I knew. This was it!

Our Chief Nurse wanted to meet with me in Nursing Administration.

The ride down the elevator and the walk down the long hall were surreal. I found myself wondering, "Is this how people feel as they walk to the electric chair?"

I think so.

I walked in and there was the person from Human Resources along with the Chief Nurse. Neither one was smiling. I smiled...I think. I really don't remember.

The next several minutes were a blur of words:

"nothing done wrong"

"purely economic considerations"

"cuts made"

"today...last day"

"take time cleaning out office"

"severance pay"

"benefits...continuing and stopping"

"classes...resumes and job search and interview skills"

"apply for other openings in-house"

"everything...fine"

Then, I was carrying an envelope down the hall to the next room to sign up for one of those classes.

The irony of the situation did not escape me. My job had been created because of health care reform. And, now, it was being terminated because of the same health care reform.

Crazy world we live in, eh?

So what was my job and why was it created? And why did it go away?

What was My Job?

I was in charge of core measures. That, in and of itself, is kind of funny. When I arrived at this hospital about 5 years ago, I had never heard of core measures. I remember making an appointment with the Director of Quality Management and asking her, "what is a core measure and why should I care?"

Fortunately for me, she and I had worked together at a previous place of employment and she already understood my sense of humor. She proceeded to do exactly that.

Core measures are quality indicators that can be used by insurance companies, the Center for Medicare/Medicaid Services (CMS), The Joint Commission, and patients to compare the clinical care provided by hospitals. These measures are very specifically defined, measured a certain way, and based on evidence-based interventions for improved patient outcomes. The sampling methods are based on statistically based research methodology. The results are reported as a percentage of patients who received the appropriate care as defined by each measure. The goal is to be 100% on every measure every time, all the time.

Why Was My Job Created?

Last July, 2011, began a new era in health care reimbursement, "Value-Based Purchasing" (VBP). Over simplified, VBP is a formula that determines overall how well a hospital is meeting the core measures and customer service goals. If everything is 100%, the score comes out 100%. The nine months from July 2011 through March 2012 constituted what was known as the "qualifying period."

Each hospital's performance during the qualifying period will determine the amount of reimbursement for a designated time frame (the next fiscal year, I think).

My job was created to maximize our hospital's VBP score. I was serving as coordinator for concurrent auditing for all core measures for the hospital. Fortunately, there were teams in place prior to the creation of my position last October. There was a team for each category of core measures [Heart Failure (HF), Acute Myocardial Infarction (AMI), Pneumonia (PN), and Surgical Care Improvement Project (SCIP)]. The HF/AMI team and the PN team had been in existence and functioning very well for about five years when I took my new job last October. The SCIP team was the newest team...only a little over two years in existence. My primary role was with the SCIP core measures.

Every day, I would extract the potential SCIP patients from the Operating Room (OR) schedule and post the list on the SCIP website for the unit based concurrent auditors (staff nurses caring for the patient, Clinical Nurse Educators, Nurse Managers) to know which patients needed to be checked for compliance with SCIP core measures. As I made rounds every day, I would check and double check that all the i's had been dotted and all the t's had been crossed so that the documentation would accurately reflect the care the patient had received and would pass each core measure. Some of the patients that were on the list would turn out not to actually be SCIP patients after all. Some cases that did not initially look like they would fall into the SCIP measures would end up qualifying as SCIP after all. This normally occurred with exploratory laparotomies or diagnostic laparoscopic procedures because the procedure ended up being more...sometimes much more.

Over time, the staff was getting better and better at knowing which patients should receive which pre-op prophylactic antibiotics and giving it within the specified time frame. Patients who needed beta blockers were receiving a dose of beta blocker on the day of surgery or the day before and another dose on post-op day #1 or post-op day #2; pre-op hair removal and post-op temp was properly documented; post-op temp was in the right range to reduce post-op complications; sequential compression devices were used and documented on the cases who needed them; appropriate anticoagulant medications within 24 hours of surgery in appropriate situations; stopping prophylactic antibiotics on time; and removal of the indwelling urinary catheter by the end of post-op day #2. These had all improved immensely over the months. They were better, much better.

Better, but not always perfect on every measure every month. Each measure had reached 100% for one or more quarters. However, we had never had a quarter where all the measures were 100% at the same time.

My job was to catch the documentation that slipped through all the other pairs of eyes and dot those i's and cross those t's before the patient's medical record went to medical records...at the time of discharge.

The official review was done after the chart was fully coded and billed...if it was selected to be in the sample for that month. The official review was on a sample of the qualifying charts; concurrent review was on about 200% of what turned out to be the actual SCIP population. Each month the number of patients concurrently audited varied slightly from 350 to over 500 potential SCIP patients.

Almost daily I would find one or two pieces of documentation that was missing and do the teaching with the appropriate staff member to make sure it was corrected. Some days, like last Friday, when the CCU was swamped, there were four that had to be corrected in that one unit in one day. This past Monday (the day before my job ceased to exist) I found five surgery cases from the weekend that all had the same documentation missing...due to handwritten Anesthesia Records. These were handwritten during the switch over from one computer documentation system to another. The CRNA forgot to document the route on the pre-op prophylactic antibiotic for five cases. I found and corrected them all...on Monday.

Then, came Tuesday.

Why Did My Job Go Away?

One of the changes wrought by healthcare reform is a 15% reduction in reimbursement to hospitals over a 10 year period...at 1.5% per year. For most hospitals that 1.5% translates into a few million dollars less in this year's budget compared to last year's every year for 10 years. For the last couple of years, our hospital has trimmed the budget by changes in supply choices, eliminating non-essential items from the budget (travel allowances, education reimbursement, continuing education reimbursement, conference travel funds, non-patient-related purchases, hospital week celebrations, gifts during nurses' week, etc.).

This year, there just wasn't any "fluff" left to cut from budgets. However, there needed to be a significant reduction from the bottom line costs. With a larger and larger percentage of uninsured patients (due to loss of patient's employment), our hospital - like others across the nation - is providing more and more charity care and writing off more and more patient charges each year. For the hospital to be able to keep the doors open, it is absolutely essential to maximize reimbursement while at the same time minimizing costs...thus came the reduction in force by approximately 30 positions this week and re-structuring of the organizational chart - yet again.

Summary

Ø My job was created to meet the quality core measures that are required for Value-Based Purchasing, Blue Cross, and The Joint Commission...in order to keep the doors of the hospital open in this time of reduced reimbursement for care provided to Medicare and Medicaid patients.

Ø My job was then cut to reduce costs because of reduced reimbursement for care provided to Medicare and Medicaid patients.

Ø These reductions in reimbursement are part of the changes to health care (voted into existence since President Obama took office) in an effort to reduce the federal budget deficit.

Ø Thus, my job was created because of Obamacare and then, in turn, eliminated by the same Obamacare.

The End...or rather, the Beginning of Looking for a New Job at the age of 58 years with more than 35 years' experience. Wow!

P.S. Wonder of if President Obama needs someone to work on the plan for healthcare reform from the grassroots level? ;-)

[merlee]

Most of Obamacare regs don't even BEGIN until 2014. As previously noted, the financial situation you find yourself caught up in began before Obama took office.

So rename your thread, and blame BUSH and the REPUBLICANS.

But I truly understand your pain - - some 25 years younger than you will have your identical job with a different title and much less money.

[MunoRN, RN]

Ø These reductions in reimbursement are part of the changes to health care (voted into existence since President Obama took office) in an effort to reduce the federal budget deficit.

Ø Thus, my job was created because of Obamacare and then, in turn, eliminated by the same Obamacare.

Neither the establishment of SCIP measures or the Value-based-purchasing reductions in Medicare were part of Obamacare.

SCIP measures went into effect on July 1, 2006. Value-based-purchasing was established in the Medicare Modernization Act of 2003 with VBP pilots beginning the same year. (Obama took office in 2009).

[kcmylorn]

I don't see the cut as the result of the healthcare reform. I see it as the way these healthcare systems have "chose" to interpret the reform for thier best profit interest.

I'm sorry to keep harping on getting the MBA and mega salaried CEO's out of our healthcare industry but I do have to say it again.

The 'Obama care'/ healthcare reform, in cooperation with the Dept of Health and Human Services, rolled out a new path a new way of looking at a person's health. - a preventative focus on health care as opposed to the acute care mentality/ focus we have been sustained by for decades. Both have recognized the millions of un insured and under insured in this country. I believe( and this is JMHO) both Obama and the DHS have studied and analyized the numbers of people with out insurance, the healthcare behaviors of these uninsured and under insured- prolong until it can't be put off any longer, and the cost of this mind set - example: instead of patient with hypertension and a medication, now becomes a patient needing dialysis. This kind of behavior has been a blockbuster for the busines MBA's CEO's in the healthcare institutions for years and years and years. The CEO's have benefited from this mindset- keep people sick; because eventually they will end up in our hospitals and the money for them will keep rolling in, they have to be cared for/hospitalized. They come in through the expensive ED, are laid up in the ICU's for days, then move to stepdown telemetry, then to med/surge and then discharged. No behavioral change on the part of the American public. Just keep those healthcare costs a rising. medicaid and Medicare were paying these costs almost with out question all the way back up until the early 1990's and hense the profits for the CEO's rise- Medicaid and medicare patients were kept the longest!!..

While Obama's healthcare reform has laid out a plan for people to get insurance, and the DHS laid the ground work for the medical community to change it's focus on patient care. The managed care movement began because hospitals began to loose money. These patients were sick, sick sick- elderly with sepsis, tubefeeds, IV antibiotics, decubs, then MRSA or VRE sets in and they honeymoon in the ICU's. It forced these hospitals to examine these costs, and discharge delays. Doctors had to suddenly justify stays for the medicaid and medicare patients. The private insured patients could pack a suitcase and move in for an extended vaca. until the insurance companies caught on and stopped their lucritive reimbursement. Then we have the dawn of the premature discharge- look my fellow CEO's we can have "it all again" the patient come back to stay with us for another few weeks and start the timeclock all over again.- These were not bedside nursing decisions. Us, nurses were appauled. Then when the CMS and the insurance companies stated to say tough crap CEO- we are not paying for this- enter core measure in 2006. Your hospital caused this, your hospital eats the costs., but the healthcare costs kept rising not leveling out or going down, to keep up with the unholy employment contracts handed to the CEO's. We must lay off nurses to pay for this expensive contract. Then the recession hits, people loose their jobs and .healthcare insurance, now we have millions who were on HTN, DM meds can't afford them, so they go to the ED when they are in hypertensive crisis(ICU), stroke(ICU), MI(ICU), dialysis(ICU). Patients are sicker than they have ever been and who know that better than the doctors and nurses who are now fewer in numbers and forced to endure this hell in hospitals. The doctors and nurses complain about how sick these patient's are, we need more staff, the administrations say, we can't afford because the cuts to our reimbursements and insurance rates are climbing.

Obama sees this millions without insurance, listens to the complaints of skyrocking costs, and sicker patients and fewer staff to competently take care of them, The DHS comes up with a solution to compliment Obams's reform that is purely common sence and the hospital's start to lay off the core measure nurse?? These hospital's have really outdone themselves in stupidity this time!!

I don't believe it's the governement's policy that got this nurse laid off- It's the hospital financial mindset that laid the nurse off.

[heron, ASN, RN]

Perhaps the priority on maximizing profit has a little something to do with the problem? The legislative/regulatory process is pretty much a reactive one, as far as I can tell.

Over the last 40 years, most of the "overhauls" I've been caught up in were triggered by spiraling costs and declining quality of care. As far back as the late 70's, I watched LTC oversight change as profit centers shifted from acute care to chronic care when Medicare changed their reimbursement to limit the use of acute beds for non-acute problems. In fact, during the middle 70's, the LTC industry where I lived was known to be a popular method of laundering shady money.

The timeline went like this: third-party payment led to a gusher of money to be had >> higher prices for health care all around >> Medicare passed to lighten the financial load on limited-income seniors >> grossly inappropriate use of acute care services with the highest reimbursement >> change in Medicare rules to incentivise more use of cheaper LTC alternatives >> gamers and fraudsters start focusing on the new profit centers in LTC >> abuses result in rising costs and yet more regulation and changes in reimbursement ... LTC to home care to hospice and on and on and endlessly on.

It's the smart business move: go where the money is. Given that there's a significant part of the business community that believes it's only ethical obligation is to make a profit, it's understandable that they would preserve their margins any way they can. When that tips over into deterioration of care, gaming the reimbursement system or blatant fraud, off we go into another round of regulatory catch-up followed by corporate cost-cutting.

So, much as industry leaders would like you to believe that it's all Obama's fault - it's an election year, after all - I think that a look at the roots of the problem presents a much more complex picture. IMHO, the politicians are just the judas goats here.

[ProgressiveThinking, MSN, CRNA]

This is why I work for the VA (Federal)! If you can't beat em, join em!!!

[TopazLover, BSN, RN]

Seems like the health Care Corporations, in their "personhood" are blaming Obama for something he had little to do with. The people affected would listen to their corporation's rendition and believe the bad man did it rather than place the blame where it belongs. Has the CEO had his (usually a he ) pay cut? Or has he been rewarded for finding another way to squeeze a bit more from that lemon that was nourished during the Bush years.

Interesting that this is presented as Obama produced by the very people who have the most to gain by keeping the Bush tax breaks. Did this "just happen"? I think not. It is part of the plan to discredit that is used so effectively by misinformation of the right wing press.

[kcmylorn]

AllynaBerry I am sorry this happened to you. It has happened to alot of us older nurses with 20,25,30 yrs in this profession over the past few years. This must have been a terrible shock. It happened to me in 2008, after banging my head against the nursing wall for most of these past 4 yrs, much personal and economic loss, I have had no choice but to rethink on where I can get a nursing position that will carry me to the last 10 yrs before retirement. These hospitals don't want our years of experience at the bedside anymore. I ended up taking alot of temp positions- ones that only those mega years of experience would have allowed. Quite afew were non traditional, non clinical positions. I ended up taking a non clinical, way out of the hospital environment permanant position in a speciality that was not my bedside speciality. All I can say now is- I hope to never work another hospital again!! Look for non traditional nursing positions that require 10 or more years of experience. Those are the positions looking for us old nurses. Isaw one posted position for a nurse navigator- requiring at least 10-15 yrs of acute care nursing experience. You know they aren't looking for a young nurse.

Chin up, give yourself a few weeks and start looking online. Take some temp positions. You have QA/QI experience. You may even find some positions for work at home- they usually want years and years of experience. Look in to QA/QI consulting. The dowside is - many of us now have to take a paycut. My psoition is approx $7-8.hr less than my acute care bedside rate was. Also, pray the government takes over the hospital systems in this country- One of my temp positions was for a governement healthcare systme- they run alot better and are more pleasant working environments without the competive profit factor.

That hosptial or any hospital's buget reduction can be fixed real quick and without the pain and suffering of so many people- cut the CEO's salary for god sakes- it's not quantum physics!!

[knustu25]

What is "obamacare"?

[KendallAZ]

This is sad because you obviously understood your position in the hospital and they lost a good nurse.

It is more disturbing that you blame "Obamacare" on your dismissal.