The good:
- Good money, especially if you have a directorship stipend.
- Full directors can make 7-10K per month on top of their insurance collections.
- Associate directors can make $5K a month on top of their insurance collections.
- Even better money if you're signing up for one of their hospitals that has had trouble recruiting. Sign-on package can be up to 50K, from what I've heard, not including another 15-20K for relocation.
- If you opt to go the independent contractor route, you set your own vacation time--your vacations are just unpaid.
- The therapists tend to be really good and trustworthy.
So far so good.
The bad:
- Lots of pressures to accept inappropriate patients who can't actually participate in therapy, nursing-home type patients who could never in a million years do 3 hours of therapy. Quite often, these patients will be sitting in group therapies, barely awake as the therapists try to desperately get some activity out of them.
- Lots of suggestions to code for diagnoses that won't impact what you actually do for a patient. What do you actually do differently if the patient has a myopathy?
- Lots of readmissions of the same patients over and over and over again. If anyone has ever had a stroke and is admitted to the acute care hospital for any other reason (UTI, CHF, pneumonia, etc), they get readmitted to HealthSouth/Encompass for "late effect stroke." As you can imagine for patients with chronic disorders like COPD, CHF, and CKD, this can happen a lot. There is always a reason someone like that will be deconditioned after one their frequent hospitalizations.
- Lots of patients admitted for "myopathy." Disuse myopathy, critical illness myopathy, uremic myopathy, ________ myopathy. Very, very few of these "myopathies" are supported by the documentation of EMG findings, elevated CK levels, or even proximal more than distal weakness. If they want to admit an old deconditioned person, and they can't say that it's because of a stroke from 5 years ago, they call it "myopathy" and admit the patient. They had to settle out of court and pay Medicare $48 million about 2 years ago. They didn't admit wrongdoing. And the behavior hasn't changed much.
- Lots of "encephalopathies" coded as brain injury. Patient is admitted to the hospital for UTI-related sepsis and develops some confusion? Great! You can admit him as an "encephalopathy" if they show some confusion at any point during their acute care stay, even if they are back to their mental baseline by the time they get to IPR. Also "encephalopathic" are alcoholics admitted after binge drinking. Many of these patients will have some deficits after being evaluated by therapy in acute care, maybe from the fact that they're still zonked, maybe from Wernicke's encephalopathy. They quickly return to their baseline after detoxing, as they would without therapy. Then the vast majority will go home, drink again, and return for another bout of "encephalopathy" a few months later.
- Lots of their hospitals have a hard time following the 60/40 rule. It shouldn't be that hard to ensure that 60% of your patients have a CMS-13 diagnosis. But when you're trying to admit every deconditioned old person in town, you're going to run out of that 40% fairly quickly. Hence the incentive to fudge and code people for "strokes," "encephalopathies" and "myopathies."
- If you make your peace with the system, you will thrive and make $$$. If you decide that you can't in good conscience participate in such a system, you will get tired of refusing patients--who will be admitted by one of your colleagues--and you will eventually leave.
- The nursing staff can be below average. Some HS facilities will hire one RN per shift--all the rest being LPNs. This saves money, but you can't always count on your nurses to catch things early.
- The staffing ratios can be atrocious: 6-8 patients per nurse, sometimes more. Not enough nurses aides. Patients complain all the time that it takes them forever to get some assistance when they press the call light. Some will decide that they might as well get up and take themselves to the bathroom. This, of course, increases the fall risk.
Personally, I have decided that I wouldn't work for a system where I wouldn't feel comfortable if my mom were admitted.
Are some of these issues fixable? Sure. If you have a good referral base and little competition in your town, the incentive to admit inappropriate patients will decrease. But my take is that the higher-ups at the company have incorporated admitting inappropriate patients into their business model. They get the money upfront. Then, if Medicare sues, they can hire enough lawyers to settle out of court and pay back part of the money. They still come out ahead. A $48 mil fine is just the cost of doing business.
If you ask me, the best way to see if you want to work somewhere is to do a stint there as a locum tenens. You're never going to see what it's really like on an interview. They're going to butter you up and show you only the good parts. And just like men on a date with a hot woman are often prone to thinking with their nether parts, you're going to be too under the allure of the $$$ to think straight, especially if you're early in your career.
That's my 2 pesos! PM me if you have any
preguntas.
