Category Archives: Ethics

Thoughts on “productivity”

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There has been a recent discussion on the geriatrics listerv about productivity (and a recent PT in Motion article about productivity), but you can probably read it anywhere on any discussion forum for rehab professionals – productivity requirements continue to rise, and it is making professionals frustrated. I said in a tweet it makes me sad, angry, and a little scared for our profession. I want to write a bit more on that.

First, how productivity is calculated: I work in a facility that calculates productivity based on minutes billed divided by hours present per day, minus any CEU time (if it takes me 30 minutes or 90 minutes for an eval, I bill 30 minutes or 90 minutes – I would take issue with some place that only allows me to bill or account 45 minutes for an eval if it takes me 60 from a professional perspective).  In my career I’ve worked in 3 SNF/TCU facilities where I’ve done sub-acute/ OP/ LTC, and interned in one other, and have had multiple friends and colleagues who have worked in similar facilities, mostly for the major companies, and the only way I have encountered productivity billing is the way I described above.  I can tell you that productivity demands that I have seen, experienced, and heard of take into account the hours paid that you worked, not your vacation time, CEU, etc, and it ranges from 65% to 92%.  If anyone else has had a different experience in how productivity is calculated they can comment on that and the impact on them; again, I want to comment on what I’ve seen and experienced.
Why it makes me sad:

Productivity is often what we are judged by, and it is often all about the money, not about the patient or outcomes. I understand this is a business (see my previous posts about the WSJ article on “copious therapy”). But seriously, productivity of 94%? To me, that sounds like a company looking at a bottom line with such a myopic view (for shareholders?) that they don’t see what they are doing to their staff.

Why it makes me angry:

What to fit in the minutes left over in the day: Using the productivity calculation above, in working an 8 hour day, if you factor our your LEGAL two 15 minute breaks (who really takes those?), and you DON’T document on your lunch, and you don’t overlap patients (which you can do with commercial insurance, but not Medicare): at 65% you have 138 minutes left, at 70% you have 114, at 75% you have 90, at 80% you have 42, at 90% you have 48, at 92% you have 8 minutes.  In those remaining minutes, you need to get ready for the day, go between patients (hopefully your patients aren’t spread out in a large facility), document to facility and payor expectations (or at least complete what you didn’t do during point of service documentation), return phone calls, respond to emails, talk to families who stop you in the hallway, talk to other disciplines you work alongside, breathe, and wrap up for the day (bathroom and water breaks are covered during your personal breaks).  I forgot to mention staff meetings (which may be factored out for efficiency, but not productivity), supervising PTA’s and co-signing their notes, waiting for nursing to give meds or finish toileting or dressing, finding patients unavailable due to an MD/NP seeing the patient, the patient refusing for a variety of reasons, the patient being out of the facility, finding OT or SLP has your patient, and answering the occasional call light, and I’m sure there is more that I’m not thinking of at the moment, all while trying to keep your focus on service, patient satisfaction, and good working relationships and not allowing your productivity requirements become the focus and becoming self-centered/ serving.

Would I rather have 138 minutes to do all that, or 8 minutes?  Some companies use transporters, which helps.  There are questionable suggestions/ recommendations I’ve heard that give me pause in even considering working for a national company that requires the higher levels of productivity.  And if a therapist can’t achieve those levels, their options would to: a) be fired, b) document off the clock, or c) try to find a company more in line with their views (my boss and her boss will probably read this – Brenda and Amy I love our company, have no issues, have no intention of leaving, and welcome a discussion on how to improve my productivity!).

Why it makes me scared:

We have done this to ourselves, and I see no end in sight. We as therapists have valued and needed a paycheck, and not stood up and said enough is enough. And for those that have said enough, someone has always been willing to come behind and take the job (at less pay such as a new grad with their student loans coming due).

What can we do?

For the benefit of therapists and our profession:

  • Refuse to document off the clock.
  • Do not work for companies with productivity standards that are so high that we document off the clock or be unethical in practice. I personally have limited who I work for to companies that put people before profit (people being patients and staff), while still encouraging their therapists to ethically do and be their best. For students interested in geriatrics, I don’t give company names that I won’t work for, but I offer suggestions of what to look for and questions to ask any employer.

HOWEVER!  As altruistic as we want to be, healthcare is a business.  Whether big business and answering to shareholders (ala RehabCare/Kindred) or a non-profit, you can’t run in the red.  We as professionals need to determine (and stand up for) what is ethical, but also be aware that this is a business; companies, it may help to show us the business numbers for better understanding and buy-in.  We need to ethically (and legally) be as productive as we can.  That may be structuring our day better (not checking/ answering emails except at specific times, seeing patients in a “geographic” sequence to limit getting our 10,000 steps a day by lunchtime, etc), thinking about using a productivity system or framework at work (Getting Things Done, Six Sigma, Kaizan, etc) not having non-work discussions during non-break time, trying point of service documentation as much as we can, giving our employers ideas on how to improve productivity to address roadblocks we encounter, etc.

I wish things were different, and hope things get better for the sake of our patients and our profession.  In the meantime if we are having a difficult time with productivity demands, we need to follow our ethical principles while either working with our employer to see the issues or look for another job that will value us and what we bring to the table, not just the number we generate (and be thankful when we find that job!).

Sorry for the length of my thoughts and opinions – I would be interested to hear other takes on productivity calculations, how to be more productive, ethical considerations in productivity, etc, be it on a listserv, FB, Twitter, or the comments section below.
Photo credit: Productivity by Sean MacEntee

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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.

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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.

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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.

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

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 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 next one are my thoughts and do not reflect the thoughts, positions, or practice of the staff or management.

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On Monday August 17th, The Wall Street Journal had a page 1 article entitled “Nursing-Home Rehab Raises Medicare’s Tab” with the subtitle online of “Medicare pays top dollar for patients in heavy rehab; the pivotal 720-minute mark” and in the paper “Federal rules can give homes financial incentive to provide ‘ultra high’ therapy.” For those who don’t have access, I will give you an overview in this post [along with a few comments], then provide a few thoughts on the article.

The article leads with a story of a 96-year-old gentleman in California who had fallen and broken his hip, had it surgically repaired, and then went to a SNF/TCU for rehabilitation. He “became severely dehydrated… in part because staff did not follow written plans for his nutrition or facility policies… still, during many of his 21 days there, the 96 year old man suffering from dementia received 2 hours or more of [PT and OT] combined.” This gave the nursing home an “ultra-High” level for rehab, billing Medicare “top dollar for his entire stay.”

Medicare use to pay based on costs, but in 1998 it adopted a new payment system based on categories, which the article points out has been billed at higher levels with increasing frequency. In 2002 the average use of RU for billing was 7% nationwide, and in 2013 it was up to 54%. The categories with corresponding minutes/week and 2013 reimbursement rates are below (I added the minutes per day per discipline).

Category Number of minutes/wk Reimbursement in 2013 (WSJ) Minimum minutes/day with 2 therapies (5 days a week) Minimum minutes/day with 3 therapies (5 days a week)
RL 45-149 $325/day
RM 150-324 $341/day
RH 325-499 $383/day 33 each
RV 500-719 $445/day 50 each 33 each
RU 720 $560/day 72 each 48 each

According to Vincent More (Brown University health services professor, and chairman of the independent quality committee at HCR ManorCare Inc), the new system “‘changed the incentives which changed the culture… playing to the max has a long tradition in health care – that tradition is based on the number of minutes of therapy given, so people give therapy up to the max.’ He says factors such as a trend of sicker patients getting admitted to nursing homes may also contribute to rising therapy.” While he acknowledges the benefits of therapy he admits that we don’t know if outcomes are better with higher minutes. The article notes that this payment system causes problems, with dozens of interviews (former and current therapists, rehab directors and others who provide care in 17 states) revealing pressure to reach the 720 minute mark. This delivery of therapy even occurs “when patients are unresponsive, aren’t likely to benefit or have declined such services” [some therapists talk about this pressure; more about this in my next post].

This high level of billing occurs across the country, in small sites and large chains, with several chains mentioned (Genesis, Kindred, HCR, and Five Star Quality Care); HCR is being sued by the DOJ for allegedly pressuring employees to provide unnecessary therapy and overbill Medicare (HRC “refutes the basic claims” and states that they provide care “based on [patients’] individual clinical needs.”).

Industry defenders such as David Gifford (senior VP at the American Health Care Association) believe the WSJ analysis “is incomplete because it doesn’t examine patient outcomes but ‘shows we are trying to provide as much therapy as possible to get people better.’ Patients generally want as much therapy as possible [in my experience this is not common] and Medicare doesn’t set quantity guidelines he says…. Factors beyond money drive increased therapy, says Kim Blunt, an nursing home consultant and former nursing-home administrator at HCR and other organizations. Patients are more educated about health care than a generation ago, she says, and demand more therapy [again, in my experience this is not common]. Providers more thoroughly document treatment she says [point of service documentation is feasible, but would not justify the increase in RU, and can be an ethical issue depending on how it is done in my opinion], and hospitals send patients to nursing homes sooner after surgeries” [true, but often they can’t tolerate an RU when they are more sick].

Critics of the high billing practices report pressure to get as many patients as possible to the 720 minute mark, but not to go over it. Therapists are asked to provide therapy to those who refuse it, don’t need it, or are in “advanced stages of illness.” WSJ analysis of data showed that from 2010 to 2013, nursing homes billed Medicare at the RU level for at least 51,000 patients “until they went on hospice… and about 110,000 patients died within five days” of RU billing. Mr. Gilford “says many patients may need lots of therapy to prepare for home-based hospice care” [they may need therapy to be able to get up stairs or improve strength to make it home, but I haven’t seen it take an RU to do it].

The billing system was developed by Dr. Brant Fries at the University of Michigan, “using statistical methods to determine categories based on examining patients at the time because there wasn’t good science predicting how much therapy was needed. There still isn’t good science, he says, adding that he named the ultrahigh category after determining patients getting 720 minutes were “a very rare group.” Responding to the Journal’s findings, he says there may be “excesses of people getting rehabilitation””. In January the Medicare Payment Advisory Commission (independent congressional agency) and the Urban Institute released a report, stating that “the present payment system continues to encourage providers to furnish clinically-unnecessary services for financial gain.” [emphasis mine]

The article closes with more to the story of the 96 year old gentleman, with snippets of information from the OT and SLP notes over the last week of his stay there, including “no understanding or recall” of OT’s fall prevention instruction and the SLP’s report that he “is unable to hold his head up for longer than several seconds.” The day before he was sent to the hospital he became agitated and tried to hit a therapist, and received 61 minutes of PT, 50 of OT, and 60 of SLP.

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I’d love to say that numbers don’t matter in healthcare rehabilitation, but this is a business and if you run your business without thinking of the numbers to some extent you won’t be around long. But has evidence for more rehab supported this dramatic increase? That is a tough question; I haven’t seen any study looking at discharge location, re-admittance rates, falls, or anything like that relating to RUG levels. But it is questionable to me with the financial incentives to provide more, and the pressures put on therapists at times to get minutes/ levels, and I don’t know that research would support the extent that RU is billed (if anyone has data, please share and enlighten me!).

So where might we go from here? This article may spur quicker changes at CMS; paying by minutes doesn’t seem to work, and MPAC/ UI’s report acknowledges the financial conflict of interest. Paying strictly by outcomes won’t work (sicker patients take longer and won’t recover as much), though G-codes make me think they are heading that way. I like the idea of FOTO, which allows comparison of patients to others with similar conditions (it is mostly an OP tool, but apparently has a SNF version). Let’s hope whatever CMS adopts is something that all parties can get behind. According to an article in the new GeriNotes, the IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation) requires the implementation of standardized assessment data by October 1, 2018 (Home Health is extended until January 1, 2019). These data are functional status, cognitive function/ mental status, special treatments, interventions, and services, medical conditions/ comorbidities, impairments, and an “other” (any category required by the Secretary of HHS). It will be interesting to see what they will do with the data and how they will tie it into payment.

You can read the APTA’s response in this PT in Motion article.

Recent readings and news

March has been very busy between work, home, continuing education classes, and preparation for a guest lecture.  This weekend I attended NAIOMT’s Differential Diagnosis class (Part A) – three days that challenged my memory, reasoning, and abilities, and that really make me want to step up to the challenge of being a better PT.  More on that later, as Part B is in a month.

I’ve also been taking Mike Reinhold’s online Shoulder Seminar, and I have to say first that I appreciate the quality of the articles and the presentations, and second that I can go at my own pace as this week I was unable to keep up.  However, I wanted to pass on a few references of papers that he is having us read, that I thought would be good if you are interested in EBP or have questions about the shoulder:

  • Regarding EBP/EBM:
    • Cormack JC. Evidence-based practice…what is it and how do I do it? J Orthop Sports Phys Ther 32(10):484-7, 2002.  A good overview of what it is, what it is not, and how to do it.  I think I’ll review this once a year as I set out professional goals.
    • Cleland JA, Noteboom JT, Whitman JM, Allison SC.  A primer on selected aspects of evidence-based practice to questions of treatment.  Part 1: Asking questions, finding evidence, and determining validity.  J Orthop Sports Phys Ther 38:476-84, 2008.  A tough but good read.
    • Noteboom JT, Allison SC, Cleland JA, Whitman JM.  A primer on selected aspects of evidence-based practice to questions of treatment.  Part 2: Interpreting results, application to clinical practice, and self-evaluation.  J Orthop Sports Phys Ther 38:485-501, 2008.  Same as above.
  • Examination of the shoulder:
    • Malone T.  Standardized Shoulder examination – Clinical and Functional Approaches.  In Wilk KE, Reinold MM, Andrews JR, The Athlete’s Shoulder, 2nd Ed.  Elsevier, 2009.  Yes, most of my patients are not athletes, but I still benefited from the framework.
    • Wilk KE, Andrews JR, Arrigo CA.  The physical examination of the glenohumeral joint: Emphasis on the stabilizing structures.  J Orthop Sports Phys Ther 25:380-9, 1997.
    • Hegedus EJ, Goode A, Campbell S, et al.  Physical examination tests of the shoulder: A systematic review with meta-analysis of individual tests.  Br J Sports Med 42:80-92, 2008.
  • Shoulder exercise:
    • Reinold MM, Escamilla RF, Wilk KE.  Current concepts in the scientific and clinical rationale behind exercises for the glenohumeral and scapulothoracic musculature.  J Orthop Sports Phys Ther.  39:105-117, 2009.  A good overview of what shoulder exercises work best given the science and the rationale of the exercises.
    • Wilk KE, Arrigo CA, Andrews JR.  Current concepts: The stabilizing structures of the glenohumeral joint.  J Orthop Sports Phys Ther 25(6):364-79, 1997. A tough read if you are having a tough week, but given enough coffee it can be done.
    • Myers JB, Lephart SM.  The role of the sensorimotor system in the athletic shoulder.  J Athl Train 35(3):351-363, 2000. Very good article, but see above!

And in PT-related news, looks like new grads can’t pick just any date for taking the NPTE, and the neuro section has come up with recommendations for stroke outcome measures.

PT’s as “fitness experts”?

Interesting article in today’s WSJ about PT’s as fitness experts for those over 50.  I think the article itself is good, however implementation of the idea is problematic due to direct access, and I think there is the potential for abuse of the idea.  However, I think that an initial eval (referral for a functional impairment, etc) with specific goals (address the three areas of the ICF, 6MWT, FTSTS, etc), then either turning them over to a trainer, a small class, or some other way of tracking adherence and meeting their personal goals would be ideal.  I think the patient in the article with a lack of direction from her PCP and a complete misunderstanding of her situation from trainers points to the need/ ability for PT’s to get a person started back to health (is LBP or a torn ACL any more special for a PT to treat than the issue of weight/ knee pain or DM2, CHF, etc affecting a persons return to what they want/ need to do?).  Health care reform will make the use of technology (Web 2.0, etc) more important, as technology may make it more feasible to improve patient adherence.  Future posts to come on this idea, both from the literature as well as my own reflections/ attempts.

Surgeon and device manufacturer conflict of interest

Lexmark Hardware Error 0502

Another article about the conflict of interest that surgeons may have with ortho hardware manufacturers. It is an interesting read – if any of my relatives have a surgeon recommend surgery, I will encourage the asking of questions such as the effectiveness of surgery vs non-surgical management options, if the MD was trained by the manufacturer, etc.

Photo credit: Lexmark Hardware Error 0502, originally uploaded by Peter Forret

MD vs TKA manufacturer

Tibia

Tibia,
originally uploaded by Laurel Fan.

Interesting window into the world of MD’s and the relationships that can be formed with industry, as well as what happens when you speak out or change your mind about how great the product is.