Nurse registries in Florida lobby together for change
Law makes them a part of the long-term care market
When USA Today last year publicized charges of fraud and abuse in the home health industry, many fingers pointed at nurse registries and private duty staff. "It is a problem specific to private duty," one person said in a message posted to an on-line bulletin board.
Nurse registries in Florida, however, have pushed for legislation that gives them the respect of their peers: They are now licensed under the state’s home health services act. Within the last year, the registries lobbied once again to be added as an provider option for beneficiaries in long-term care insurance contracts.
Mark Catalano of Catalano’s Nurses Registry in Hialeah was instrumental in getting the state of Florida to license nurse registries.
"Some policies had been saying, We’re not going to reimburse if you buy your [long-term care] services through a nurse registry only through a licensed home health agency,’" says Catalano, who has been in the private duty industry since 1964 and also is the current president of the Private Care Association, a Washington, DC, organization that represents private duty registries.
Although many long-term care contracts at that time excluded nurse registries as reimbursable care providers, many of the contracts broadly defined a home health care agency as an agency or organization that is licensed by the state and qualified to provide home care services, and an organization that keeps medical records and works within the scope of its license, Catalano says. All of these described nurse registries in Florida, he adds.
"Patients were coming to us because we were more cost-effective, we did a good job, and we specialized in private duty. They were forced to use the higher-cost companies that were more geared to the Medicare model.
"You pay your money on a claim," Catalano continues. "You get $100 a day to use. You can come to [the nurse registry] and get the care for $8.80 or $9.90 an hour, or you can go to [a home health agency] and pay $12 to $15 an hour. Where are you getting the most benefit out of that policy?"
Catalano and other registry supporters asked the legislature to forbid long-term care insurers from discriminating against nurse registries, since the registries also were licensed under the state’s home health services act. The registry proponents also met with representatives from the insurance industry to show them the rules that regulated registries. The bill that requires long-term care policies to offer registries as an option went through the legislature the first year it was introduced.
"Registries have a lot of credibility in the state of Florida, says Gary Jacobs, president of Capitated Health Care Services (CHCS) in Sunrise, FL. CHCS is a home care network management company that is working with long-term care insurers to offer a managed long-term care benefit in Florida. Catalano’s Nurses Registry is one of several registries that receives referrals for long-term care from CHCS.
"As long as registries meet the state requirements and our screening and credentialing requirements which we modified for their needs because they don’t have to meet all the home health criteria we are very comfortable in using them," says Jacobs. (For more information on CHCS’ requirements, see story above.) CHCS encourages the education of registries about opportunities such as long-term care, Jacobs says. CHCS also encourages state regulations for registries. "If people are going to accuse providers of not being at the same level in standard, then the providers being accused should have at least the collective strength to approach the legislature on a state-by-state basis and get states to create a monitoring mechanism. This mechanism will give them the legitimacy and credibility I think they are going to need if they are going to do business with Medicaid programs, Medicare programs, and insurance programs. It has to be a concerted effort by both the industry and the regulators."
According to Florida law, nurse registries must meet 19 minimum standards of operation to be licensed, including the following:
• an administrator who has health care experience and is knowledgeable about health care licensure and certification;
• written procedures for the selection, documentation, screening, and verification of credentials for each licensed health care practitioner referred by the registry;
• employment histories on file of all health care practitioners working with the registry;
• copies of each health care practitioner’s license or certification, evidence of completion of required per-service training, evidence of HIV/AIDS training, and documentation of training in the nurse’s specialty in each individual’s registration file.
In addition, nurse aides who are doing hands-on personal care have to be state-certified. These aides make up the bulk of the registry business, Catalano says. "There has been a huge shift over the last five years from when we used to do a lot of RN private duty work. I think this is because of cost, but also because the needs of people tend to be more chronic in nature than acute." Out of the 2,000 health care professionals enrolled with the registry, about 30% to 40% are skilled nurses, with the rest being personal care aides. Catalano says about 450 of the registered health care practitioners work at one time.
The registry receives reimbursement from an array of payers, including out-of-pocket private pay, long-term care insurance policies, bank trust funds, some major medical policies, and Medicaid waiver funds. It doesn’t, however, receive funds from Medicare or HMOs.
As usual, HMOs want Medicare certification
Even with registry licensure and regulations in Florida and the new law addressing long-term care insurance policies, registries are still locked out of providing care reimbursable by HMOs.
"When we deal directly with our HMOs, they want care provided by a Medicare home health agency," says Jacobs. "That’s been the interpretation. That applies even to custodial care when they cover it. It would be cheaper for us to use registries in certain cases, but if our HMOs require us to [use only Medicare-certified agencies], we do so."
Catalano says the HMOs will have to change their minds eventually. "If the HMOs are looking for ways to be more cost-effective, then they are going to have to shed that kind of an idea," he says. "It says the only thing [consumers] can buy is what’s proven to be cost-ineffective for the last 30 years.’ In other words, consumers can’t come to a nurse registry or to a home health agency that is streamlined in saving costs but yet is doing a good job and is licensed by the state. In short, it is nonsense."
The registries, though, have found their niche in the long-term care market, and payers are pleased with their cost efficiency. "The registries can give us a much better price," says Susan Zimmerman, RN, CCN, chief operating officer of CHCS.
Catalano says his registry cuts costs by acting as representatives of independent nurses and caregivers and working off straight commission, usually about 20%. "We market them to the public, but we act as a screening mechanism so the people are relatively sure that what they are getting is what they are asking for and that this person has been screened and is qualified," he explains. The registry looks at the needs of the client and matches them up with the abilities of the caregiver.
Most of the quality control is on the front end of the process in terms of screening and credentialing of the health care practitioners, Catalano continues. The system also works because it is market-driven and is based on outcomes, he says.
"We have never had the right of control of the individual," he says. "Our people’s next job is only secured by how well they did their last job."
And private duty clients have no hesitation in complaining if that job does not go well, Catalano says. "In private duty, we are generally dealing with affluent people or semi-affluent people. If they don’t get what they want, they think nothing about picking up the phone and letting you know."
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