Registries vs. agencies: Who should decide?
Registries vs. agencies: Who should decide?
Florida is making its decision
Immediately following the 1999 session of the Florida Legislature, Associated Home Health Industries Inc. suggested that the state’s Committee on Health Care Licensing and Regulation conduct a review to determine whether the Legislature should repeal the nurse registry regulation. What follows is a compilation of information gathered by the committee from individuals within the industry, jurisdictional agency personnel, and other public and private sources with expertise in specific areas. It is intended to provide options that the Legislature might consider in determining whether to repeal licensure of nurse registries.
Separate entities
Part IV of Chapter 400 of Florida state law provides for the development, establishment, and enforcement of basic standards that will ensure the safe and adequate care of persons receiving health services in their own homes. Section 400.506 recognizes home health agencies and nurse registries as two entities that may be licensed to provide home health care.
A nurse registry is defined as "any person that procures, offers, promises, or attempts to secure health care-related contracts for health care providers who are compensated by fees as independent contractors. Nurse registries may work exclusively with independent contractors, but may only procure contracts for RNs, LPNs, home health aides, CNAs, and homemaker companions.
Details on rules
Home health agencies must provide at least one service using an individual who is an employee of the agency. They may supply all of the above services as well as provide various types of therapists and social workers. They may also supply nutritional guidance and medical supplies to patients. Home health agencies must also have a registered nurse or physician available during operating hours. Any patient receiving skilled care must be visited by an RN every two weeks. Nurse registries are not required to provide any RN care except to patients receiving CNA or home health aide services.
Home health agencies are also required to obtain a physician’s order prior to the start of all services, while nurse registries only need a medical plan of treatment if medication or medical treatment is administered. Home health agencies must submit evidence signed by a certified public accountant that they have the financial ability to operate for two years. Nurse registries must present a first-year operating budget. Home health agencies and nurse registries are each required, by law, to carry liability insurance. By rule, home health agencies are assessed a licensing fee of $830, while nurse registries are assessed a licensing fee of $689.
Homemakers or companions employed by home health care agencies must be evaluated by an RN every six months; homemakers or companions referred by a nurse registry require no supervision. Home health agencies are required to develop a plan of care for all patients; nurse registries are not. When a home health agency discontinues care to a patient the agency must inform the patient of the reason, develop a plan of care, and make a referral to another home health agency. Nurse registries must only inform the patient of the reason for termination of services.
During investigations, legislative staff members developed a survey that was sent to members of both groups, and met with group representatives. The Agency for Health Care Administration, the Department of Labor and Employment Security, the Department of Revenue, and the Internal Revenue Service were also solicited for input.
Those in favor of repealing nurse registry licensure contend that the current regulatory situation is unfair to:
• the state;
• health care providers that function as independent contractors;
• patients receiving care in their homes;
• home health agencies.
Proponents of repeal contend that unless registry licensure is repealed, all privately funded home health agencies will eventually seek licensure as nurse registries. They maintain that the current situation is unfair to patients of nursing registries, who have no recourse for liability claims except to the independent contractor, and to the independent contractors, who have no protections afforded to employees under federal and state statutes.
Opposition cites cost-effectiveness
Opponents of repeal maintain that nurse registries are a cost-effective alternative for consumers, and cite the fact that no complaints have been made to the state by consumers or caregivers who contract through nurse registries. They contend that that home health agencies are seeking this change because of a reduction in available funds due to Medicare cutbacks and want the government to regulate their competition out of existence. They also maintain that registries benefit those caregivers who choose to operate as independent contractors but desire assistance in obtaining contracts, and that changing the current regulatory status would simply raise the cost of care.
Thirty-five percent of the surveys mailed out were returned. Based on the survey results and conversations with members of both industries, legislative staff identified the central concerns for this project are taxes, liability, and cost of care.
Research showed that allowing individuals to operate as independent contractors who seek contracts through nurse registries does not subject the state to any undue tax liability, though home health agencies do afford greater assurance of recovering damages to a patient in the event of an injury. It also indicated that nurse registries offer care at up to 20% to 30% lower cost than do home health agencies.
Staff reported these options the Legislature might pursue:
• Act to eliminate nurse registries, which would leave consumers with two alternatives:
— Seek home health care from home health agencies, which would cost consumers more money when obtaining care from a state-licensed entity.
— Hire an individual not affiliated with any organization, which would expose consumers to independent contractors not subject to any manner of background screening.
• Make no change to the current regulatory process, which would allow home health agencies and nurse registries to continue coexisting, which would give consumers greater choice when seeking in-home care. This would enable the state to maintain oversight of independent contractors wishing to use nurse registries to market their services.
Based on the findings and conclusions in its report, legislative staff found it would not be beneficial to the state, independent contractors providing home health care, or consumers seeking health care for the Florida Legislature to repeal nurse registry licensure.
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