Maximum reimbursement to managed care
It won’t happen overnight, so take these 6 steps now
By Beth Krehbiel, PHN, MBA
Director of Community Services
River Region Community Services Home Health and Hospice
Red Wing, MN
You can make all the plans you want for lowering utilization, but the admitting nurse ultimately will be responsible for convincing patients and families they need fewer visits. Without support from your line staff, carefully laid plans will fail.
In the current managed care environment, much is being written about making home care agencies more efficient. The market is flooded with information management, computerized documentation, and telemedicine systems. Surely, these have value and will increase efficiency as payer groups continue to shift the responsibility for appropriate utilization within reimbursement limits to providers. However, a crucial question needs to be asked: How can agencies align their culture for managed care?
It is very difficult to change and maximize reimbursement mentality overnight with line staff, but there are six key steps home care managers can take to instill a managed care culture among their staff:
• Keep a healthy community focus.
While you certainly want appropriate utilization discussions within your agency, your agency cannot afford to have an admitting RN insinuate to a patient that he/she disagrees with the number of visits per week or have your home health aides telling family members that they prefer to stay two hours for a visit when only one hour has been scheduled.
Collaboration with staff is crucial
To succeed under managed care, you must have a healthy community focus that encourages a collaboration with other providers. Staff meetings should focus on patient needs. Continually ask: Is this the most efficient way to provide service? Can we educate the family to do more? Train staff to think of the end result and patient independence immediately. Talk about this issue in case conferences and staff meetings, and determine what other services can be pulled in to help the patient become independent faster.
The challenge is getting staff comfortable with prospective payment and managed care. It is difficult to do when the change is still happening, and the hidden incentive behind the two types of pay sources Medicare and managed care are in conflict with each other.
• Eliminate hidden incentives for staff to work inefficiently.
What are the incentives for your staff regarding utilization? It may be difficult to motivate staff who are getting paid per visit to get excited about providing longer but fewer visits. Pay systems that do not support efficiency must be changed.
Are nurses ever encouraged to visit more often because the patient has "good insurance"? Do nurses ever come into the office excited about a patient with twice-a-day dressing changes or extensive home health aide needs? Staff may prefer these situations because it keeps them busy and employed. Internal discussions with staff should focus on patient safety, family capabilities, existing community resources, and existing strengths.
• Make sure hiring policies encourage efficiency.
Your company’s hiring policies also may have followed a maximize-reimbursement mentality. Staffing, training, and equipment decisions made based on Medicare cost reimbursement will not be affordable in the prospective payment system (PPS) or managed care environment. As fee-for-service reimbursement ends, agencies will face changes in work load and maybe even layoffs in certain areas. Managers and administrators need to examine the way they hire and make sure they only hire new people that best fit future needs.
Share outcomes data with staff
Make the change from two hour home health aide visits to allowing patient need to determine visit length. Encourage aides to leave the patient homes when they’re done and pay their downtime during the transition to shorter visits. The aide’s schedule must also be filled accordingly. If a visit is scheduled for one hour but takes only 45 minutes, then the aide’s schedule should be changed the next time to allot 45 minutes for that patient.
How will you prepare home health aide staff who are used to spending up to two hours per visit to make the change to half- or one-hour visits? Sharing outcome studies that measure clinical improvement will assist staff to see that efficiency doesn’t mean poor quality.
Insurance the big bad wolf’?
• Adopt staff orientation programs to managed care needs.
Make sure orientation of new staff focuses on providing efficient, effective care. Operational efficiency is important, but it is only half of the solution in preparing your agency for managed care.
Real success depends on your ability to develop a culture where staff believe they can find ways to provide excellent care with less. Staff need to fight for what’s needed and advocate for patients, yet still assess true need.
• Discuss with employees how they talk with patients and their families.
In the past, insurance was the " big bad wolf." You could tell the patient, Your insurance won’t pay for more visits.’ But now it’s up to the home care provider to be both the patient advocate and the insurance company’s gatekeeper.
Discussions with patients must reflect problem solving based on actual needs, plans to decrease services as conditions improve, and long-term needs. Nurses accustomed to authorizing services based on patient wishes regardless of need will find the transition difficult.
Developing staff to educate patients is important. Start upfront by explaining to staff the financial side of your business and how the industry and your market are changing. In some states the cost of a visit is printed on Medicare bills the patients sign. Patients often ask staff, Why are you charging $90 for this visit?’
Provide your staff with the information that proves the visit cost not only covers their direct hourly pay and travel but all the other hidden costs the patient doesn’t see. These include having an RN available 24 hours on-call, education and training so staff are competent, staff to cover for vacation and sick time, clinical supervision and oversight, coordination time with the patient’s physician and therapists, etc. Also, for agencies under the cost caps, Medicare only pays a percentage of the listed visit price.
Per diem doesn’t cover direct time
The feelings staff have about patient care are vital because they are in the field with your customers. Empower staff. They really have the ability as professional nurses to know, in conjunction with the physician, when enough care has been given and what is really needed.
• Let your staff understand reimbursement.
Teach your staff that in a capitated system, your $80 per diem doesn’t cover just direct time. It also covers their benefits, on-call pay, overtime, insurance, supplies, billing, medical records, rent, and phones. Staff need to see where the money goes and how much it costs all of us to provide care.
[Editor’s note: Beth Krehbiel, can be contacted at: 434 West Fourth St., Suite 200, Red Wing, MN 55066-2538. Telephone: (612) 385-3410. Fax: (612) 385-3414.]
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