Pay-per-visit system adds nurses, not expenses
Entrepreneurial efforts increase productivity
Managers of hospital-based home care agencies who suddenly are faced with the challenge of developing a new salary structure for their nurses may want to consider a pay-per-visit system. One agency has found that it has increased efficiency and boosted business.
"We have been able to grow our business tremendously since we adopted a pay-per-visit format last year," says Maura Trilla, director of MacNeal Home Care, a not-for-profit agency in North Riverside, IL, In April 1995, MacNeal Hospital in Berwyn, IL, implemented a change in administration. The entire staff was reorganized and reengineered. To increase the number of patients it was serving without adding significant additional expenses, the agency changed its nursing compensation method to a pay-per-visit system.
Nurses are paid $30 per billable visit to each patient. Visits usually last from 45 minutes to two hours. Nurses are paid extra if more time is needed for follow-ups with doctors or MCOs, paperwork, and inservice. "Our nurses ended up making more money with this system," explains Kuzas. "Plus, nurses have control over their own schedules."
Because the agency tries to link nurses with patients who live nearby, travel time is reduced. Kusas says that nurses rarely travel beyond a five-mile radius of their own homes, adding that this factor has increased productivity and job satisfaction. Nurses are reimbursed for mileage at a rate of 31 cents a mile.
MacNeal Home Care made more than 200,000 home care visits last year. "We are a full-service agency with no subcontractors at all," says Maria Kuzas, MacNeal Home Care’s manager of business development.
MacNeal’s home health care nurses are paid $30 per billable visit to each patient. Because the agency tries to link nurses who live near their patients, travel time is reduced. Nurses are reimbursed for mileage at a rate of 31 cents per mile.
Kuzas explains that nurses rarely travel beyond a five-mile radius of their own homes and says this factor "has increased productivity and job satisfaction."
The agency enjoys low turnover among staff, adds Kuzas. Many of MacNeal’s nurses are mothers who work part-time, and they like not having to travel long distances.
Adds Trilla, "By generating a geographical team structure, we’re able to respond to increases in demand and be more receptive to our customers’ needs. Also, there is the issue of continuity of care. The same nurses who open the case can keeping working with that patient. And in some cases, if the patient moves from a hospital care environment to a home care one, because our staff stays within one hospital system, that patient has the opportunity to have the same nurse at home as he or she did in the hospital. We have a bridge manager on staff who manages our Hospital to Home program."
Nurses receive full benefits, including health and dental insurance, educational courses, sick leave, and vacation time. MacNeal’s Weekend Program offers part-time nurses the opportunity to enjoy the same benefits as their full-time counterparts, with a minimum of nine visits required.
MacNeal’s system also allows flexible working schedules, as some nurses prefer different hours than others. "Some people are early risers, and some are later," Kuzas says. "If a nurse wants to set up appointments at 6 a.m., that’s fine, as is an appointment later in the evening. Our patients like this flexibility as well. The elderly especially like early morning visits, so they can get on with their day and not be kept waiting for a nurse to come in."
Quality needn’t suffer under pay per visit
Although there have been industry concerns about quality of care suffering from a pay-per-visit system, Kuzas says its patient satisfaction surveys and focus group interviews show the quality of care is not impaired by the new payment method.
"We conduct patient satisfaction surveys each quarter regarding the delivery of our clinical services, and our scores are in the 95% range and higher," Kuzas says. "None of our patients have rated our services in the fair’ or poor’ range. Also, we’ve asked an outside consultant to come in and conduct focus groups among our patients since we implemented the pay per visit, and [we] have received outstanding comments regarding our quality of care, services, availability of nurses, and our critical paths.
"And our physicians have given us high marks, which was not the case before we changed to the pay-per-visit system because we were previously turning away referrals because we didn’t have sufficient staff to cover the case," Trilla adds.
Patients no longer complain about "therapy visits that are too short or different staff coming inside their homes," Trilla says. "We provide reliable and consistent staffing, and employees are happy to spend their time providing hands-on care rather than charting and photocopying paperwork."
Nurses’ compensation is directly tied to the number of patients they visit, thus giving these nursing entrepreneurs the incentive to visit as many as they can.
"Under our previous system, we had different reimbursement levels for different individuals, as well as different reimbursement levels for workers on weekends evenings and holidays," Trilla says. "We used to see our nurses make no more than two visits a day. Now they’re making an average of six visits per day, and some make as many as nine per day. But we have not seen any decrease in quality or productivity. In effect, our nurses are being paid for being nurses, and performing such tasks as case management, patient and family education, etc., rather than filling out paperwork and documentation."
Paperwork was bogging them down
Before implementing the program, managers met with core groups of nurses to get their input regarding problems with the existing system.
"The most common complaints we heard from our nurses were the paperwork that was bogging them down and the long drive times to their patients’ homes," Trilla says. "At the same time, our human resources personnel were surveying other agencies and sources for current pay-per-visit rates."
Kuzas says that because each nurse is equipped with high-tech tools such as laptop computers, less time is spent creating the cumbersome paper trail. "Nurses are more efficient with these tools, and they don’t have to come into the main office if they are far away," she says. "Most of our documentation from our nurses comes via the fax machine and phone lines, because all of our nurses are on line. As a result, they’re spending less time performing documentation and are not stuck doing medical charts for two to three hours during the evening."
However, no nurse gets paid until all the documentation is completed.
"In our market here in suburban Chicago, a lot of our home care patients are Medicare insured," Trilla says. "No nurse is paid until all of the appropriate forms are completed. Being on a pay-per-visit system is a tremendous incentive for nurses to turn in their paperwork in a timely fashion."
Some staff making more under new stucture
When changing from a salary system to a pay-per-visit format, perhaps the biggest obstacle to overcome is convincing the salaried staff they won’t be making less money.
"In every organization, concerns are different, and at first, we had this problem," Kuzas says. "Many of our nurses who had been here for longer periods of time were especially concerned they would lose money, and some of our older nurses actually predicted that we would lose personnel under the new system. But no one has, and the key is demonstrating to the staff that pay per visit means nurses control their own salary. Because of its entrepreneurial nature, nurses can make as much money as they want to. And we don’t have to worry about their productivity, because greater productivity is in their best interest. We now actually have personnel making more money than they did under the old structure."
Kuzas also notes that the pay-per-visit system encourages loyalty to one agency. "Under our previous salaried structure, we actually had nurses working for more than one agency or company in order to make more money," she says. "Now, most of our nurses work only for us, because of the pay-per-visit system’s potential for more income."
Trilla emphasizes the necessity for managers to support the system during its transition.
"Before implementing any kind of pay-per-visit format, the home care agency’s management needs to critically examine every single component of the existing system and identify any sources of duplication, inefficiency, etc.," she says. "MacNeal Home Care itself is not a top-heavy organization in terms of management," she says. "We have a middle managerial level and a divisional director. That’s all."
Both Trilla and Kuzas stress that an organization should undertake some streamlining efforts before a pay-per-visit system can implemented.
"One area that really helps to be streamlined is the intake, or administrative process," Kuzas says. "We visit more than 200,000 patients annually. Before we became computerized, three copies of the initial referral were circulated to the nurse supervisor, physical therapist, and the nurse. It was incredibly cumbersome. Now, the initial referral information is immediately entered into the computer, and the nurse supervisor can assign a nurse to the patient much sooner."
Finally, perhaps the biggest attraction to the pay per visit systems comes in the form of its entrepreneurial simplicity. "MacNeal Home Care gets paid by the visit," Trilla adds. "We wanted to develop a system to pay our employees in the same way we are compensated as a company. When they’re making money, we’re making money."
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