Medicare Probe

req_read · Nov 18, 2007

PeacePisceRN…

Interesting… that the demand at night has remained about the same while the overall pt population has decreased by 33% to 40%. That would seem to indicate that the 100 pts who were discharged probably were not appropriate.

It is always interesting when nurses blame themselves for the failures of their agency; e.g. your statement, “I think part of the problem is that any nurse on staff does admissions… etc.” So is it the nurse’s fault if they are not trained properly by their agency? Are your nurses not being properly supervised?

I am also curious… you seem to have been conscientious about the appropriateness of pts you admitted. What proportion of your admissions were among those discharged? Please do not think I am being critical of you personally. My question is: Do admissions by conscientious nurses (who operate like you do) tend to be more appropriate than admissions by nurses who may be less conscientious? Are there (within your agency) rewards of any kind for nurses who admit the most pts… as opposed to nurses who admit the fewest inappropriate pts. By “rewards,” that could be something so seemingly innocuous as a pat on the back or an “attaboy!” by a supervisor.

I stated that hospice has been drifting in the direction of greed for quite some time. Bear in mind this is seldom done purposely or even consciously. These things happen little by little by little. No one (almost no one anyway) starts out thinking, “I’m going to rip-off the government.” It happens over time, without really being aware, until one day you look around and realize things have changed somehow.

A hospice RN I ran into here left… in disgust… went back to his home State. He basically said every hospice he had worked for over the last few years turned sour… turned to greed instead of quality care (he had worked for 3 different agencies.) I asked him if they had been taken over by different management or ownership. He said, “No. It was the same people throughout.” I asked what happened and he explained that it was a process. They would buy a new home and then have to pay for it and then find ways to generate more income and then would buy a hummer and then would look for ways to generate more income and on and on it would go until the focus had finally shifted onto generating income. Little by little by little.

In other words, the SYSTEM lures agencies in this direction. It is a SYSTEMS problem. It plays to human greed… little by little by little. And since it is a systems problem, you can bet the system will be changed. The question is: To what?

On a somewhat different tack…

You mentioned “appropriateness worksheets.” Those were just being developed (for non-cancer diagnoses) when I was near getting out. They were based largely on objective clinical data of course, and I suppose they have been expanded and tweaked a good deal since my time. I did consider them interesting… but never paid that much attention to them. When I evaluated someone for hospice appropriateness I focused on eating patterns, sleeping patterns, dreaming patterns, their attitude… or one might say the degree of acceptance/denial they displayed. In other words, I looked at things that were more nebulous… but which often seemed to be better predictors of longevity than concrete data like labs & x-rays. I relied more on what I had learned about dying process itself… aside from objective, clinical data. Dying process tends to unfold in an identifiable pattern regardless of the particular disease. It makes little difference whether the underlying malady is cancer or non-cancer. If you evaluate where the person is in the process you will probably do better prognosticating longevity than if you look at VS, labs, etc.

Also, in retrospect, I probably relied (to one degree or another) on intuition. How intuitive do you suppose your admissions evaluations are? (Don’t worry… I won’t tell your supervisor.) To restate the query more generally: Which do you suspect would be the better predictor of longevity; 1- an appropriateness worksheet, or 2- an experienced hospice nurse’s intuition?

By the way, I was never denied payment because a pt was deemed “hospice inappropriate.” There were a couple of times when I reached that conclusion on my own however and discharged a pt. Has your agency ever done that? On its own I mean (before this recent unpleasantness.)

Michael

mc3, ASN, RN · Nov 18, 2007

Oh, I could write a book on this!!! Yes, this happened to our hospice. Ramifications were what you'd expect - lots of nurses were let go - not management, of course. You'd think we'd learn from our past mistakes, but no - I see many things I disagree with ethically - don't want to go into specifics here - and have changed my job because of it. I don't know the answer - I wish I did. I, like so many here, love hospice work, but not the ______ which is getting worse and worse.

Allow Mystery · Nov 18, 2007

Hello Michael, good to have your input again, it's not the same

around here without you, very wise, and always relavent.

I believe the 'drift' has been intentional, you are being kind; but, you can't sugar-coat greed. Pure and simple, greed, be it in the form of competition, is driving Hospice today and will continue to

dictate inappropriate admissions and recerts until Medicare slams the

door shut, it's time. Hospice has been watered down, and it is unfortunate for pioneers such as yourself who utilized sound nursing judgement and intuition to bring Hospice into the 21st century.

Personally, I'm ready to get out, and just looking for an excuse and/or

a career alternative. Take care.

req_read · Nov 19, 2007

Thanks Allow Mystery

You take care too. Nursing is a mine field out there. My wife (also a nurse) is now in the midst of changing jobs for many of the same kinds reasons being spoken of here. It is difficult and has been hard on her. With luck perhaps she will find a job worthy of her talent and skill.

Best wishes with your search. I hope you too will find a job where you can practice nursing in its most untainted and rewarding form.

Michael

gypsyfirebird · Nov 24, 2007

I really like hospice, but I'm not too sure that 'for profit' and 'hospice' are such a good combination...... :nono:

I couldn't agree more!

Multicollinearity, BSN, RN · Nov 27, 2007

The OP mentioned medicare troubles with non-cancer TI patients. This NYT article may be relevant:

http://www.nytimes.com/2007/11/27/us/27hospice.html?hp

req_read · Nov 27, 2007

multicollinearity…

Very interesting article… thanks.

Previously (in this thread) I made some dollar calculations that I said were conservative. They were based on $120/day for routine home care. According to this article the actual figure is $135/day. When I got out (about 8 years ago) it was $90/day. In other words, in 8 years hospice reimbursement rates have increased about 50%. Has inflation?

The article is written with a pro-hospice agency bias. For example, the author states, “The charges are assessed retrospectively, so in most cases the money has long since been spent on salaries, medicine and supplies.” This implies that agencies are caught unaware by repayment demands. Actually, the capitation system is clearly delineated. The math is concrete and not overly complex. Any agency caught unaware is simply not doing their math… not keeping an eye on their average length of stay. If agencies are keeping track of their data they have no excuse for being taken by surprise… other than their own negligence.

I have explained the capitation system previously (different thread) so won’t repeat myself here, but there is a factor that was not mentioned in the article in question and that I do not recall any poster having alluded to. I hesitate to mention it because of the potential for abuse, but it also has potential for good so here it is…

When I first started in hospice I spent time with people from an established, experienced hospice who were kind enough to give me some pointers. One of the things they told me was to avoid picking up patients who were short term… as in, life-expectancy of less than a couple of days. They had all the stats worked out on cost. I forget the exact numbers but they explained that admissions and discharges are the most cost-intense periods… which is true. According to their calculations it took something like 2 weeks to recover the cost of an admission. Therefore, they suggested avoiding picking up patients unless they were likely to live long enough to recoup admission costs.

However, after being in the business long enough to finally figure out the capitation system I realized this approach was nuts (not to mention not very ethical… which is why I have not mentioned just which large, well-known agency this was.)

The capitation system works on averages. If your agency’s AVERAGE length of stay exceeds a certain number of days, it will have to pay back all funds exceeding that cap (the cap is actually a dollar amount but it still boils down to average length of stay.) Any agency can (and should) keep tabs on its average length of stay. If they aren’t, they’re begging for trouble.

To illustrate…

Let’s say you cap is set at 120 days (4 months.) Then let’s say you have a pt who lives a year and you bill Medicare for all 365 days ($135/day x 365 days = $49,275.) However, your cap was 120 days, not 365. You over-billed Medicare for 245 days, or $33,075… which at the end of the year you will have to repay.

Now let’s say you had 3 patients; 2 lived 1 day each and the third lived a year. Your total number of pt/days = 367. Divide that by 3 pts and your AVERAGE length of stay is now down to 122… or just about exactly at your cap.

The moral of the story is: avoiding short-term pts is penny-wise and dollar-poor. What you lose in the short-run more than pays off in the long-run.

There are lots of other things in this article I would love to comment on, but as usual, my post is already running overtime.

Michael

doodlemom · Nov 28, 2007

The amount of reimbursement is dependent on the area you live in and (supposedly)reflects the cost of living - for example, I think I remember the NYC reimbursement rate is around 190/day. Our reimbursement is around 120/ day and has only increased by about 20/day in the last 5 years.

Because for-profit hospices have a larger percentage of long term patients (most of the time residing in facilities), they would benefit greatly if the cap were removed (and have been lobbying congress strongly for this to happen. (Most) non-profit hospices do not have a need to worry about the cap. I think the cap can be very useful in curbing abuse.

req_read · Nov 28, 2007

I was aware reimbursement rates varied by region but had no idea how much.

According to the article, the majority of hospices having to repay Medicare are in the south & west. I wonder if that correlates with a concentration of rural poor?

It does seem obvious that some agencies are trying to (as the article mentions) morph hospice into a long-term care program. That is understandable if you are a clinician/provider and you have pts with immediate needs and no program to cover them. If a pt has a need today and the solution is to write your congressman suggesting a program be developed to meet that need, your pt will not be helped. On the other hand, using hospice for long-term care instead of terminal care runs a very real risk of damaging individual hospice agencies and hospice in general.

It would make sense to develop a long-term care program, perhaps based on the hospice model, although the hospice reimbursement scheme is a little frightening in that it offers financial rewards for agencies to provide the least amount of care. It creates sort of a squeeze, or pincer movement… it requires certain services, then rewards agencies for keeping those services to a minimum.

I got a chuckle out of the MD at the agency mentioned in the article passing the blame onto the nurses, although I do not doubt he actually does rely heavily on their judgment… and I also suspect those nurse’s judgment is sometimes influenced more by their hearts than their heads.

While there are agencies out there using hospice inappropriately out of compassion, there are also those using it inappropriately for monetary gain. Either way, average length of stay is THE one piece of data that tells you where you’re at in terms of the cap. When I moved west I was politely informed that asking a rancher how many head of cattle he has is impolite. It is very much like asking, “So, how much money do you make?” Similarly, if you know an agency’s average length of stay (and their regional reimbursement rate) you can quickly calculate their annual income.

However, next year’s elections may render all of this mute. Some sort of nationalized medicine is probably in our stars.

Michael

doodlemom · Nov 29, 2007

There are ramblings that the Medicare reimbursement for hospice patients in nursing homes is going to greatly decrease or go away completely at some point. If this happens, many of the for-profit hospices may decide that this business is no longer a good deal for them - or they will figure out another way of making a buck. While the for-profits have taught us a great deal, I wouldn't mind seeing some of them going away!

Allow Mystery · Nov 30, 2007

There are ramblings that the Medicare reimbursement for hospice patients in nursing homes is going to greatly decrease or go away completely at some point. If this happens, many of the for-profit hospices may decide that this business is no longer a good deal for them - or they will figure out another way of making a buck. While the for-profits have taught us a great deal, I wouldn't mind seeing some of them going away!

I agree, and the sooner, the better!

CANRN, MSN, RN · Nov 30, 2007

This is interesting! I have not heard about the possibility that this was to happen. Couldn't happen soon enough for me either! Our hospice is non-profit and our marketer is convinced that the future is in nursing homes for hospice. Although I enjoy my LTC patient's, working with patients and their families in their homes is so much more rewarding. I often wondered when Medicare was going to start looking at hospice/LTC reimbursement, hope it's soon. Also, have any of you had the feeling that the LTC staff would rather we were NOT there?