Stories from the frontline

WillMon Oct 16 2023

Author’s note: this looks like an intimidating blurb of text, but it is a fun and important read - trust me :)

I have a friend who is a homecare nurse, we’ll call her Teresa. Teresa has been a homecare nurse for several decades, all at the same organization in the same suburban-rural Minnesotan town.

Teresa is damn good at her job. I know because I lived in that town for many years and heard from many patients and coworkers that she is a caregiver in every sense of the word.

Sure, Teresa is incredibly intelligent in a quantitative way - the valedictorian of her high school and college classes, and consistently a top rated nurse at her organization. But Teresa is also talented qualitatively, in her “bedside manner” - this is often tougher to cite examples, but the fact that she has delivered several patients’ eulogies and remains connected with countless patients’ families from throughout her 30-year career seem to prove she is quite adept.

Teresa is a good nurse, a great person, and she loves her job.

So when I recently asked “How’s work?”, I was unpleasantly surprised to hear her response - a set of frustrating stories from the frontlines of care delivery. Stories I want to remember as I try to make a positive impact in healthcare. Stories I want to share with you in the hopes you do the same.

As I mentioned, Teresa works for a homecare agency which means she travels to peoples’ homes and performs visits wherever they live. As you can imagine, she has seen it all! The good, the bad, the ugly. Homecare may seem rare but it used to be the norm, and today it offers a lower cost plus more convenient method of care to some of the most vulnerable and in-need populations.

Teresa’s organization serves a large percentage of elderly patients, who are insured through Medicare. So when the organization gets a new patient, Teresa or another nurse goes out as part of an initial “assessment”. This is basically a visit to collect background data - nurses review whatever information they’ve received about the patient and assess the patient’s ailment, status, and need for treatment.

During this assessment, Teresa is oftentimes required to perform an OASIS test to quantify the patient’s functional impairment. This functional impairment test means what it sounds like, and is scored on a simple rating of 1-5: 1 indicating very high impairment and 5 indicating very little impairment.

Recently Teresa was assigned a new patient, traveled to their home, and performed an OASIS assessment - super straightforward, something she has done thousands of times. It was clear this patient wasn’t very inhibited, and Teresa scored them accordingly with an OASIS score of 4 out of 5. As always, Teresa meticulously documented her work - jotting down the patient’s various movements and mannerisms within her Electronic Health Record (EHR) system. Everything justified this patient was a clear 4. She concluded the visit and documentation, told the patient that the scheduling department would be in touch, and was on her way to the next visit.

You may ask, like I did at this point in Teresa’s story, “how does the scheduling department determine timing of the next visit?”. Well, it turns out that the OASIS score decides this. The agency uses a standard algorithm, based on the patient’s score, to auto-calculate the number and frequency of visits the patient needs.

Teresa explained that a low OASIS score (high impairment) suggest that the patient needs many visits, all of which the agency makes money on by billing Medicare. Conversely, a high OASIS score produces a schedule with fewer visits, and the agency makes less money.

At the end of her day, after a full day’s worth of visits, Teresa almost always logs back into the EHR and polishes up her documentation from throughout the day. Part of this nightly process is communicating with “coders”, who are part of the agency’s billing team. Coders? Software? People writing code? Nope, these are medical coders. They review Teresa’s documentation and assign various medical procedural (“CPT”) and diagnostic (“ICD10”) codes, all of which have dollar amounts tied to them for which Medicare pays the agency.

On this fine evening, Teresa logged into the EHR and saw a handful of messages from her coding team asking about her assessment from earlier in the day. All their questions were focused on Teresa’s documentation, along the lines of:

Did you make sure the patient could do this, that, and the other thing? Without ANY impairment AT ALL?

From what we see, this looks like it could be scored a 3 or a 2. Are you sure on your scoring?

Listening to Teresa, I was taken aback. These coders, who literally sit in cubicles while translating clinical professionals’ documentation into medical codes, are the ones questioning Teresa’s in-person assessment? This must be rare, right? Nope. Teresa went on to explain to me that this is almost always the case. You see, if a patient scores a 4 on the OASIS assessment, as Teresa had determined for this patient, Medicare will only pay for the limited set of services to get that patient back to no impairment. (This makes sense, too much treatment is an unnecessary waste.) But what does that mean from the agency’s standpoint? Less revenue. Therefore, the constant push from the coders, which is surely mandated upon them from higher-up executives, is quite obvious “get money” behavior: set low-score / high-impairment baselines, deliver more services, collect more revenue.

My pair of rose-colored glasses? Shattered.

So what happened from there? Being the high-integrity, somewhat stubborn nurse that she is, Teresa didn’t budge on the OASIS score and it remained a 4. This patient would be seen once per week for the duration of 30 days.

Why 30 days? Well, again, that’s the result of the algorithm and business model. For most Medicare patients, Teresa’s organization gets paid on bundled “episodes of care” - basically a time period of ongoing visits, typically 30 or 60 day increments, paid as one bundled payment for that 30 or 60 day period. For this patient, with low impairment aka an OASIS score of 4, the billing team indicated to Teresa and the scheduling team that they would only be able to bill for 30 days. That is how long the patient would be seen for.

So Teresa continued her weekly visits with the patient, seeing them a few times as they progressed. All during this time, her billing team is tracking utilization. You see, the agency has to make sure they are hitting pre-set metrics defined by Medicare. If Teresa doesn’t spend enough visits with the patient, the agency will get docked revenue in the form of a LUPA “Low Utilization Payment Adjustment”. And if, god forbid (!), Teresa determines the patient needs to be seen an extra time for a one-off service, then the agency needs to perform a new assessment in order to trigger a new set of codes and kickoff a new episode of care.

Teresa feels this tension everyday at work.

She told me that she got into nursing to care for those in need. That’s it. And so she tries to pack as much care as possible into the allocated number of visits. She tries to go above and beyond to provide holistic treatment that is best for the patient while warding off the business interests that continue to get in the way of this pursuit.

Similar to my previously published blog focused on incentives, the goal in sharing these stories is not to convey doom and gloom. There’s plenty of that throughout the industry. Rather, this serves as a reminder that the only people who matter in healthcare, the patient and provider, are being exploited by a system architected to drive profits independent of outcomes. A system built on a business model for which profit is derived from doing more to patients - assigning lower OASIS scores, adding more codes, and delivering more treatment.

I am here to say that this is not the way it has to be. There are people bucking the trend, such as the growing Direct Primary Care movement, who are restoring healthcare as it ought to be: with the patient and provider at the center. Profit derived not from doing more, but from keeping people healthy and happy.

In a lot of ways, it is that simple. And at Yuzu, we are trying to help bring that to the masses. So people like Teresa can keep doing what they love: providing care to those in need.