MCOs require Medicare certification, for now
But emphasis may shift to accreditation
Private duty home health providers say it’s almost impossible to get business from managed care organizations without being Medicare certified. But if you aren’t Medicare certified, is there a way you can still appeal for their business?
According to one managed care company, being accredited by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) helps, but if you’re not Medicare-certified, you’re out of luck.
"All of our home nursing providers are Medicare certified as well as JCAHO-accredited," says Krista Blakely, RN, CCM, manager of medical resource management for ChoiceCare in Cincinnati.
"We feel the criteria they use to survey you to make sure you’re meeting all the standards you need to to keep your business up and running are some of the same standards we actually use in our Request for Proposal process," she explains. "When we are seeking to renew our contracts, we follow some of the same guidelines as JCAHO does as well as adding some [guidelines] if we feel we need to."
Managed care organizations let other entities such as Medicare give providers a quality stamp of approval, in essence saying "If you’re a Medicare certified home health agency, then we assume you give good quality care because of the survey process," says Stephen Tweed, health care strategist for Tweed Jeffries LLC in Louisville, KY. "So what they are really doing is using that Medicare certification as a method of determining quality of care."
This may seem like bad news for private duty providers, especially in light of the August 1996 state survey letter issued by the Region IX office of the Health Care Financing Administration (HCFA) in Baltimore. The letter threatened the certification of home health agencies that don’t focus on serving Medicare patients. (For an update on Region IX letter, see story, p. 13.)
If HCFA does indeed begin pulling certifications of agencies, how will the managed care organizations respond? "Eventually I suspect the managed care organizations will step back and say, If that’s the case, we will use some other method of assessing quality, and that might be JCAHO accreditation or [Community Health Accreditation Plan] accreditation,’" says Tweed.
Individual marketplaces may dictate that managed care organizations switch their allegiance to accreditation rather than Medicare certification, especially if agencies start losing their certification, Tweed says.
"I think that as it becomes more and more difficult for managed care organizations to take cost out of health care, they going to look more to home care as a way to do that," he explains. "They’re going to recognize that a Medicare-certified agency typically is more expensive than a noncertified agency. Eventually they are going to say, We won’t require them to be Medicare certified. We’ll just require them to be accredited by some recognized accrediting body.’ Then you’ll be able to have a private duty agency that is not Medicare certified and still be able to do managed care business."
To be ahead of the game, Tweed recommends being able to show managed care organizations that your agency can measure outcomes and demonstrate cost savings. (See related story on outcomes reporting, p. 18.) A private duty company that can do these things and is focused on doing business with managed care organizations and other commercial payers will be able to convince a customer that there is some advantage to doing business with them, he says. "They’ll not only be able to talk the talk, but they’re going to have to be able to demonstrate it with hard data," he says.
ChoiceCare likes to see information based on accessibility and timeliness of service, Blakely says. "All of our agencies will report to us that they were able to see a member within X amount of hours, that the member was able to call in at any time and speak with someone or have someone after hours return their call. Also, [they must report] that the physician is kept in the loop and works with the actual case manager or nurse who is assigned to that particular patient’s care," she says.
In addition, agencies provide ChoiceCare with data specific to the organization’s members that they service, such as the number of visits per diagnosis and any adverse outcomes, Blakely adds. "We don’t have a general format that we say, You’re going to provide X, Y, and Z.’ We leave it up to them." All of the agencies serving ChoiceCare use critical pathways, she says.
Unfortunately, few home health agencies in the United States use hard data to demonstrate outcomes, Tweed says. "There’s a lot of talk about it, and a lot of people working on it, but I haven’t seen anyone who really has the data, particularly small private duty companies."
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