Is it a question of ethics, or is it just business?
How to manage with managed care
If it hasn't already happened, one day in the near future your hospital is likely to have two patients with the same diagnosis, similar functional status, and managed care plans with widely varying reimbursement guidelines. One patient's insurer may allow only a short inpatient stay and a limited number of outpatient visits, while the other patient's plan may cover a much longer stay and unlimited outpatient therapy.
This can create conflicts for rehab providers who have worked for years to standardize treatment procedures and want to give every patient everything he or she needs.
"As therapists, we see value in everything we do. When you have your hands on another human being, you don't ever want to stop until you can see that person maximize their potential," says Nancy Beckley, MS, MBA, president of Bloomingdale Consulting Group in Valrico, FL.
Rehab managers must help their therapists understand that it is the payer who is buying the service and not the patient, Beckley says.
And they must realize that the payer is providing the service that the patient, or his or her employer, bought when the insurance policy was purchased, she adds.
"We constantly have to remind staff that their job is to provide the service within the parameters that are set out by insurers," says LeeAnn Sims, MS, CRRN, clinical nurse specialist at Legacy Rehabilitation Services in Portland, OR, where the market is 90% managed care and 63% of the elderly population is covered by a Medicare managed care policy.
Legacy doesn't put anyone in jeopardy by discharging them when it's unsafe, but the system does sometimes discharge patients when they are uncomfortable with going home, she adds.
Here are some ways Sims copes with the managed care marketplace:
· Remember the case manager calls the shots. "They tell you what the length of stay is, and you figure out how you are going to address that patient's needs," Sims says.
· Consider the case manager a member of your team. At Legacy, case managers are invited to team meetings so they are part of the process. If they can't attend in person, they can participate in a conference call.
· Set priorities for your part in the continuum. Acute rehab providers need to get patients medically stable and able to function at the next level of care, Sims says. "You have to remember that you can't always deal with all the issues in a limited time frame. Some things will have to be managed at another level of care, such as home health or outpatient services," she adds.
· Look at the big picture. Staff should be reminded that because reimbursement is limited, taking too much of a resource for one person means there is less for others.
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