Steven Littlehale

“If I could work my will, every idiot who goes about with ‘Reimbursement Reform’ on their lips would be boiled in their own pudding and buried with a stake of holly through their heart!” Ebenezer Scrooge hissed after the conclusion of a CMS Open Door Forum. 

Those around him recognized his raspy-gravelly voice and quickly distanced themselves. “Why is he always so negative?” Mary whispered in a hushed tone to her director of nursing. 

“He made a fortune in contract therapy under the RUG system. You’d think he’d be grateful!” the director returned.

As Scrooge made his way out of the conference room, he encountered some elderly residents congregating by the oversized birdcage in the sun-filled atrium. “Hello there, Mr. Scrooge. Listen to this bright green one chirp,” one of them chimed. “Bah, humbug!” was his response. Thankfully, his retort was lost on the enthralled residents who continued to delight in the bird’s merrymaking. Little did Scrooge know that his life was about to forever change.

As the chimes of midnight came and went, Scrooge shifted in his bed, finding it difficult to sleep. He fondly recalled the transition from cost-based reimbursement to PPS and how therapy minutes had driven reimbursement for almost two decades. Early on, he’d seen the opportunity for contract therapy and worked diligently to establish a regional therapy company. But as quickly as he settled into his happy memory, a loud thud — no, more like a crash — echoed from the corner of his bedchamber. And before his eyes appeared the Ghost of Reimbursement Past!

“You may be an undigested bit of brisket, a dollop of mustard, a morsel of cheese, a sliver of underdone latke. Leave at once!” Scrooge cried. “Oh, Ebenezer,” the translucent entity bellowed as she extended her index finger toward him, “you have much to see and so much to learn.” With that, the two were transported back to 10 years ago, standing within a skilled nursing home Scrooge had provided services to … and Scrooge could hardly believe what lay before him.

Through a slight haze, he saw a packed therapy room filled with patients, therapists and therapy aides. Up, down, left, right, large motor skills, small motor skills, rubber bands, therapy clay, and more nearly overwhelmed his vision as he struggled to control his excitement. “Spirit, this is a happy and prosperous time. Thank you for showing it to me,” he said. But the spirit forced his gaze to an elderly man struggling in the parallel bars.

As Scrooge drew near to him, he could hear staff talking about this patient’s failure at therapy, and about how withdrawn he was. He overheard comments about not achieving enough minutes. As the spirit nudged him even closer to the failing patient struggling in the parallel bars, Scrooge thought this man was near death — and then, looking deep into the man’s eyes, Scrooge realized in horror that the dying man was himself.

“This cannot be! Not in my contracted facility, not I! Leave me alone, you terrible spirit!” With a final shudder, Scrooge sat up in his bed as the bedroom clock chimed one. As his racing heart quieted, he convinced himself what he’d seen was a mere artifact of an unsettled stomach and pulled his comforter up to his still-quivering jaw.

Scrooge fell into a fitful sleep, and his dreams were filled with annoyances — all driven by the new Medicare reimbursement system, PDPM. He was constantly confronted with the unpleasant realities of renegotiating therapy contracts. Operators insisted contracts be changed, always seeming to want more and pay less. With shock and agitation, Scrooge found himself debating the veracity of not linking contract therapy payment to PT/OT and SLP component scores. “Isn’t this perpetuating the past?” some of his clients had the insolence to suggest; others even proposed a value-based incentive payment on top of a flat rate. Scrooge, with all his courage, pulled the corners of his mouth into a forced smile, revealing his bright white, recently veneered teeth.

Oh, but Scrooge was a tight-fisted hand at the grinder — a squeezing, wrenching, grasping, scraping, clutching, greedy sinner. As he woke from his troubled dreams, he recommitted aloud to the empty room that he would not see his revenues dwindle. And with half an eye opened, he glimpsed the clock as it struck the next hour.

“Come with me!” a robust, heavily robed spirit shouted as he began to take bodily form at the foot of Scrooge’s four-poster bed. “I am the Ghost of Reimbursement Present! We have many miles to cover, many stones to turn over.” Scrooge at first was intimidated by this new visitor’s deep voice, but soon gave into the paradoxical sense of calm this spirit seemed to radiate. With a dramatic gesture, the spirit enveloped Scrooge into his long, richly ornamented cape, and in a moment, they were brought to Atlantic City, New Jersey. 

The conference room was filled to near capacity. Well over 1,000 nursing home operators, clinicians, owners, REITs and attorneys listened with focused intent as various industry experts went into great detail about PDPM. Scrooge recognized many of the audience members: They were his clients and prospects. As the sessions continued, though, he suddenly realized the nature of the audience’s unblinking attention, and it sent shivers up his spine. 

“Why, spirit,” he postulated, “this conference isn’t about coding to make money under PDPM. It’s not about the money drivers at all!” The spirit returned Scrooge’s excited gaze with a neutral stare, encouraging him to continue. “They generally see this as being good for the patients in their care. They are learning about proper depression and cognitive assessment and how to match the right therapy intervention to each individual.” And as quickly as the words came out of his mouth, he was pulled into a whirling twist of time, to several months later — emerging from the vortex into a sea of words, both written and spoken.

“BUDGET-NEUTRAL.” “TAKE-BACK.” “RECALIBRATION.” “COMPLIANCE.” “MAC.” “PEPPER.” The words filled his eyes and deafened his ears, and Scrooge felt his knees weaken. So much volume, so little substance. He shouted as best he could to be heard over the din: “Spirit, these words are nothing more than meaningless gibberish spilling out of the mouths of fear-mongering consultants who don’t have answers, but seek to profit! Please return me to the warmth of that conference room.” Yet the spirit boomed in reply: “Oh, but Scrooge, just yesterday you wished that all of mankind be ‘boiled in their own pudding and buried with a stake of holly through their heart’ for merely uttering the phrase ‘reimbursement reform.’ Wasn’t that out of fear of your own profit?” As the spirit spoke, his face distorted into the visage of the dying man in the parallel bars. Scrooge let out a blood-curdling scream and abruptly awoke in his own bed, sheets thrown asunder.

Resigned, Scrooge didn’t try to fall back asleep. And he didn’t even stir when, in the next hour, the Ghost of Reimbursement Future made his cold, foreboding presence known. Unlike the others, this messenger was silent, his face hidden under the cowl of his cloak. Scrooge swallowed, yet found his voice. “I fear you more than any spirit I have seen,” he ventured. “Show me your face, I insist.” But the robed spirit said nothing, nor did he draw back the cowl. Instead, he beckoned Scrooge forward, and the two began a walking journey, invisible to those they passed. 

They made their way down the streets of the night city, then into the suburbs, then the quiet countryside, all at quick and unnatural speed. Along the way, Scrooge became increasingly troubled. “But spirit, this cannot be right! Where have all the nursing homes gone?” He received no reply.

The shift in atmosphere was palpable as they made their way down an undulating country road. A cemetery from Scrooge’s memory came into view. “Spirit, I know this place,” he said. “My parents and grandparents were laid to rest here.” Still the spirit said nothing and directed him through the cemetery, stopping in front of a freshly dug grave. Dread filled Scrooge as he approached it. A deep foreboding saturated his soul as he read the epitaph — not his own, as he had expected, but the gravestone of his once-beloved nursing home industry.

Here lies the industry: skilled nursing facilities

Destined never to realize their true abilities

They captured the acuities

But documented ambiguities

And couldn’t justify their high cost promiscuities

Scrooge couldn’t believe it. The post-acute sector — once poised for greatness under PDPM, the very stepping stone to PAC site-neutral payments — had cannibalized itself by not embracing the true spirit of clinical reimbursement. “Please, spirit, I beg of you: Return me to the present time so that I may engage more fully and honorably in reimbursement reform, embracing the true meaning of patient-centered care!” a trembling Scrooge pleaded. “I will honor payment reform in my heart and try to keep it all the year. I will not live in the past, but the present, and ready my profession for the brilliant future. The lessons of all three spirits shall guide me! God bless us, everyone!”

… With greetings for the holiday season, and apologies to Charles Dickens whose timeless classic inspired these musings!

Steven Littlehale is a gerontological clinical nurse specialist, chief innovation officer at Zimmet Healthcare Services Group, and chief clinical officer emeritus at PointRight Inc.