Part II: “Copious Therapy”: Ethical Considerations

Again, a disclaimer before I go further – I work at a wonderful place that listens to its therapists’ recommendations regarding level of minutes. They respect our professional recommendations and encourage evidence-based practice, and we work together to deliver what is appropriate, adjusting levels as needed. I am very thankful to be working there; this blog especially this post and the last one are my thoughts and do not reflect the thoughts, positions, or practice of the staff or management.


Read this first: Part I: “Copious” Therapy in Nursing Homes – Financial Gain or Good Therapy? (or both?)

It seems that some days, therapists can’t win, and these days can stick in your head. Patients or families are unrealistic about outcomes and appeal the decision to discharge, managed care limits your number of visits for a patient and you know if you had more visits you could accomplish more, Medicare (or the RAC) audits your records to determine if your documentation supports your billing, your company insists you need to get the minutes and you insist the patient isn’t appropriate for that much that day, or that an article in the WSJ calls into question what therapy companies do so you get included in the suspicion by patients and families that you are doing too much. What is a therapist to do? Two things come to my mind: we need to be professional and ethical when it comes to visits and billing (the visit as a whole), and we need to practice according to the evidence as best we can (the parts of the visit).

Visits/ billing: Billing can be made harder because as the article notes, there is a pressure on at least some therapists to achieve minute expectations (not to mention productivity – a different topic and post!). If you read the APTA’s Code of Ethics for the Physical Therapist, several principles appear to be applicable in light of the article (underlines are my emphasis):

  • Principle #2: Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients. (Core Values: Altruism, Compassion, Professional Duty)
    • Physical therapists shall adhere to the core values of the profession and shall act in the best interests of patients/clients over the interests of the physical therapist.
      • I would add “or the employer.” With the financial conflict of interest, are more minutes in the best interest of the patient? If it is quality therapy (evidence-based – see below), then yes. If not, we need to stand up for our patients.
  • Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity)
    • 3A. Physical therapists shall demonstrate independent and objective professional judgment in the patient’s/client’s best interest in all practice settings.
      • Therapists should be recommending the minutes, not management. We should be open to being challenged in our thinking, but we are the ones doing the evaluation; the patient is our patient.
    • 3B. Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.
      • This is the therapist’s experience, not the minute manager’s; the patient’s values, not the company’s; the current literature and best practice, not the company’s practice.
  • Principle #7: Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society. (Core Values: Integrity, Accountability)
    • 7A. Physical therapists shall promote practice environments that support autonomous and accountable professional judgments.
      • PT’s are professionals, and it is our judgment of what therapy the patient needs. Bowing to pressure of the company when the level is not appropriate is giving up autonomy and professionalism, but you will still be accountable.
    • 7E. Physical therapists shall be aware of charges and shall ensure that documentation and coding for physical therapy services accurately reflect the nature and extent of the services provided.
      • If you are providing exercises just to get the minutes, is your billing accurately reflecting the nature and extent?
    • 7F. Physical therapists shall refrain from employment arrangements, or other arrangements, that prevent physical therapists from fulfilling professional obligations to patients/ clients.
      • I would argue that if there is a pressure at your facility to provide therapy just to get the minutes, you should leave if that pressure continues. There are other facilities and settings that can use your talents.

The long and the short of it is that the reimbursement system is flawed, and being based on levels of minutes there can be a pressure to achieve these so we have a job. However, we as physical therapists need to stand up for what is right – what is right for our patients, and what is ethical toward the payer. I know therapists may be pressured into getting those extra minutes by any means necessary on a patient who is not appropriate, but we are not technicians.

Evidence-based practice: The other issue that comes to mind in reading the article is quality of therapy in the SNF/TCU setting. Several years ago I came across a PT Advance article (the link I had back in 2012 is broken, and I can’t find it for citing now), which said in part:

Being a specialist in geriatrics has a down side at national meetings, at times. We see our peers in sports medicine and manual therapy projecting a veneer of being the “best” in the profession. When we encounter them after many years and we are asked our specialty there is an uncomfortable somewhat condescending moment. We feel like our specialty is not as rigorous or deserving of praise. This is a bad feeling. When we reflect on the complexity of our patients, their multiple co-morbidities and medications as well as challenging functional levels we wonder why anyone would not think we are the brightest and hardest working of the profession?

As I have said elsewhere in the blog, “I love my specialty – it combines medical complexity with patients who really need help to function better.  But are we in SNF/TCU settings challenging ourselves (or students), let alone our patients?  And I mean really challenge.  Could that be a major reason why we feel that way?”

I suspect the author of the 2012 article still feels that way. Recently the APTA acknowledged that physical therapists need to challenge their older patients , and a current student notes the disconnect between evidence and practice in skilled nursing. In my six years of practice, we still seem have the reputation of not challenging patients. We need to step up and utilize the evidence (and the outcomes) out there, otherwise one could make the argument that we are providing an inferior product and not being responsible for health care resources. The following principles from the APTA Code of Ethics seem to relate:

  • Principle #3: Physical therapists shall be accountable for making sound professional judgments. (Core Values: Excellence, Integrity)
    • 3B: Physical therapists shall demonstrate professional judgment informed by professional standards, evidence (including current literature and established best practice), practitioner experience, and patient/client values.
      • Read up on the evidence for strength training in older adults, the use of ultrasound, number of repetitions for recovery from a CVA, the intensity for balance training (or the theories of balance), or any number of other approaches to treatment, then compare that to what we do. I know I continually need to be challenged and challenge myself – I know I can do better for my patients.
  • Principle #8: Physical therapists shall participate in efforts to meet the health needs of people locally, nationally, or globally. (Core Value: Social Responsibility)
    • 8C: Physical therapists shall be responsible stewards of health care resources and shall avoid overutilization or underutilization of physical therapy services.
      • To be responsible stewards of health care resources, we need to ensure we are not providing subpar therapy. Otherwise we are really overutilizing by having to provide more therapy minutes to get the same outcome.

We are professionals, and we have a responsibility to our patients, our payers, and our profession to provide high quality therapy influenced by the evidence and measured by standardized outcomes.


Now I’m not advocating abandoning creativity or “out of the box” thinking (I use this in the best possible sense, not in a “how can I get my mandatory minutes?” way; for another post maybe), nor am I against being challenged in my approach and thinking. What I am advocating is that our primary responsibility is to the patient (one could argue our second responsibility is to the payer, in this case ultimately the tax payer). If we are looking at the whole patient and their situation, and practicing in accordance with the evidence, an RU may very well be the most appropriate and I’m fine with that. What I’m not okay with is ignoring or minimizing our responsibilities to the patient and to the payer in regards to practice and billing to “get the minutes.” We owe them, and ourselves, more and better than that.


One response to “Part II: “Copious Therapy”: Ethical Considerations

  1. Pingback: Aging and Population Health | PT for Boomers - and beyond

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