Category Archives: Legal/ regulatory issues

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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Outcome measures and G-codes

Reliable, ADM In afternoon light

I’m finishing up the May 2013 issue of GeriNotes, the newsletter for the Section on Geriatrics. There is an article “Section on Geriatrics Recommended Outcome Measures for Medicare Functional Limitation/ Severity Reporting” which I found interesting. There is the background/ reporting process for G-codes, the different categories for G-codes, and then the SOC recommended outcome measures for reporting. They have “a list of recommended [emphasis theirs] measures with best evidence, practicality of use, responsiveness, and psychometrics.” This list includes:

Walking speed
Six-minute walk test (or 2 minute or 3 minute version)
TUG and/ or TUG Manual
Five Times Sit-to-Stand and/or 30 Second sit-stand
Sitting Balance Scale
Berg Balance Scale
Patient Specific Functional Scale
Disabilities of the Arm Shoulder and Hand Scale (DASH or Quick-DASH)
Fullerton Advanced Balance Scale
Elderly Mobility Scale
Falls Efficacy Scale – International

What does the list not include? First, I noticed OPTIMAL is missing, despite CMS listing it as one possible tool. Second, there are no recommendations for taking the results from one of the tests and translating that into one of the severity modifiers (CH-CN). I think this is also an issue for OPTIMAL.

I am for using reliable outcome measures. Just as a manual muscle test is variable across practitioners, transfer grades (min/mod/max) can be about the same. I appreciate that the Geriatrics and Neuro sections have developed a toolbox of outcome measures. The question or issue I have in relation to the article is how does a 47/56 on the Berg, a DASH of 61, a FTSTS of 25.3 seconds, or a 6MWT of 1300’ relate to a percent disability. It can’t be a straight cross walk (if the severity modifier is 0-100% and the Berg is 0-56, 28/56 on the Berg is not validated to 50% disability). Also, the Berg measures fall risk, not percent disability. For other outcome measures, what about the situations where there are age-matched norms such as walking speed? Or if they can’t do the FTSTS without using their arms, how does that mark them down in the percent disability? Or what if they improve greater than the MCID but it doesn’t improve their “disability score” (if they are 39% impaired at a CJ, they would need to get better than a 19% improvement to >20% to move into the next category)?

At work we are using the OPTIMAL tool primarily (we can use others so long as we justify our severity modifier in the description section of the G-code of our EMR), and it is the best system available to us. When CMS came out with the new requirements, I thought there would be a silver lining of encouraging us all to use outcome measures more. That silver lining has tarnished after the July 1 deadline. My professional concerns are how CMS will use the data we are all submitting (affecting both the patients and rehab professionals), and if the data we are providing is really accurate (and if it isn’t, is this helping or hindering us). I only have questions, trying to sort all this out in my own mind as I try to be the best therapist I can and look out for the best interests of my patients. Given the lowering reimbursement, the changing caps, and the increasing regulations, I’m not surprised practices are refusing Medicare, going to a cash-based system, or shifting focus entirely.

Addendum: FOTO reminded me that they were also left off the recommended list but are “approved by CMS for several years now.”  Sorry about that!

Photo credit: Reliable, ADM In afternoon light, originally uploaded by swanksalot

A silver lining to the Medicare changes?

Silver Lining

We had an inservice today on how the Medicare changes to the cap and the new threshold will affect our computer documentation and billing, and how it may affect us as a facility. I hadn’t thought that with the new rule of fining hospitals for re-admissions, hospitals will have an incentive to keep a person there under observation status if there is nothing seriously wrong, which means if they can’t go home our TCU/SNF will receive the person with only MedB benefits (so they would be paying privately for the room and board, vs having a 3-day qualifying hospital stay for MedA). On the face of it, there only seems to be losers in this new set-up, and I can think of many patients in the past three years that would probably be under observational status and come for rehab under MedB.

With the limitations in funds for MedB, as well as the manual review if we reach the threshold, there will be likely be renewed pressure from management in many facilities, as well as pressure from the patient/ family to get home to reduce their out of pocket cost. However while in the training, a thought occurred to me. Maybe with this new situation there will be an incentive not only to document better, but also to improve our practice for all of geriatrics (SNF/TCU and outpatient) for better outcomes, and for researchers to help deepen the pool of literature out there for issues facing this population.

One of the reasons I chose to do the residency is that I saw changes would be coming, not just the population shift but also in Medicare. I wanted to deepen my understanding of geriatric PT and improve my practice, because I knew the game would change on many levels and I wanted to be ready. I don’t think the changes to Medicare are finished, no matter who wins in November. But I think we have an opportunity to step up our knowledge, improve our practice, and sell ourselves and outcomes (not our nifty gadgets, although the NeuroCom is pretty cool). If I ever have to tour rehab facilities for temporary placement of a family member, I’d rather pay for a one that is knowledgeable about geriatrics and seeks to improve themselves and their practice. I’d rather practice there too.

Photo credit: Silver Lining, originally uploaded by TwelveX

Dementia, and reflections on Legislative Day and geriatric PT

Tomorrow is Legislative Day for Minnesota PT’s.  Last week I went to class with the 2nd-year PT students at the UMN.  The presenter talked about the history of PT legislation in Minnesota, the importance of being involved, and the possible items on the agenda for tomorrow.  Afterward I talked to her in the hallway and asked – given the importance of PT related legislation and relatively less involvement of acute care and SNF/TCU PT’s in the APTA and state chapters, how do you “sell” non-members on being involved in the APTA?  For full disclosure – I am an APTA and MNAPTA member, and belong to geriatric, neuro, and ortho sections. I believe in the importance of membership, and while I am a new professional and thus have limited exposure, wherever I have worked or interned in a rehab setting relatively few were APTA members, and I know long-time PT’s who work in rehab settings that aren’t APTA members.  My discussion and this post are from those views and interactions.

In politics it comes down to a numbers game.  Outpatient PT’s are often leading the charge (thanks all!), but it seems that relatively few of us working in other settings (as a percentage) are members or are involved.  Reasons I’ve heard include that it doesn’t seem that advantageous to spend hundreds of dollars to get journals that don’t make much of an impact on how we practice (more on that later), and it seems like all the legislative action needed affects outpatient (direct access, manipulation, ATC’s trying to be PT’s, etc).  Why invest time and money in a cause that doesn’t benefit me?  Involvement of the APTA at the Federal level is abstract (can we really make a difference?), and we in rehab settings are basically guaranteed patients (vs outpatient where you rely on referrals or marketing) so there is less of a sense of urgency to even participate at that level.  She and I hope to continue the discussion tomorrow.  I think the APTA should work on recruiting rehab PT’s (for those rehab PT’s reading who are involved, thanks for your involvement!), starting with surveying PT’s in acute and SNF/TCU settings to see why there is a difference in membership rates between outpatient and rehab – how do we view the APTA?  What is our view of the profession?  What is our view of where we are headed?  Is there a generational difference in this or in where we practice?

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When I was searching for resources for dementia and physical therapy for the end of my journal club presentation on dementia (future post), I came across this PT Advance article, which says 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 ?

I love my specialty – it combines medical complexity (with meds issues) with patients who really need help to function better (and are largely a joy to work with).  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 think we unfortunately have a reputation of not doing that.  The highest weight I’ve ever seen used in a SNF/TCU is 5# (the favorite weight is 3# for some reason).  We seem to love Theraband (blue, green, or red, and sometimes yellow) and seated and sometimes standing exercises, 3 x 10 of course.  We grade strength improvement based on a MMT, rely heavily on the Berg or Tinetti (using the cut-off scores to indicate fall risk or improvement for a goal).  We only take vitals if the patients are on O2 and if the oximeter is handy.  We are only now starting to time gait speed, and seem to only record (approximate) distance walked, not time that it took to go that far.  As a group we don’t seem to belong to the APTA, or utilize literature from at least PTJ.  It doesn’t mean that people don’t read it, but I’ve never seen an issue of PTJ or any other journal where I’ve worked or interned unless a student brought it.  We don’t have journal clubs or discussions unless a student does it (because it was required by the program).  We aren’t involved in using social media (blogs, twitter, FB, Google+, etc) for promoting/ enhancing our skills, knowledge, or professional interactions.

For non-geriatric PT’s, I’d love to hear your thoughts about PT’s that work in geriatrics – is the quote above accurate?  For those geriatric PT’s who are challenging yourselves and your students and patients, I’m glad that you are out there making a difference (this isn’t about you).  Please, let me know you are out there, and volunteer to be a guest blogger!  But as a whole, if we want to feel respected that our specialty is “rigorous or deserving of praise” or that we are “the brightest and hardest working” or even change a student’s mind about geriatrics, I think we (including myself) need to truly practice Evidence-Guided PT, be an example to those around us to step up their game, and be involved in the greater community of PT’s through the APTA and social media.

WA PT vs. POPTS

You can read the full opinion here, but the conclusion seems to be that POPTS are okay in WA….

“This case presents numerous issues relating to the important issue of delivery of  health care services in the state of Washington.  In resolving the matters before us, we have relied upon the intent of the legislature.  The legislature remains free to adopt another course should it see fit to do so.  With respect to the case before us, we affirm the trial court’s grant of summary judgment to BFOA on Columbia’s PSCA claim and direct the trial court to enter summary judgment for BFOA on Columbia’s corporate practice of medicine doctrine and antirebate statute claims.  We affirm the trial court’s denial of the remaining summary judgment motions, including the court’s denial of summary judgment on Columbia’s CPA claim.”

POPTS case on the docket

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Washington State Supreme Court in Olympia, November 17th, 1:30pm (it is the last one of the session – at the very bottom of the page).

Photo credit: templeofjustice-dsc_2483, originally uploaded by luckynoob.

Fraud involving physical therapy

goniometer

Three years for practicing PT without a license.  (thanks to Doug White, DPT, OCS for the link).  This was not a PT involved in fraud, but an owner of a clinic (Reconditioning and Exercise Physiology Specialists – REPS, get it?). Turns out he is an exercise physiologist who figured he could a) perform PT without a license, and b) inflate the time spent with the patient. Fortunately he was caught (defrauding the Ohio Bureau of Workers Compensation – he owes them $2.1 million and the IRS just over $92K). 

Suggestions on protecting yourself

Dr. White sent the original link on the APTA education listserv, and makes the following suggestions:  “The salient point of the article is this person used a licensed PTs identity to commit fraud according to the article. This is one of the most common types of health care fraud. Students and PTs should be mindful of these crimes and take appropriate precautions to protect their identity for obvious reasons. Such steps should include:

  • Avoid signature stamps when possible
  • If you use a signature stamp take it with you when you leave the facility
  • Be knowledgeable about how your services are billed and perform informal audits to make sure your services are not misrepresented
  • Send a standardized letter to major payers when you leave a practice setting saying you no longer practice at xyz facility as of a certain date.
  • When leaving a facility document in any open cases, “I am no longer the attending PT. Responsibility for the care of the patient has been turned over to Dr. xyx””

I feel bad for the PT whose name and reputation were on the line – thankfully it wasn’t a PT that was doing the defrauding.

Picture credit: goniometer, originally uploaded by hmmlargeart.