Are Home Health RNs really paid what they are worth??

Home Health can not run without RNs so why are we at the bottom of the payscale compared to other disciplines in home health?

Are Home Health RNs really paid what they are worth??

I am an RN, have been for 10 years. Almost 8 of those 10 years I have been in Home Health. The longer I worked as an RN the more I realized that hospitals, clinics, and home health care agencies were all still businesses where the dollar was all that really mattered in the end. Not the patients, not the clinicians, not the community. I remember when I was working in the hospital I was told I had to scan everything from the water pitcher to the bedpans. I remember a patient getting an itemized bill while still in the hospital showing a charge for near $50 for tylenol that was administered to him..This amazed me and I certainly couldn't explain or justify why he was charged that. During my 8 years working in home health I have learned that most home health care agencies are no exception, being more about the dollar then anything else. I would also like to bring up how every agency I know of offers much higher pay for physical therapy, occupational therapy, and speech therapy then they do for registered nurses. I learned that these other disciplines were held up higher then the nurses not only with pay but respect from the agencies.

I started questioning why this was and why I was the "case manager" the main point of contact for the patients, the one all clinicians reported to when there was an issue, and the one needing to do supervisory visits when I was the lowest paid discipline. I have also learned in my time that RNs are needed to do the admissions and be the first point of contact in order for the agencies to get reimbursed more money by Medicare, not any other clinician. I recently decided to go PRN, applying st several agencies and have been offered the job by every agency due to my experience. My resume and references will show I know home health, am successful with case management, and am good at what I do. What has blown me away in all of this is the pay per visit I have been offered from every agency. They are all pretty close so I know this must be the "standard" but I wanted to do a little research on what these companies get reimbursed for SN services.

I was very surprised to see that medicares reimbursment rate for an RN visit was around $140 $144 a visit. These agencies are offering anywhere from $36 to $40 per RN visit which me having 8 years experience. Now I understand a company needing to profit but this is plain greed. Most nurses in home health that are PRN use their vehicle, their phones, and pay for their own gas. I believe the federal standard for mileage reimbursement is about .52 cents a mile, these agencies pay anywhere between .45 to .47 cents a mile. The rates they set for pay per visit are basically formulated using a figure of what you could make per hour. Now take a follow up visit (not including oasis documentation) and figure on $36 to $40 per visit. Let's say you drive 10 min to and from this visit, spend 30 to 45 min in the home, and spend another 15 to 20 min documenting (documenting as thorough as they would like) you actually made less then $36 to 40 an hour.

Once you figure in gas, using your cell phone, wear on your vehicle (even with their mileage reimbursement) you technically made even less. At this point you are making about the same or less as their hourly/salary employees and you do not get any benefits, sick time, paid vacations etc. With this said not only are you making less, but you are saving the agency even more money. The point in PRN nurses in home health is to allow the company to except more pts when their full time staff already have a full patient load. This in turn obviously allows the company to make more money because they are able to take more patients. More patients more money, right? Then why is the agency paying a pay per visit rate of $36 to $40 when they are making at least $140 on your service and expertise? 8 out of 10 visits dont require any supplies for wound care, labs, catheters, etc. The only thing being provided to those 8 out of 10 patients is nursing care, patient education, and skilled assessment that you are providing. You then provide the company with your documentation on what you did as well as the progress made.

For a home health care agency, they get reimbursed per episode (60 days) about $3000. Very rarely do you see patients needing physical therapy, and occupational therapy the whole episode compared to nursing. With this for example you figure physical therapy visits 2xwk for 4 weeks, same for OT this brings you to about $880 cost to the agency. This leaves the agency with $2120. Now let's say nursing 2xwk for 4 weeks then 1xwk for 5 weeks brings you to about $520 cost to the agency. This leaves the agency with $1,600 of the $3000 they got reimbursed per patient every 60 days. The agency is profiting about 50% (not much less when taking into account mileage reimbursement to clinicians). My purpose in writing this article is for nurses in home health to realize what their worth really is, to realize that it is in the agencies budget to pay more then they offer, and to realize just how money hungry these agencies are. The majority of nurses are nurses because they care about the patients and it isn't about the money.

However in a world where money and greed drive these agencies, where business is business, we need to start thinking business as well. My brother once told me stop always thinking with your heart and think with your head. The fact is not that PT, OT, ST, and MSW are not important in home health but technically a home health care agency can run without these disciplines. It however can not run without RNs, yet we are paid the lowest by these agencies and respected less then the other disciplines. I remember being told by an old boss that PT, OT, MSW, and ST got paid more because Medicare reimbursed more for these disciplines per visit however when you look at the total amount the company receives in the end, nursing usually makes the agency more money total, and again we are paid less. What upsets me is these agencies keep tabs on what the other is offering when it comes to per visit rates or hourly/salary really, trying their hardest to stay as low and close to what everyone else is offering. This makes it hard if not impossible for nurses to negotiate pay or research what this position really should be paid. All I know is there is a huge discrepancy in what medicare feels we are worth and what home health care agencies feel we are worth. The only reason for this that I can come up with is because we continue to except these low ball offers from these agencies not realizing what our worth is in home health. I feel these agencies know what RNs are paid while working in a hospital so they offer a little more knowing most of us are probably comparing their offer to that which makes us think their offer is fair. The fact is though that an RN in a hospital and an RN in home health are two very different positions. RNs are in demand everywhere really but what we fail to realize is the demand is probably the greatest in home health.

A home health care agency can not run without an RN. With this said, RNs should be one of the highest paid positions in home health if not the highest. Unfortunately being under paid as an RN in home health will never change until we acknowledge our worth and demand to be compensated accordingly. Go to cms.gov under certification and compliance for home health providers. Here you will see it says specifically that a home health agency is an agency or organization which is primarily engaged in providing skilled nursing services and other therapeutic services and has policies established by a group of professionals including one or more Physicians and one or more registered professional nurses to govern the services which it provides. Also provides for supervision of mentioned services by a physician or a registered professional nurse.

Again, why are the RNs paid less then any other discipline in home health? It is up to us to make this change.

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Scorpiostngrn

About Scorpiostngrn, ASN, RN

I have been an RN for 10 years, almost 8 years experience in home health.

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I couldn't have said it better myself. Exactly why I will no longer do home health.

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Specializes in Case Manager/Administrator.

What you are showing is how much we need to change and how negotiation must be made for a better wage for professional nurses. If I was making business decisions in a hospital or SNF and I had to look at my necessary cost of RN's I would hire the least cost effective nursing services, would not really look at the years it took for school. All I want to see is if you have your license for RN and this is how much I am willing to pay for sunk costs (nurses cannot submit CPT codes for what they do in the hospital and SNF). PT I know I am getting my money back because they will be billing for their services (CPT codes) and am more than willing to pay more and pass that onto the insurance company or patient...see the differences.

If I was looking to hire nurses in the HH arena I would automatically think lower wage than hospital and maybe the same as a SNF, you hear all the time nurses make more in the hospital. This keeps our wages down because in the hospital they do not charge for nursing services it is a necessary operating expense (sunk cost).

We are actually comparing apples to oranges in the nursing field in work location and we are allowing this, shame on us. Comes down to CPT codes/cost.

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Specializes in Travel, Home Health, Med-Surg.

No, HH RN's are not usually paid what we are worth. The responsibility and stress is not usually worth it especially if you work per-diem. Exactly what you state, everyone constantly calling you, you having to constantly call the team, the patient, the Doctor. Patients supposed to go home so you keep your day open to do admission assessment and then they don't get dc'd, etc etc. By the time I figured in the mileage, cell phone, driving time, time with the patient, time on the computer after seeing the patient I was luck to be making $10/hr. If I was going to make $10/hr I might as well go work somewhere else without all the stress and responsibility. That is why I don't work HH either. Kudos to you for doing it for so long, maybe you make better money doing it full time.

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I understand where you're coming from and I can't say that your pay is below what the market will bear or if it's unreasabaly low but if you're going to do the math, you need to include the many more bites out the reimbursement pie than just your visit rate to be close to accurate. There many other substantial costs of an employee that an employer pays and then there's the indirect costs. You are significantly inaccurate by omission with the figures you are claiming are profit. My staff know our total average cost per visit, it's pretty high, about 4 x higher than the RN perceives their pay for a single visit.

Therapists are paid more because 1) supply and demand* 2) their visits generate revenue** with Medicare PPS whereas nursing, social work and home health aides do. It. The only aspect where they generate revenue is in avoiding a LUPA.

An agency also can't run on nursing alone. To become licensed/Medicare certified, the agency must provide at minimum skilled nursing and one other discipline.

My former smaller company struggled financially, I saw the financials, they were not sitting on piles of money.

My current employer receives a management variance. If we were a free standing agency our doors would be closed but thankfully we aren't profit driven, just need to come within budget and support ourselves. We do need the variance to do so however, small companies couldn't survive paying our respectable wages and benefits while providing generous patient focused care regardless of reimbursement.

That said, a good RN Case Manager has a complex skill set and a much wider scope than therapy if they're working at the top of their license and truly case managing versus simply being task oriented. My current organization doesn't pay the therapists more than the RN Case Managers, another way that they are employee focused in addition to being patient focused. (I've gotta give my CEO a show of gratitude the next time I see her).

* at my former agency we had literally recruited from across the country to bring on therapists, never had to do that with nurses.

** you're familiar with CMS threshold incentives and how specific numbers of total therapy visits generate additional revenue? A bump in pay? Reportedly going away in 2020 which I would expect to see therapist pay leveled with nursing.

If many clinicians knew the business side, the other side of the curtain and all that goes into operations, they would wonder why anyone in their right mind would want to own or run a home health agency.

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This brings back a ton of memories. I was in HH in the heyday, 25 years ago or more. I loved it so much, I was certain it would be my life's career.

The rules were so much looser then. Our charting was handwritten and often wasn't that much more than- "dressing changed per protocol, asepsis maintained, pt tolerated the procedure well with scant serosanguinous drainage."

Ok that was long ago. This was before the Internet. We were paid about 15 dollars a visit, on average. One day, I stumbled on some numbers somewhere and I discovered that Medicare paid about 75 dollars per RN visit!

I crunched some numbers. Of course there is insurance to pay for, an office, the supervisors, etc, etc but I still think that someone was coming out well ahead at this "non-profit" agency.

As for any RN pay, it is market driven, supply and demand.

I have heard the HH business is totally different now and I am thankful to no longer be in it.

Much has been written about how the current working population over the last 3 to 4 decades has had to regularly re-invent themselves just to stay in a job, and it is so true.

It will be even more true in the future.

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Specializes in Home Health, Primary Care.

It's like you're in my head LOL. I've been in home health for most of my nursing career (which is now going on about 13 years now). And I too have had it with home health. It's all about that bottom line! It's rather disgusting. I understand a company needs to make a buck but at what cost?? Sure, nurses don't get them the BIG bucks like their precious therapists, but what would happen if RNs were to take a stand and then they'd be left with therapists who do NOT want to or LIKE to do OASIS....what then?? I'm sure they could find a nice balance between compensation of RNs vs Therapists because right now, as it stands, those scales are totally unbalanced!!

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I work HH in the 90's: RN admission paid $100 & then $65/visit.

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Specializes in Home Health, Primary Care.
I work HH in the 90's: RN admission paid $100 & then $65/visit.

Wow!!! Here we are about 25 yrs later and many agencies are still paying those rates....total insanity!!

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We have a union and wages are set by #years as an RN and we are paid by the hour. Best compensation I have had as a home health nurse yet.

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This was the first post I ever left on any site so first let me apologize for the typos. I never realized it actually got posted. I want to explain some things about. The pay rates that I mentioned were not my pay rates. Since 2017 I have had 2 agencies pay me $150 per SOC/ROC/RC and $80 per regular visit. At the time I wrote this, the agency I worked for had slowed down and I was looking at getting another PRN position with a second agency. The rates I mentioned in this article/post, were the offers I was receiving by almost every agency (which every single one I declined). Shortly after I wrote this, I started at another agency which also paid me the higher rate of $150 for SOC/ROC/RC, with a regular visit rate of $65. The pay I have personally received, is what brought me to writing on this topic. I realized that higher rates were not out of line and that the agencies can obviously afford to pay more for RNs if they absolutely have to. I know all home health care nurses are familiar with the scenario where the agency doesn't want to turn any referrals away, offering nurses, that will work the weekend last minute, incentives such as $100 to $150 per visit. Interestingly, when the nurses are needed they can suddenly afford more then double the amount. This not only shows that they can afford to pay the nurses more but also (in relation to the comment about nurses not being "revenue generators" in home health) that the nurses are very much needed to generate that revenue.

During one interview, around the same time I wrote on this, a nurse manager, I had worked with prior, told me the agency could not meet my current rates, of course. She further explained how they came up with their rates. She said that they stay close to what the current market is, what other agencies are offering, and that they know when its time to increase the rates, when nurses no longer accept the current rates being offered for the position.

A commenter, in relation to what I wrote, posted that "There many other substantial costs of an employee that an employer pays and then there's the indirect costs. You are significantly inaccurate by omission with the figures you are claiming are profit."

I apologize as I did not explain this well and did not mean to say the agencies "profited" the $1600. What I was trying to show was this is what they had in the end after paying the clinicians for their services. Of course, they would probably pay around 20% or 30% overhead which still leaves them $1120 which is pretty good. Trying to find exactly what these agencies profit is very complicated and not easy to research so I can only go by what I have been able to figure out with what I have and what I have personally seen and since the owner of the last agency I worked for full-time, was on the show Secret Millionaire, I am pretty sure my figures are not too far off.

In that same post it says "Therapists are paid more because 1) supply and demand* 2) their visits generate revenue** with Medicare PPS whereas nursing, social work and home health aides do. It. The only aspect where they generate revenue is in avoiding a LUPA."

I am assuming the last part "aides do. It." means to say don't. This is not correct in home health, however does apply in hospitals where nurses are seen as an expense and not a revenue generator because, lets face it, people are not hospitalized for nursing care. The hospitals see nurses as part of the hospital basically. As an example you would expect to have a waitress at a nice restaurant or concession staff at a venue, but these are not the reasons you came. You came for the food at the restaurant that needs a chef/cook to prepare, and you came to the venue to see a or the performers perform, etc. The doctors are the chefs and the performers basically, this is why they are considered "revenue generators" and they are not looked at like an expense (take the nurses out of the picture and I bet you the doctors will turn into expenses too).

Home health is different, so the two can not be looked at the same when it comes to expenses vs revenue generators. You expect, and will need, the agency to have someone answer the phones, bill insurance, order supplies, and run the agency, but they are not why home health was ordered. They are the waitress to the restaurant and the concession staff to the venue, just like the home health clinicians are the chef and the performer.

Regardless of how anyone thinks, feels, or looks at it, the fact remains. If an agency did not have at least 2 RNs, they could not run. Per CMS, "a Home Health Agency (HHA) is an agency or organization primarily engaged in providing skilled nursing services ( and I repeat, skilled nursing services) and other therapeutic services (which can include just CNAs technically) and the agency must have one or more physicians and (notice it says and not or) one or more registered professional nurses, to govern the services which it provides." So basically a home health care agency can run with 2 RNs and PT, 2 RNs and OT, and/or 2 RNs and a CNA. Medicare also lists that the eligible home health services that they will cover (pay for) include part-time or "intermittent" skilled nursing care, physical therapy, occupational therapy, speech-language pathology services, medical social services and part-time or intermittent home health aide services (personal hands-on care).

Because some nursing services require "expenses" such as wound care, IV, catheter, etc., may be why they are not seen as "important" or a "revenue generator" in home health. Agencies can continue to look at nurses like an expense if they want to, but lets face it, the show wouldn't go on without the performer, the food would not be prepared without the chef, and the agency would not exist without the RNs, therefore there would be no revenue to generate ?

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