Here's what's ahead in COP changes
August 1, 1997 5 minutes read
Here’s what’s ahead in COP changes
Regulatory expert offers tips on new rules
The knock-out changes to health care that are proposed by the Clinton administration include a few that could take more than a nibble out of the home health industry’s revenues.
Major changes are being proposed for Medicare’s home health Conditions of Participation (COP), and about every agency will be affected if these become final. The Health Care Financing Administration (HCFA) of the Department of Health and Human Services in Washington, DC, is expected to make a decision later by fall.
The changes proposed for the COPs are part of the recent trend in which the federal government is attempting to switch the home health care industry from a process-oriented system of cost-base reimbursement to a patient-oriented, outcome-centered system, says Jill Daniel, director of regulatory affairs for Medical Innovations of Brentwood, TN. Daniel, who is in her third year of law school, first became involved in the home care industry through a family business.
"What they’re going to do is place responsibility on home health agencies internally for improving their performance, rather than have them rely on regulations and prohibition from the federal and state program," Daniel says. "It’s a shift toward a managed care approach."
Daniel says the proposed changes look at four basic areas: patient rights, patient assessment, care planning and coordination of services, and quality assessment and performance improvement.
"Within those there are some significant issues facing the home care industry and some things we’re concerned about," Daniel says.
Education managers can update their staff about these changes and put together an inservice when they’re made final, Daniel suggests, by covering these basics:
1. The proposed regulation contains a requirement that at least 50% of the total skilled nursing services are provided through agency employees rather than subcontracting.
This proposal was aimed at shell home care agencies that consist of little more than a storage shed and home fax machine, Daniel says.
"In effect, what some people have done is they’ve set up a glorified billing service, and they sub out all their employees; they have subcontractors do all the site visits," she explains. Those agencies were able to meet the current Conditions of Participation, but the new proposal would put them out of business.
The problem is it would also harm rural home health agencies and small agencies, Daniel says.
Smaller agencies and agencies just starting out often have a low-visit volume, so it’s cost-prohibitive to hire all full-time employees. So they tend to sub-out their services. This way they can pay for skilled employees only when they need them, instead of paying a high salary during slow times.
Under the proposed change, these small and rural agencies could be affected because the change would apply to agencies that subcontract for physical therapy, occupational therapy, skilled nursing, and other services that require a high volume to be cost-effective, Daniel says.
This requirement and Medicare’s push in the direction of a prospective payment system (PPS) can only spell bad news for small agencies, she adds.
Under a PPS, agencies are paid a set fee to provide an umbrella of services. If that umbrella has to include services that the agency has subcontracted out, then the agency will find itself losing money because the subcontractors would still be paid a higher rate per service.
"If Medicare goes to PPS, it will be extremely difficult to sub-out services and still be under the fee-for-service payment," Daniel says. "This is another nail in the coffin on eliminating those low-volume contractors."
2. The proposed COPs would require an agency administrator to have a bachelor’s degree.
Daniel says this is a sore point in the home care industry because it doesn’t make a lot of sense.
According to estimates Daniel has seen, more than half the nation’s home health administrators wouldn’t qualify. "They’re saying people currently in place would be grandfathered-in, or there would be exceptions for people with so many years of experience, but placing some arbitrary requirement for the position is just ludicrous," she says.
"It just seems like a penalty for a few agencies that have been mismanaged, but I don’t think having a bachelor’s degree has any effect on mismanagement," she argues.
If this change is implemented, then the home care industry might have the same troubles the long-term care industry has had in attracting and retaining administrators, Daniel says. That industry already has a requirement of a bachelor’s degree and a one-year internship for administrators, and it has a high turnover rate, she adds.
Another change would be to require the administrators to have one-year supervisory experience at a home health agency or a related health-care facility.
3. Criminal background checks would be required for all home health aides.
Daniel questions why federal officials chose to look only at aides and have ignored requiring background checks for nurses.
"And it’s not specific. Do you do the check in your state only or nationwide?" Daniel says. "You could do a criminal background check in Texas, but the person could have a conviction in the state of Tennessee."
Medical Innovations provides background checks on all full-time employees except for contract employees, secretaries, and schedulers, Daniel says.
It costs the agency $125 per person, and it includes a nationwide criminal record check, a credit check, a driver’s license check, and a full employment check. "It also checks for any exclusions from Medicare or Medicaid programs."
Daniel says Medical Innovations is against the proposed requirement because the company believes any background check should be for all employees, and it should be held nationwide.
Another objection to this requirement is that under a PPS or managed care, home care agencies will be forced to cut as many costs as possible, yet the federal government is forcing them to add costs, Daniel notes.
4. Another proposed requirement is that home care agencies collect OASIS documentation.
This mandate would have all agencies collect outcomes data through the Outcomes and Assessment Information Set (OASIS). (See OASIS cost tables, inserted in this issue.)
Daniel says the government has underestimated how long it will take agencies to collect this data. HCFA has stated that it will only increase the nurse’s time by 15 minutes. "That’s ludicrous! It has 80 questions," Daniel says.
Medical Innovations has estimated it will take nurses 30 minutes to an hour per patient, costing each office $2,500 to $3,000 in training cost. HCFA has estimated it will cost $2,256 in training cost. And all of this is without any additional reimbursement from Medicare.
This requirement also says that the information will be gathered by a clerical employee instead of by a registered nurse.
"I don’t know how you can get a clerical person to gather that information; they can crunch it; they can compile it, but to have them gather the data? Clerical persons don’t do patient visits," Daniel says.
Suggestions have been made to HCFA that agencies be allowed to exclude collecting data on any patients who are seen for 10 days or less and exclude patients who are seen only once every two weeks. "Most of your expenses are in upfront costs, and if you’ve discharged that patient immediately, you’re in the hole," Daniel says. "Plus, I don’t know how they could get good outcomes data from patients who are seen 10 days or less."
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