Blanketed by RUGs.

I don't know about you, but I'm not sure I can attend one more presentation on the Medicare PPS. Of course, I've seen more than a few at various national meetings, traveling as I do; a conservative estimate would put it at about 20. Maybe it's just me, but it just isn't getting any easier.

It's sort of an otherworldly experience, really. At the front of the room is the expert. He/she knows all about how to prepare the MDS for appropriate PPS reimbursement-- the RUGs, the RUGs definitions, the MDS sections that are the toughest or the easiest-- and the speaker discerns a pattern in all this that seems to make sense.

And sometimes not.

I have seen the experts be unsure, offer conflicting interpretations and sometimes even contradict themselves. I saw one recently stymie himself on an MDS multiple-choice test that he, himself, had devised. There are exceptions: for example, the always clear and commonsensical Sue Nonemaker, RN, of HCFA's Office of Clinical Standards and Quality, and the peppy Andrea Platt, RN, BS, a consultant with KSM Healthcare Resources (Indianapolis), who leaves you feeling that you could do anything well, even PPS. Such advisors cannot be at all places at all times, however.

That's unfortunate, because the PPS system is of such Rube Goldbergian complexity as to be overwhelming. I have seen audiences of long-term care administrators and nurses sit, jaws agape, and listen to descriptions of this, and it would have been funny if one didn't realize that these people have money on the line. It doesn't matter how tough or, sometimes, incomprehensible PPS is--if they don't get it right, they're looking at steep financial losses and today, more and more, bankruptcy.

The disconnect between government regulation writers and long-term care industry managers is not only astonishing, it's becoming tragic. The continued growth of the brand-new American Association of Nurse Assessment Coordinators (AANAC), dedicated to furthering understanding of the PPS system, is encouraging, but it'll be a while before it's of sufficient size and reach to help rescue skilled nursing facilities in general.

So I offer a couple of modest proposals:

1. The Feds should postpone their plans to expand the number of RUGs from 44 to 178 (believe it or not) this fall. I know the idea behind this is to enable higher-end rehabilitation facilities to file more accurate claims for better reimbursement--but doesn't quadrupling the number of RUGs seem a bit much right now? Everyone knows that this is really a software developer's problem, because only well-designed computer software is capable of working the PPS system. But there's a question as to whether the software developers themselves will be fully up to speed on 178 RUGs anytime soon. And as for their customers--well, too many are still trying to figure out why their post-acute care outgo keeps exceeding their income. In short, let's take a breather to work on what we already have.

2. To bridge the government-industry disconnect, perhaps the long-term care community might consider establishing a "summer camp" for government officials. For example, you might want to invite your local congressperson to visit the facility and work the RAPs with you. If you're an Iowan, maybe Senator Grassley could come by for a couple of days to help you prepare for the annual survey; maybe he could help with an MDS review or debate a surveyor. Maybe someone from HCFA would like to drop in at a town hall meeting now and then to hear what local administrators might have to say.

I don't know whether any of this would solve anything. It might keep things from getting worse.

RICHARD L. PECK