• Feature

    Measuring by Value, Not Volume

    Physical therapists increasingly are being judged by employer-established productivity standards. What are the implications for the profession and physical therapists?

    Feature Value PT With Patient

    When his employer decided to fire him, Gerald Pica, PT, was hardly surprised. Earlier, he recalls, he'd been "brought into the office" several times and told that, in his capacity as clinical coordinator, it was up to him to ensure that the facility's physical therapists (PTs) "were 87.5% productive." Further, in order to hit that number, "we needed to be seeing all of our patients for 45 to 60 minutes for at least 11 to 12 visits."

    Pica had come to this job almost 4 decades into his career. He was hired, he says, after leaving another facility that had its own "productivity standards." If a patient cancelled, the PT was supposed to clock out, even though he was still completing plans of care or catching up on paperwork, so that "unproductive time" would not decrease the overall department's productivity numbers.

    There, Pica says, he refused to do as his manager asked, which "got me in hot water." Here, he thought, things would be better. "But they weren't. It was even worse."

    Soon after the last of those office meetings in which he verbally was informed he had to pick up the pace, Pica received a written warning for the first time in his 38-year career, "stating that I was not providing quality care." He tried to rebut this claim with the company's corporate compliance office, explaining that the warning was "not about quality, but quantity—they need x number of units per patient per day in order for us hit their productivity quota."

    He also told corporate compliance that, as a PT, he had issues with this requirement. "I'm not going to let a manager or supervisor, especially one with no clinical training, dictate that I have to see someone for 60 minutes if it's not warranted. Nor can they tell me that every patient needs to be seen 12 times. These decisions are ours to make as the evaluating clinicians." Sure, Pica told them, you can talk about productivity, but those "standards" should be targets, and his performance should not be based on charged treatment times alone.

    Pica asks, "What about the other aspects of our job that are productive as well? Things like documentation and verbal communication with staff and physicians? What about training and public relations?"

    When PTs are unable to meet their employer's productivity requirements, Pica says, "that doesn't mean they aren't providing quality patient care." It may just indicate that they're doing their job—and doing it to the best of their ability, and in their patient's or client's best interest. "Anyone can meet 'productivity' requirements by performing interventions that are not evidence-based and not beneficial for the patient," he says. "But that's unprofessional and unethical, and, in my opinion, it's entirely inappropriate."

    Ultimately, Pica says, his employer let him go for reasons it said were unrelated to productivity. But he thinks his complaints about inappropriate productivity standards played a big role.

    A Widespread Problem

    Pica, who is central district chair for APTA's Illinois Chapter and now works with Carle Foundation Hospital in Champaign, Illinois, is not the only PT frustrated with the disconnect between measuring performance and productivity by volume only and missing the "value" part of the equation.

    "I know there are places where it's not a problem," notes Jeanette Knill, PT, MBA, a staff physical therapist with Berlin Health in Green Bay, Wisconsin. "I've worked in those places. But I also think they're getting harder to find. And if you're in an organization where they're only looking at the numbers—where they're [volume] driven," as opposed to patient-focused with reasonable production part of the overall goal—"you're going to start seeing a lot of discontent with management."

    Many physical therapists, including Pica and Knill, acknowledge that productivity is an important practice consideration. But, they say, there's a balance to be struck between the need for more patients and for more revenue and the respect that is due to PTs for their clinical judgment and professional expertise.

    "The concern," reiterates Matt Elrod, PT, DPT, MEd, NCS, "is that organizations are pushing volume quotas without consideration for the value that is delivered." Elrod, a senior clinical practice specialist with APTA, is leading a staff work group initiative related to productivity standards. If providers truly are to meet the health care "triple aims" of improving individual patient outcomes, improving the health of populations, and reducing costs, then quality must be measured over quantity, and value over volume.

    A better approach, Elrod says, is to "understand the resources you're using"—and patient volume does play a part in that—"but also consider your outcomes. Because if you don't demonstrate your outcomes, how will you show the value of your services?"

    Jim Dunleavy, PT, DPT, MS, director of rehabilitation services at Trinitas Regional Medical Center in Elizabeth, New Jersey, agrees. A copresenter, with Lynn Steffes, PT, DPT, on an APTA webinar about transitioning from volume to value, Dunleavy notes that facility-based practices, in particular, often have difficulty verifying or quantifying the true value of their services, "especially when they're forced to use measures developed by nonclinical sources." (For more information, go to http://learningcenter.apta.org/Courses.aspx and search on "volume.")

    In response to cost-cutting pressures, some facilities have become "productivity systems," he says, that attempt to push PTs toward unethical practice to meet their unsubstantiated benchmarks. One PT who asked to remain anonymous says, "You really start to feel the pressure—you know, 'Can't you get that patient an extra 15 minutes?' Or 'Can't you give that person an extra little bit here or there?'

    Dunleavy sits on APTA's productivity staff work group with Elrod and chairs a similar group within APTA's Acute Care Section. The latter notes in a position statement on the subject that "productivity, when measured solely as a percentage of daily staff time engaged in direct interventions, holds little value for the stakeholders of physical therapist services."1 CPT codes, that is to say, aren't enough.

    Even though CPT coding is not required in the acute hospital setting to document for payment, some hospitals ask PTs to report their services using CPT codes so that they can track productivity. "PTs in acute care do many things that don't fall under a CPT code," Dunleavy says. "We may have to do case rounding with a team of physicians and nurses. We may need to meet with a patient's family, or with social workers, and take time to figure out what we have to do from a discharge-planning standpoint. The problem is that none of that is taken into consideration in [code-based] measurement systems developed by outside, nonclinical business entities."

    Typically, Dunleavy adds, such systems neglect to measure a patient's functional-status change, or the intensity of service being provided to achieve clinical goals. Thus, he says, "there is no measure of the value of the service for the patient, the facility, or the health care system as a whole."

    Feature Value Female PT

    The task force, Dunleavy says, is developing what it hopes will be an improved measurement system that will incorporate those very factors. "Because, in an environment in which we're not generating dollars every time we touch someone, which is the way most of health care is headed, if we can't show why we're here and how we're helping, we're in trouble."

    Many organizations, agrees Elrod, have moved away from the fee-for-service business models that were common before the Affordable Care Act. "In fee-for-service, you're basically paid based on the volume of what you bill. But that's not the way it works with accountable care organizations. With those, you're reimbursed, in part, based on the quality and cost of care"—which means that it's up to the facility to determine how to use that money, and to determine, most critically, the role of physical therapy in the "value equation."

    APTA, and the PTs and physical therapist assistants (PTAs) it represents, have long argued that using PTs and PTAs to their full potential is a cost-effective approach that doesn't compromise quality care. Employing physical therapist services early on in settings ranging from the intensive care unit to the emergency department can avoid more costly services later and improve patient outcomes. Educating facilities about the research behind these assertions, and sharing positive results from facilities that have embraced them, are critical to showing the value of physical therapist services in facilities seeking cost-effectiveness.

    To help the profession in this effort, APTA's 2014 House of Delegates voted overwhelmingly to identify and develop resources that will help PTs and PTAs negotiate successfully around productivity and performance in ways that ensure the provision of quality physical therapy care.

    According to the statement supporting the charge, the need for more analysis and tools has arisen amidst a changing health care climate that has created "uncertainties" that have caused some employers to turn to "productivity" measures as their primary measure of PT and PTA performance.2

    These measures may not be realistic and generally do not reflect the value of physical therapy and the patient-related outcomes of physical therapist practice. "At such times, PTs and PTAs need not just ethical courage to stand up for what is right, but also tools and resources to fortify them to engage vigorously and effectively in the dialogue and negotiations with administrators/employers and consultants who are pressuring [them] to adopt productivity measures or practices that may represent sincere but archaic or misguided notions of the nature and role of PT practice," according to the supporting statement.

    The APTA webinar by Dunleavy and Steffes is an example of the types of resources APTA offers. Others can be found on the association's Integrity in Practice website (www.apta.org/integrity).

    Following the House of Delegates, vote APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association in October released a "Consensus Statement on Clinical Judgment in Health Care Settings" as part of a combined effort to highlight the central role of the clinician in a health care landscape that increasingly looks to patient-centered outcomes as the true measure of quality. (See "APTA's Position on Productivity Standards" on page 26.)

    Finding Room to Improve

    This isn't to say that costs shouldn't be a consideration in providing services or that there aren't ways to contain them. Edward Dobryzkowski, PT, DPT, MHS, ATC, holds what he describes as a "broad view" on the subject of productivity. Dobryzkowski is director of system rehabilitation services and sports medicine at St Elizabeth Healthcare in Edgewood, Kentucky, where he oversees physical therapy, occupational therapy, speech, and a number of other services. Dobryzkowski also teaches throughout the United States for a therapy-focused continuing-education firm.

    At home, he says, his facility has productivity "target goals" for its therapists that he believes are "very reasonable, because they account for the variance that exists on any given day."

    On the road, however, where he often leads courses on productivity and efficiency, the refrain he hears is of stressed-out clinicians under pressure from employers "who ask about productivity all the time." The question those employers should ask, he says, is "'How can we optimize your professional time, considering the limitations of your particular practice?' If I'm in an ICU, I won't be able to see as many patients as the PT who is on an orthopedic floor, so I shouldn't be held to the same requirements. The standards should reflect the realities of the workplace."

    Dabryzkowski has talked to many PTs "who say we shouldn't even be having this discussion about productivity." Dobryzkowski responds, "I understand their resistance—that quality suffers when they're continually required to do more and more. But we have to look at the big picture. The fact is, the financial margins just aren't there anymore, and organizations—if they're going to keep their doors open—have to keep their costs down." For managers like him, he says, this means "we need to eke out everything that we can from system and workflow perspectives and hold everybody accountable for doing their parts as members of the team."

    In his own facility, Dobryzkowski says, most therapists have no trouble hitting their productivity targets. "And for those few who do struggle, we go through a number of different interventions to try to help them." For example, a common issue for acute-care therapists is the time spent on chart reviews and documentation. Sometimes the issue as simple as laptops crashing or wireless connectivity—"system problems that are outside of the clinician's control."

    Feature Value Presentation

    In other cases, though, it's more about efficiency. "People who are very efficient might spend 5 minutes on a chart review, while someone who is a little less efficient, maybe because he's not as computer-savvy or she's reviewing things she really doesn't need to, might take 10 minutes."

    Documentation, similarly, can be time consuming for therapists who struggle with typing or are uncomfortable using templates and smart phrases. Another area that often is ripe for efficiency gains is time spent looking for equipment. "If you have more aides and techs available, that's one thing," Dobryzkowski says, "but if you don't have that help and you're on a floor where supplies aren't readily available, you'll spend a lot of extra time on set-up." Tally that time over the course of a day, "and you could save 40 minutes just by teaching PTs to maneuver through the EMR (electronic medical record), or half an hour just by keeping your equipment organized."

    One way to encourage productivity improvements, Dobryzkowski says, is to make staff efficiency data available for all to see. "We blind the names … but each therapist [can identify his or her own figures] and can see how he or she is doing compared with everyone else."

    Baseline productivity expectations are established according to where the therapist works, he adds, with PTs in outpatient settings expected to handle a higher caseload than those who work on inpatient floors. "The biggest issue in outpatient care is the cancel/no-show rate. Otherwise, it's a more controlled environment than inpatient, where many variables can influence a therapist's ability to deliver care." Everyone on his staff is paid by the hour, Dobryzkowski notes. "So those targets we establish are based on the lengths of their shifts."

    Standards: A Financial Reality

    The bottom line when it comes to productivity has everything to do with the economic realities of today's evolving health care system, says Bob Wiersma, PT, CPE, CHFEP, FAFS. Wiersma, who owns Michigan-based consulting firm Performance Builders, spends his days advising private-practice owners on everything from business strategies and marketing to variable-compensation models. He calls productivity "the critical issue" in physical therapy today.

    Wiersma adds that productivity standards are poorly understood by the majority of physical therapists, and therefore can seem arbitrary and unfair. "But there are all kinds of reasons why productivity standards make sense," he says. "We've seen huge shifts taking place with reimbursement and high-deductible plans, and yet we've also seen increasing compensation, so there's a disconnect. This is about therapists being able to earn what they want to earn. And if you want to earn more, you have to be able to create more economic value—it's that simple."

    In Wiersma's opinion, physical therapy needs "a different kind of business model"—one designed, from the bottom up, to pay for contributions to a system's financial success through variable compensation. "The more value you contribute, the more you get paid," he concludes.

    Going forward, Wiersma says, PTs must better use their support staff, from the clerical teams who work the front office to aides, techs, and PTAs. Documentation must be streamlined "so that we document only what's necessary, in the most efficient way possible."

    The definition of what it means to do quality work may need adjusting as well. Wiersma says, "Quality of care is important, but what is 'good quality'? In a lot of the profession, it's assumed to be 1 hour of 1-on-1 time with a single patient. Well, that may mean quality in our eyes, but it may not translate to value in the patient's eyes. And from a productivity standpoint, if we can only see 1 patient in 1 hour, there is a cap on what that metes."

    Such models do exist now, of course, and many physical therapy practices are doing quite well as they strive to remain productive while providing high value. One example: Benchmark Physical Therapy in Tennessee, where David Harris, PTA, oversees daily operations for 14 outpatient private-practice clinics in the eastern part of the state. There, Harris says, PTs are asked to see 12 patients per day, which "we think is pretty easy to do, and also appropriate, given our payer base and clientele load."

    The goal is for Benchmark's PTs to "spend as much quality time with their patients as they can," but to see them only in the capacity that they're needed. In practice, with a PTA shouldering a portion of the work and the PT moving, as necessary, between patients and clients, the typical patient receives care for an hour or more. Whether Benchmark is paid for that entire visit depends on the patient and the applicable billing guidelines. But overall, Harris says, the approach is "efficient and productive and good for our patients." Further he adds, "It keeps the lights on."

    Chris Hayhurst is a freelance writer.


    1. Position Statement on Value vs. Productivity Measurement in Acute Care Physical Therapy. Acute Care. http://c.ymcdn.com/sites/acutept.site-ym.com/resource/resmgr/Files/2014-11_Productivity_Value_B.pdf. Accessed May 1, 2015.
    2. From the House of Delegates: Help in Responding to 'Productivity' Issues on Its Way. PT in Motion News. July 14, 2014. http://www.apta.org/PTinMotion/NewsNow/2014/7/9/HoDProductivity/. Accessed May 1, 2015.

    APTA's Position on Productivity Standards

    APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASL) in October 2014 released a "Consensus Statement on Clinical Judgment in Health Care Settings" as part of a combined effort to highlight the central role of the clinician in a health care landscape that increasingly looks to patient-centered outcomes as the true measure of quality.

    "Respect for the therapist's clinical judgment and expertise is critical to achieving optimum patient/client care," according to the statement. "Overriding or ignoring clinical judgment through administrative mandates, employer pressure to meet quotas, or inappropriate productivity standards may be a violation of payer rules, may be in conflict with state licensure laws, and may even constitute fraud."

    The statement provides examples of unacceptable practices and reminders on the importance of knowing all rules and regulations, following proper evaluation and treatment protocols, and completing all documentation. The statement encourages clinicians to take action if they encounter a billing process that may be suspect and are provided with possible steps to take in response to employer policies or practices that conflict with clinical judgment.



    The stories presented by Chris Hayhurst in the article outline the career experiences of many, probably most, Physical Therapists in 2015. "Top Jobs" seem to always list PT but the fact is that there are too few good opportunities for professionals. The trend towards heightened productivity negatively effecting job satisfaction is not a development lost on our patients. The real victims are our patients, as the dark side of heightened productivity expectations continues to be revealed - gaming archaic reimbursement methodologies. The public is increasingly turning to alternative providers where they can. Why would the public continue to trust us under these conditions? If there is a silver lining to this morass it's that the continued commodification of PT services is increasingly opening up the market for providers focusing on customer service. Imagine that? A healthcare provider focused on customer service? What a novel idea! Just as consolidation and standardization dominated other retail and service industries, counter trends focused on quality services and products become available to the public. It will be no different as courageous entrepreneurial PT providers seek to create work environments conducive to heightened customer service and professional satisfaction. Fiscally responsible returns can coexist with professional satisfaction and good service. I'm not certain however that quarterly earnings per share growth pressures can achieve the same peaceful coexistence. Just peruse the OIG's CIA (Corporate Integrity Agreement) pages. I continue to be confident that PTs will evolve opportunities that move away from systems that do not benefit the patient and our linked professional interests. The APTA has been critical in providing us the tools to create those systems.
    Posted by Joseph Libera on 6/27/2015 7:45:08 AM
    ".. important, but what is 'good quality'? In a lot of the profession, it's assumed to be 1 hour of 1-on-1 time with a single patient. Well, that may mean quality in our eyes, but it may not translate to value in the patient's eyes" SIMPLE , ASK THE PATIENT BEFORE THEY SCHEDULE THE FIRST VISIT
    Posted by jerry Durham on 6/30/2015 5:08:55 PM
    And Kudos To Joseph above for his thoughtful comment. Agree 110%
    Posted by Jerry Durham on 6/30/2015 5:13:03 PM
    As a clinician in my fifth decade of practice, this discussion is old news to me, but long overdue in our professional discourse. i have worked in every setting available to us - acute care, home care, ECFs, military hospitals, POPTS, my own private practice for the last 12 years of my full-time work. Now that I am semi-retired, I am employed as a PRN therapist for a local ECF corporation. My perspective is different from my much younger colleagues, since I work because I want to, not because I have to. First of all, I have to say that the contemporary P.Ts. with whom I work are as dedicated, compassionate, and empathetic as any in my previous experiences. However, they are under the daily productivity pressures described and are increasingly disillusioned by the trend. I hear the term "burn out" more and more. Working only a few morning hours a week, I am not subject to the degree pf productivity pressure. In any event, in discussions with management when my productivity has been questioned, I assert a degree of resistance and rebuttal not available to the full-timers by virtue of their job security considerations. I believe we, as physical therapists nationally, have been ill-served by the APTA regarding this issue. The national leadership should have been vigorously out front in resistance to quantity over quality.
    Posted by Herschel BUDLOW on 6/30/2015 5:30:09 PM
    I agree with Jerry. It's the patients who ultimately determine the value. It's dangerous to define value merely based on an outcome scale, which is largely determined by a self-report form. Not sure that is what anyone is recommending in the long run, but it sure feels like it. And to recommend a very low baseline from which value bonuses are added or underperformance penalties would be deducted would be very dangerous for patients and providers. Very low payment is largely what is causing the basic productivity standards to be put in place by some institutions. If an institution went too far overboard on their productivity standards, it seems like the free market would work it out- as long as there were no inherent conflicts of interest guaranteeing continued referrals to the practice despite the relatively poor care. I don't really understand what the goal is with this project.....Is this another way to back in standards of care for PTs and/or micromanage my practice? Private practices are already being told by some that they should not use aides for even menial tasks. On the other hand, many find that if aides are trained well they add to the overall patient experience. What I expect from my associations is to protect my patient and practice. Most I know do not need another guideline telling us how to run our practices.
    Posted by Paul Gaspar on 6/30/2015 8:48:15 PM
    On a second reading of my comments above, "The APTA has been critical in providing us the tools to create those systems." should read "The APTA has provided us with the tools to realize our values through excellent service to our patients" were I articulate or at least better rested :)
    Posted by Joseph Libera, PT on 7/1/2015 12:33:32 AM
    Either I did not catch it in the article or it is not mentioned, why isn't anyone mentioning the biggest expense to a business or department?- Payroll! If an insurance reimburses $50 per visit, and the treating therapist wants $30-50 per hour, plus factoring in the remaining expenses for that hour-supportive staff, insurance, utilities, rent, etc It is easy to see why productivity expectations are so high.
    Posted by Kamal Mody on 7/1/2015 7:51:13 AM
    The idea of measuring productivity by quality sounds good. This states that billing by the CPT code system doesn't do that. But it does not specify a workable alternative.
    Posted by Maureen Lyons on 7/1/2015 8:49:49 AM
    I have worked in the SNF for many years and am finding not only productivity standards to be an issue, but the dictation of which patients to be placed on caseload and length of treatment per session greatly affects the quality of care. I have also found it to be a problem when the managers dictate which patients are to be seen by which staff member, thus not considering the need for PT vs PTA treatment and judgement. It's been quite sobering learning that some companies no longer care about the skills and decision making abilities of therapists, preferring to place the profits ahead of the care of the patient.
    Posted by Anne Thomas on 7/1/2015 1:31:19 PM
    "Either I did not catch it in the article or it is not mentioned, why isn't anyone mentioning the biggest expense to a business or department?- Payroll! If an insurance reimburses $50 per visit, and the treating therapist wants $30-50 per hour, plus factoring in the remaining expenses for that hour-supportive staff, insurance, utilities, rent, etc It is easy to see why productivity expectations are so high." byKamal Mody - I agree. Recte dicis. Bene ais.
    Posted by Florida PT on 7/1/2015 7:16:58 PM
    Good points raised by all. 1. Wages are an issue as they compare to reimbursement. With associate degrees now being sought after by companies trying to lower costs the equity to education of a DPT is becoming unbalanced. 2. How services are modeled in a center (in-house vs contract)impact cost,productivity and overall expectations. 3. Dictation of how many minutes vs a patient's profile is what has triggered the incresae in audits as well as the changes in RUG system (COT, EOT, etc.) 4. EMR- the world of computerized documentation. This alone has slowed down the efficientcy of therapist not just on the dictation side but couple that with connection problems and you have added more wieght to a strained back trying to keep up to 85% direct billable time. In closing, we need to re-think the goal- which is outcomes- with patients, families, centers and our profession as a whole. This means setting reasonable productivity expectations,therapist accountability on quality and best practice,and reasonable wages (not going for the almighty dollar at all cost - in this case outcomes and best practice). I tell cadidates on interview- If you want the absolute highest wage- if a $1.00 an hour is more important than the envioronment and standard of best practice- than they are not the right person for the job. If a client wants productivity and highest RUG as the key measure to a departments performance than they too are not the right fit for our services. Believe in what you do, why you do it and ultimately that is where the reward lies. Business owner : Rehab consulting in LTC since 1999
    Posted by Jacqueline Rougeau -> BIWaAN on 7/1/2015 10:34:15 PM
    Bravo - Its unethical!
    Posted by Jens Olesen on 7/2/2015 2:59:15 AM
    It is not unusual in any service industry for labor salaries and wages to constitute the bulk of direct expenses. The time honored and immutable truth in services is that an hour billed requires an hour paid. Group treatment and a heavier reliance on PT extenders - PTA etc., notwithstanding. It's just unfortunate that at this point in our profession, we are all suffering (especially patients) from PT becoming a commodity. Quality simply does "not pay" in most settings under current payment methodologies. There are greater returns to the agency and therapist by squezzing an extra dollar out of productivity. This is changing, led by small entrepreneurial ventures. An interesting corollary to what will happen in service-related healthcare is what is now happening with craft brewers. They are disrupting the market of the large brewers through an attention to quality, good working environment, and local investment and involvement. Interesting how beer may hold some lessons for PT :-) I suggest we ponder that over a pint!
    Posted by Joseph Libera -> =FY\? on 7/2/2015 7:28:08 AM
    Unless the PT's are salary, which they are obviously not, having someone clock out to meet productivity during a cancel and continuing to work is against the law. Someone needs to file a class action lawsuit against this pmace, and obviously clean house with a new manager and director who have clinical experience or training. Sounds like someone there has friends in high places to get away with that. Measuring productivity is something all business need to do, however, the repercussion of not meeting productivity needs to be knocked down when your dealing with someone's healthcare!
    Posted by Renee Torres on 7/2/2015 12:40:40 PM
    Thank you for bringing light to a stressful, disappointing situation. The more it's discussed makes me hopeful a solution will be met. Our profession is hands on based on quality, not creative "point of service documentation for reimbursement".
    Posted by Barbara McLoughlin on 7/4/2015 8:45:52 AM
    As a partner in a private practice, this topic is at the forefront of every meeting. Just because we deal in healthcare doesn't exempt us from the realities and ultimately costs of doing business. The margins in physical therapy are just not what they used to be. The tighter regulations, lower reimbursements and higher payroll demands make a PT business a difficult balancing act. At the same time, I am not an advocate of placing unethical and illegal productivity demands on my therapists, as described in this article. It seems to me that the way we get reimbursed needs to accompany this discussion on productivity. Timed CPT codes are a major obstacle in achieving productive patient management. How can we be expected to freely make treatment decisions but only in 15 min intervals? Also, not every patient needs me at "contact assist" level supervision so why can't I manage 2 ankle sprains at once and not have to use a group therapy code? Bottom line is that productivity demands stem from financial restraints. So let's not discuss the symptoms and how about we go after the root? What ever happened to the alternate payment model APTA was working on?
    Posted by Bryan Lee on 7/5/2015 2:24:22 PM
    Yes Joseph, you are spot on! I am an OT with a small entrepreneurial venture called "Quality of Life Extension Services", disrupting the market in exactly the way you describe. If you are in the NY area on July 18th, I invite you to join myself and my nephew, a craft beer entrepreneur, as we do some business research touring some local craft breweries and continue our discussion of the very set of strategies you mentioned; attention to quality, good working environment, and local (community and consumer) investment and involvement. Whether you can make that date or not, please call in either event to discuss possibilities for potential collaboration. Cheers! 516.943.4396
    Posted by Ken Snyder on 7/6/2015 5:39:34 AM
    Reframe the Productivity Debate: Productivity, in business terms, equals billable time/total work time. This ratio is the rate a therapist posts charges for billing purposes. The term carries no clinical significance yet your annual review doesn’t go well if one falls below employer productivity expectations. Accordingly, the prized, “highly productive” therapist maximizes revenue for the owner/company. My professional aspirations clash strongly with this, cold cash, business as usual, spin on my therapeutic clinical efforts. I am a “highly productive” therapist when I provide maximum Value to my patient/client consistently. Wherein Value=Quality/Cost and quality has two components: outcomes and customer satisfaction. Productivity, in business terms, acts as a spur toward greater heights of revenue production. Productivity, in professional terms, is achievement of enhanced functional outcomes cost effectively. The professional side of this conflict will find more public support if we reframe the argument by redefining productivity in clinical terms. Who is a productive therapist anyway? In the eyes of the public, I’d wager, it’s the therapist that gets good clinical results at a fair price. Let’s reinterpret “productivity” to reflect the values PT’s aspire to. Let’s add a human face! Signed, Corporate Refugee PT
    Posted by Rodney Dennehy on 7/8/2015 11:55:14 PM
    Here is a simple solution--get a job that does not have unrealistic productivity standards. As a 20+ yr. PT that owns his own practice and was a traveling PT for years prior, there are these clinics in EVERY city. I have no sympathy for the PT that laments the stress of high productivity expectations, but won't cross the street to the clinic that does it right. Blame management, blame EMR, blame APTA, blame everyone except yourself. You are part of the problem or part of the solution.
    Posted by TeamJ on 7/9/2015 12:46:52 PM
    This is exactly what outcome measures are all about. Changing reimbursement to pay for outcome makes quality more important than quantity. This will improve the quality our patients receive and reduce the cost as over utilization, which is epidemic, a thing of the past. This will be a shock to many providers, but they need it.
    Posted by Timothy Hoerner on 7/9/2015 10:33:45 PM
    I am a 3rd year PT student in my final internship at a long term care facility/SNF and have seen the dark side of unrealistic productivity standards. This is my 3rd rotation in my education and finally have a clinical instructor who cares about value and putting evidence based practice into motion. However, because I need time learning the new facility and about the setting, my CI's productivity went down and her job was threatened. The regional manager states she doesn't care that she has a student, that learning opportunities and feedback need to be done during patient care as to not fall below productivity. Now, my learning to be a well rounded therapist is short changed. I find it so hard to swallow on how much I am paying for school, pursuing my passion to help others, and my teachable moments are being dictated by productivity. I'm learning that to maintain productivity and comply with point of service documentation, that I have to put a patient on a NU-step or LE bike, to meet that requirement all the while knowing a better intervention is well suited. I feel like I've just spent over $100,000 and countless hours studying to have that all go to waste. I don't feel like I'm doing anything skilled or applying any clinical reasoning when I have my hands tied with what I can do for my patients.
    Posted by Student PT on 7/20/2015 6:57:07 PM
    I have been a PT for @ 30 years and in private practice for @15 year. PT's salaries have almost doubled in the last 15 years and reimbursement has decreased @30%. Productivity and understanding the business of health are a reality for all of us.
    Posted by MaryEllen Axner on 7/20/2015 7:14:52 PM
    I have been in practice approaching 30 years. I owned and operated a rehabilitation organization for more than 15 years. We have been been pushed into this overall situation by decreasing reimbursement combined i with several mandates that make no sense clinically, professionally or financially. APTA and CMS has allowed the cap, one patient at a time constraints and cuts to reimbursements. The effect is that if we are only being reimbursed 60 dollars and god forbid work with two patients at once, we cannot produce a margin, How much does it cost. Medical Doctors are not restricted nearly as deeply when performing office visits and use much more logical and efficient methods which physical therapists have been forced to abandon. I believe we need to have stronger and better representation. One way is to lower the membership costs for APTA and then seek to have more PTs and PTAs at least contributing. We need to act as an entire profession. We suffer and as such I see things like putting a patient on a new step just to get minutes, when the functional or clinical value is another discussion for another time.Most important is that if revenue then increases for APTA, we need action not talk. How long has the ridiculous cap or the one patient rule been allowed to remain now? It comes down to money people. Unfortunately first is invested stakeholders, then the revenue source which are PTAs PTs OTs OTAs and SLP,s.Combine those with decreased reimbursemnts and crazy mandates and we arrive here. If we as a profession do not have competent representation and do not act, we will continue to complain on website forums until we don't have jobs.
    Posted by JCP on 7/30/2015 10:10:18 AM
    I appreciate all of the knowledge on this feed. Typically, therapists calculate productivity using units billed and hours worked. I've recently had productivity conversations with my HR director, whom is very knowledgable and respected, and he firmly believes that productivity is calculated not by hours worked but BUDGETED hours. To clarify, if a therapist is on vacation their productivity is 0%. I am in search of documentation supporting productivity calculation using hours worked.
    Posted by Karin Sykes on 3/30/2016 7:39:33 AM
    Thank you for this article. I have just been reprimanded for the nth time about my productivity. I work in a SNF setting and been called to the DOR's office several times in the past few months. My manager tells me that I am a good PT, that I am good with communicating with patient's family, Physicians, Nurses and CNAs but...my productivity does not meet the required productivity that the facility requires. That statement is always said in every time I am in the office. Then she would always threaten me with "If your productivity does not change, I will be forced to make necessary sanctions towards you". Yes, it always ends with the threat. I felt like the threatening was too much, I had to complain to the rehab's regional manager, still the same thing was said to me, that I am not meeting productivity. This is simply too stressful for PTs, OTs and SLPs.
    Posted by RGPT on 4/23/2016 1:10:40 AM
    the surgeons don't do surgery on more than one patient at a time. most people would probably not want their mechanic to work on their vehicle and another person's vehicle at the same time. having therapists see more than one person simultaneously is the therapist's fault for not saying no. as an OT, CHT, and pending manual therapist i have seen clinicians and middle managers sell out the profession and themselves by somehow thinking having therapists splinter their attention between two patients not to mention having basically double the paperwork to do be a therapeutic and sustainable set of circumstances. we are supposed to be skilled works who are advocates for the patients not meek puppets.
    Posted by ralph voorhies on 12/28/2016 12:23:55 PM
    Under the "Productivity Curse", a PT has 2 options: cheat yourself (work off the clock) or cheat the patient. The ethical therapist will cheat themselves rather than participate in false billing, lazy chart reviews and documention, and "convenient" interventions. It's ironic that the unethical therapists are the ones being praised by management due to their high productivity which occurs through less attention and devotion to patient wellbeing.
    Posted by NH on 2/26/2017 10:23:35 PM
    I do not think comparing productivity is a good solution to potential change, as mentioned several times, the therapists with “good “ productivity are more than likely commiting some sort of fraud during their day, while us therapists who are ethical are getting fired for believing and caring about what we do and our patients . Stand together therapists !!!
    Posted by Kim on 11/30/2017 7:07:38 PM
    HI there, I'm a business owner for a private pt,ot,speech practice in NJ. Is there a metric system that you utilize such as a FTE(therapy equivalent) measure for therapists to monitor productivity. I'dlike to talk to you further if you do. thank you
    Posted by davina on 1/30/2018 11:39:58 AM
    Folks, the fact of the matter is that we are not worth the hourly rates we seek. At least based on what insurance is wiling to pay. Lowering our rates is the only way I see that we can get reasonable productivity requirements. That's a painful reality, but every time productivity standards are raised we are, in fact, being given a pay cut. It may be time we adjust our income expectations (sadly...wow we are overeducated for that!) and relax our frenetic work pace. That, or go into private practice offering fee for service cash based service so that people can get real therapy. What we are doing now is a disgrace to the profession. Churning patients in and out and cycling them through. So many folks I've known have sought PT for pain only to be out on a bike x 15 minutes and given a few home exercises. Shameful! And we know it. But we are just trying to get through the day and pay our bills.
    Posted by Ginny on 9/12/2018 11:29:17 PM
    The current productivity standards used in the industry are unethical and are actually used to pressure staff in the unethical treatment of patients and/or unethical reporting of treatment times. For a honest and ethical productivity standard, you must include non-billable time for listening to and responding to voicemail messages, reading and responding to emails, non-billable documentation time, team meetings and care conferences (even when the prt cannot attend), consultations to other staff, schedule management, internet time (staff should have built in time to use the internet to optimize their understanding of conditions and treatments as they arise). The problem is that the standards typically count productive time only hands-on treatment time. That is the big lie perpetuated by the industry.
    Posted by JJ on 10/29/2018 7:18:04 PM
    I am a physical therapist first, and a manager second. While I have no intent on requiring certain time per visit or total number of visits for my staff, I also think that when we only talk quality vs. quantity. With shrinking reimbursements in which insurance only may be paying $40-$50/unit, a therapist seeing 12 patients/day for 30 min/visit generates $1,200/day, 300,000 per year, subtract out bad debt and denials you have roughly $270,000. Take out private billing fee rates of 5% now you have $256,000. If a f/t therapist makes $40/hr, that's $104,000/year. For a net of $152,000. Additionally factor in rent, malpractice insurance, utilities, support staff salaries and margin to reinvest in equipment and building upkeep and we can't be blind to the fact that actual volume of patients has to be taken into consideration. This is no different than other medical providers that we wish to emulate.
    Posted by EM on 2/26/2019 4:17:02 PM
    If requiring productivity standards is "possibly in violation of state laws and/or payor policies" I hope some definite answer to that is coming soon. My employer was bought out and the new company requires 30 minute treatment times for all outpatients regardless of diagnosis (including multiple body areas to treat or neuro), complicating medical conditions, mobility limitations. Expectations are to bill 3 units for each patient. Our productivity is solely based on units billed and hours worked. Part time PTs are to document on the clock but then that paid time is figured into the productivity for the day. It is a lose-lose. It's sad that the patient now comes last.
    Posted by JG on 3/27/2019 7:11:59 PM
    I practiced physical therapy for 12 years, and worked in the field as an aide for 5 years before that. After the "great recession" of 2007, there has been an increased focus on productivity. Essentially, most employers are pushing for the 80% benchmark. However, they only consider time you spend 1:1 as productive time. Any time you spend working on documentation, interdisciplinary communication, or patient communication is not counted towards productive time. Unlike any other profession I know, health care workers are subjected to this type of benchmark, essentially they are telling us that they won't pay us to do anything except see our patients, however if insurance claims are denied due to tardy or incomplete documentation, we are held accountable for it. Essentially, they are requiring 110% productivity. I've seen many therapists spend a good portion of their patients treatment time working on their documentation. I have heard from countless patients that they do not appreciate this type of approach, and see it as a sign of low quality. There problem is multi-fold. We have some therapists who "cut corners" by using treatment time to document, and we have others who are burning themselves out by staying late or getting stressed to meet documentation deadlines. Neither of these cases are ideal, however I argue that clinicians which continue to "cut corners" to meet productivity standards are seriously harming a profession. I tend to run in the school of meeting my patients needs, then worry about the documentation. It kind of makes me sick when I read comments like "seeing 12 patients a day is easy". I would have to think that either the patients in that clinic are really easy, or something is seriously lacking in the care you provide. We are the profession, and we need to preserve it. We shouldn't have to be 110% productiv
    Posted by Brent Perdrizet on 5/28/2019 8:45:17 PM
    Productivity is merely the number of minutes spent in treatment, divided by the number of minutes or hours you are paid for. Companies are productivity focused, they want to get the most out of your day. However, those treatment minutes don't take into account everything you may need to address, during the course of the day, in order to complete your treatments and address your pts. needs, such as pt. being ready for therapy, pt. needing to be transported to/from therapy, nursing issues affecting availability, family discussion not scheduled, communications with other medical staff, documentation issues that come up and are added to your day and the list goes on. The one thing that is always rewarding is when the patient says, I have no problem with Physical Therapy, its the other stuff that doesn't work well,
    Posted by Denise Jackson on 5/31/2019 11:56:38 PM
    I have seen this issue of productivity at all most all the nursing home facilities I’ve worked at. It is truly difficult to deal with ethical issues. But we must stand up and remember therapy is our patients best chance of getting home and gaining independence. .
    Posted by Lois Foreman on 9/4/2019 9:21:46 PM

    Leave a comment: