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  • WSJ Article on Nursing Homes Alleges Productivity Pressures to Bill for Ultrahigh Therapy Hours

    The volume vs value debate, long-familiar to physical therapists (PTs) and physical therapist assistants (PTAs), is now getting wider exposure by way of a recent Wall Street Journal (WSJ), article on the "copious" use of ultrahigh therapy hours billed to Medicare by skilled nursing facilities (SNFs).

    In a story published on August 16, WSJ describes results of an analysis it conducted on SNF billing patterns between 2001 and 2013, which found that the use of the ultrahigh category of rehabilitative therapy reimbursement—720 minutes or more a week per patient—has increased from 7% of patient days in 2002 to 54% of patient days in 2013.

    While the story acknowledges the benefits of rehabilitative therapy, describing physical therapy, occupational therapy, and speech therapy as often "crucial to recovery," it also cites interviews with "more than two dozen current and former therapists, rehabilitation directors, and others" who told WSJ reporters that "managers often pressure caregivers to reach the 720-minute threshold."

    These therapists and directors related instances of therapy "sometimes delivered even when patients are unresponsive, aren't likely to benefit, or have declined such services, at times distressing vulnerable patients," according to reporters.

    The article, which includes personal accounts of seemingly questionable care, points to an issue that APTA and its members have emphasized for some time: the obligation of the PT and PTA to bring their clinical judgment to bear in circumstances that open the gap between productivity demands and the actual value of those services for patients and clients.

    "Unfortunately, it's not uncommon for PTs and PTAs to find themselves in situations where they feel pressured to meet goals that are less about the patient and more about the volume of services provided," said APTA President Sharon L. Dunn, PT, PhD, OCS. "But we need to understand that every time we allow our education and clinical judgment to take a backseat to this pressure, we're potentially putting patients at risk—and our licenses on the line."

    This idea is at the heart of a collaborative effort by APTA, the American Occupational Therapy Association (AOTA), and the American Speech-Language-Hearing Association (ASHA) that produced a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)," which highlights the important role of the clinician in patient-centered outcomes.

    "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 theme is also central to the APTA Center for Integrity in Practice website, which houses information on how PTs, PTAs, and students can continue to uphold the profession's high standards. Resources include information on the recently released Choosing Wisely® list of "5 Things Physical Therapists and Patients Should Question;” a primer on preventing fraud, abuse, and waste; a free course on compliance; and other information on regulation and payment systems, evidence-based practice, ethics, professionalism, and fraud prevention.

    More on productivity: check out "Measuring by Value, Not Volume," a recent feature article in PT in Motion magazine that takes a closer look at how some PTs are responding to the challenge.


    • very very true-respectfully

      Posted by donna on 8/18/2015 8:58 PM

    • This article is full of so many truths that I have encountered in my limited experience as a recent grad. I have been working in SNF close to a year and have ultimately decided to leave for the very reasons outlined in this article. More and more the choices made in this environment seemed unethical and I worked so hard and place such high value of my PT license that I felt it was in my best interest to no longer associate myself with the establishment. It's sad because I so much enjoyed the patients! I guess it does make me feel that I'm not alone in noticing that things are not always handled appropriately by SNF managers when they do not place value on a therapists clinical judgment.

      Posted by Chelsea on 8/19/2015 12:17 AM

    • INDENTURED SERVITUDE--this is the reason for likely > 75% of the collusion , abuse/fraud/waste of the Medicare system, when it comes to the arbitrary cut off of 720 min/wk of therapy for patients who receive the "Ultra High" RUG level--by my account. This comes in 2 forms: A) the extraordinarily high cost to produce a new grad, and B) the relative ease of importing a lower-cost (foreign-trained) one. The cost of the DPT (start to finish) from those I've talked with can run one back about $100K now (so why would anyone go to work in a Hospital and make $27-28/hr). This places new grads in uncomfortable positions with employers, especially when one's salary (hours they will work on a given day) is based on patients being seen 720 min/wk--wether needed or not (I guess they could always go home early, but who'll pay their mortgage and student loans?). Regarding foreign-trained therapist, it is good to get an outside view/opinion for anything--i.e., think outside the box--even therapy. But I have seen varied practice that is good, bad (indifferent), and even ugly by foreign-trained therapists, new and old to the profession. For instance who would try to provide e-stimulation to a patient's tibialis anterior to address foot drop in a patient > 5 years out? The answer is the above: the INDENTURED THERAPIST (I've witnessed it, and been asked why I didn't consider providing it to my patients like others).

      Posted by Andy Harrison, PT on 8/19/2015 4:05 PM

    • I was so glad to see this article. During my observation hours I became aware of how some SNFs milk the insurance system by multi-booking therapists (at risk to their licensure) and bringing patients in for therapy despite the patient's inability or unwillingness to do anything - and billing for the time. Abuse of the system hurts everyone. Quality over quantity is generally less costly in the long run. I also noticed that some SNFs "force" therapists when mobilizing a patient using a gait belt, with or without a walker, to simultaneously pull along a wheelchair. Yikes!

      Posted by Perri on 8/19/2015 4:19 PM

    • I would suggest that one reason for the increase in the RU category is due to the fact that more and more diagnoses are being denied acute rehab and we are seeing many more short-stay, younger patients in SNFs. These patients are in and out in week or two and can tolerate RU. Our local hospitals are no longer sending joint replacements to acute rehab and this trend is going to continue with this new upcoming bundle payment system.

      Posted by Stacey Twoguns on 8/19/2015 4:55 PM

    • Medical business vs clinical judgement! Unless PT has a seat at the table where decisions are made this system will not have a chance to make any difference or change. It all comes back to recognition for rehab specialists other than MD/DO with PM&R cert. I applaud APTA for its tireless work on this issue. Thanks for everything.

      Posted by vrinda on 8/19/2015 5:30 PM

    • Hooray! Someone has finally recognized the problem with managers assigning RUG levels and expecting therapists to "do whatever you have to to get the minutes even if you have to go back 2 or 3 times". This type of pressure forced me to leave the LTC/SNF setting because I decided NOT to play the Ultra high game!

      Posted by Sherry Roberts on 8/19/2015 5:46 PM

    • This is absolutely true, and the reason I will never ever step foot in another nursing home agan. EVER... I think Medicare should crack down on this abuse of PTs and of pt's by big faceless corporate executives who care much more about the bottom line than they do about about people getting better.

      Posted by Paula A on 8/19/2015 8:05 PM

    • I have been working in SNF for 4 years now, a small fraction of my career. I struggle daily with the main issues in this article. I am unable to reconcile doing good for the patient and doing good for the company. money has to be made by the company so that it can continue to provide care for patients also so that I can make money. like most people who enter healthcare I entered the field to help people get better. No one works for free but at what cost should this really occur.There is an extreme pressure on therapists and assistants in SNF to make numbers and high utilization of the ultrahigh RUG. If after a week or two the patient is unable or unwilling to participate at this rate then dropping the RUG is considered. This practice is backward a patient should be set at a lower expectation unless clearly able to meet the 720 minutes, then ramped up as clinically appropriate. I agree with those of you who have stated that this is a misuse of the system and that it can lead to safety and legal issues.

      Posted by Megan on 8/19/2015 9:25 PM

    • and this is a surprise to whom?

      Posted by John Krug on 8/19/2015 9:29 PM

    • Great article on this subject. I was fired from my job for the exact reasons mentioned in the article. I know first hand how managers pressure the staff to meet these productivity expectations and when you don't meet them, you are given a written warning to "shape up or ship out". I stand by my beliefs that we as PTs are the ones to decide on type of care and need for services. I cannot in good conscience let a non-clinical manager or supervisor tell me how long I need to see a patient and how many visits they need for their care. We need to stand by this statement made above in the article "Respect for the therapist's clinical judgment and expertise is critical to achieving optimum patient/client care," This our expertise, not someone who does not treat patients.

      Posted by Gerald Pica on 8/19/2015 11:12 PM

    • I have a COTA friend who interviewed for a job at a SNF recently. In the course of her conversation with the administrator about expectations when scheduled minutes are not clinically appropriate the administrator asked why she can't you do therapy on a dying person.

      Posted by Ryan Murphy on 8/19/2015 11:31 PM

    • When a new director of rehab told me,"If you had seen that patient for 3 more minutes we could have captured $23.58- I called my office at the contracting company to get me out of there! It is now standard to expect 85% billable activity, at a minimum, regardless of paperwork needs, patient level of care needed, because it's all about the income produced. I am now happily retired and doing pro non very happily! I did not get into this profession to make money for a corporation but to help patients achieve their goals. Many times the pressure is huge to over treat or over bill. When the view is not the best care for each patient, the professional is forced to become a widget maker vs a healing influence.

      Posted by Laura Coykendall on 8/19/2015 11:33 PM

    • Agree completely with the comments regarding this issue of overuse of therapy minutes in SNFs. As a semi-retired P.T., I continue to practice a few mornings/wk as a PRN therapist for SNFs. There is continual overuse of all rehab therapies and essentially a corporate policy mandated productivity protocol that guarantees unethical practice. A truly professional initial evaluation is impossible to provide in these for-profit facilities. However, the practice of following a patient with a wheelchair during gait training/practice is not inherently wrong or dangerous if the patient is carefully selected and is judged by the therapist to be safe during the session. I disagree completely with the opinion that the wheelchair-follow by a single therapist is always incorrect. That being said, I and my colleagues have always been able to have another therapist/PTA/aide available to do the 'follow" if the patient needs closer guarding.I deal with productivity nonsense by doing what I feel is proper and when my productivity % is awful by corporate standards, I remind the department director that I work by choice -- not necessity.Of course, most employees do not have that option, but after 5 decades of clinical practice I am not going to practice by an unreasonable policy developed by corporate suits. The director can choose not to call me when they need coverage.

      Posted by Herschel Budlow on 8/20/2015 8:13 AM

    • We have to also ask ourselves why these patients shouldn't expect to have high volume therapy. The PPS system is not based on the patients diagnosis, acuity level, or discharge plan. It's based on how much human resource will be needed to assist the patient in reaching their goals. Essentially how much time does the individual therapist need to spend with the patient a day/week. In many SNFs therapists are seeing patients who mirror IRF admits. In the IRF they are required to provide 3 hours a day, how can you differentiate this need? Today the assessment of a patients need for therapy is a fairly subjective account, with ICD-10 the acuity will become more comparable. In conclusion the only real solution is to move into a value based reimbursement system.

      Posted by Billie on 8/20/2015 2:43 PM

    • There couldn't be more truth to this. This is why I won't work in a SNF again unless I can be a DOR to try and change things. RUG levels are one of the worst things someone has come up with. I think nursing facilities should be ran like inpatient care, you get as much time you can with a patient. I worked at a facility where 90% of our pts were ultra's. What happens is there's a lot of rest breaks when you "have" to get 90 min of therapy with just one discipline.

      Posted by Maggie PTA on 8/20/2015 5:08 PM

    • I agree with the article. Unfortunately skilled care has turned into a greedy, financial opportunity versus patient centered focus. While there are patients that benefit from 720 minutes many do not. However I feel the cause of this is due to multiple issues. The government has decreased payments for Medicare and Medicaid reimbursement so companies are trying to make up for that shortfall. Another reason is that most skilled facilities have contract companies running the therapy departments due to lack of knowledge of the therapy professions and the lack of ability to track all of the data needed for requirements such as ICD 10 coding and CPT along with G coding for the long term care residents. This leaves the rehab companies with increased overhead due to multiple layers of management requiring higher cuts for profit. Due to the lack of knowledge of the therapy professions the SNF listens to the contract company's promises of better therapy and more treatment without realizing the true nature of what they are getting. I have been disappointed in the number of therapists that choose to follow the RUGS and not their ethical and moral backbone on appropriate patient treatment. Unfortunately it leaves therapists like me ( a PT who believes in high quality of patient care based on my decision of the appropriate treatment and amount of time during treatment ) unemployed because I don't play the game.

      Posted by Anne Thomas on 8/21/2015 11:09 AM

    • As therapists we must each look at the treatments we are providing in SNF and Rehab settings. All too often I have seen therapists "walking" patients and not gait training. PT treatment should address those parts of rehab that an unskilled person cannot provide. Why are the skills of a PT indicated? Is the therapy challenging enough to allow the pt to achieve their goals in the shortest amount of time? Education of patient & caregivers: Have we provided excellent recommendations to the nursing staff for restorative nursing programs on the unit? Have we educated the pt & family to follow up on a floor program when they visit their loved one? Our role goes beyond what we provide in the "therapy room." As far as PT being indicated for an unmotivated patient: Many elderly patients decompensate when hospitalized or post surgery. The SNF model under RUGS to try to return these patients to their least restrictive environment is a good one if skilled services are provided with a total team approach. Only when the entire team(including family if available) is involved can one decide that therapy is no longer appropriate. Administration/management is not part of this team. As therapists it is our ethical responsibility to make these decisions as part of the team. Every elderly patient should be given a chance to improve. Every elderly patent that can achieve the ability to stand and transfer and use a toilet will be a patient who will avoid bed sores and decreased ROM, and all the problems that come from being immobile. Patent's with decreased cognitive status are able to receive rehab services. Only we have the skills to know how to prompt patients to stand, wight shift and provide gait training. I found working in a SNF, and as the director of rehab of a SNF to be the most challenging of my 38 year career. A SNF may be a for profit business, but as professionals working in a SNF it is our responsibility to ensure that the best physical therapy care be provided. For those who are being pressured, I would recommend speaking to 'management" and not compromise. Educate management and also make sure that every minute of your rehab session counts. If you are at a loss of what to do with a 90 minute session find a more experienced PT professional to guide you in how to schedule your day and your sessions. Yes the elderly do need breaks which may require patients to receive shorter but more frequent sessions.

      Posted by Vivian on 8/21/2015 6:55 PM

    • So much truth in this article. After experiencing the same, I am considering NOT being a PTA after just 4.5 years. I was expected to get high Rug levels and the next day, the patient would pass away. This happened to me at least four times and has left a lasting impact. I voiced my concern but it fell on deaf ears. I was also expected to get 90% billable time, causing me to work for free for multiple hours per day just to keep from getting the trickle down effect showered on me and the entire team. I entered this profession to help people and I love my patients. I encourage them to participate and rejoice at their milestones…but sometimes they should not be pushed.

      Posted by Unhappy PTA on 8/22/2015 11:29 AM

    • I am a new grad who has worked for 4 years in a SNF. I completely identify with the topics in this article and could provide multiple examples of each. I have had many experiences that have really made my skin crawl. One DOR actually said something to the effect of "we should get as many medicare dollars as possible out of _____," a pt who was 100 years old. The system is set up for directors to have extraordinary pressures placed upon them from corporate. It seems like everything Medicare tries to do to address the problem only makes it worse (COTs and RUGs and the complicated algorithm necessary to meet minute levels to get paid). Therapists are caught in the middle and also are asked to push the limits of ethical boundaries. I was once told by a nursing directer to "make sure this pt's rehab goes slowly". His priority was to maintain higher census. Again, therapists are caught in the middle and there is a feeling that if I speak up I could get fired for insubordination. Unfortunately this is standard practice, as I have asked other more experienced therapists if it is like this everywhere, I get the response that my company is actually a little better than most. I am making plans to change my career course and I've learned a lot, but I have a feeling I will not miss this area of practice. I enjoy working with older adults, but there are too many major problems and too much pressure to do things that I don't fully endorse. I get the feeling that they are looking forward to hiring another new grad that will be more "compliant" than I am. How do we fix this situation? It seems that the incentives are all wrong and the system is to blame. Bundled payments and incentives to achieve better outcomes in shorter time spans instead of counting minutes.

      Posted by This needs to change on 8/24/2015 2:12 PM

    • I've been working in SNFs for the past 25 years as a PT and as DOR. My experience (except for the brief time I worked for a contract company and quit for the above reasons)has been that since CMS created the PPS system, we have to play the game.......not to milk the system, but to get paid for the care we provide. If I provide an RU level of service for 5 days and the 6th day that patient doesn't feel well, should I fall short on minutes and not get paid for the 5 days I did provide RU level? What would anyone do if their paychecks were based on the same PPS reimbursement plan? For the most part, the short term rehab patients I treated, those hoping to return home, needed 2 hours of therapy a day - that's not that much with PT/OT and sometimes Speech. They basically do nothing the rest of the day. Comparing 2002 numbers with 2013 numbers is ridiculous, so much changed....the percentage of short term rehab patients compared to long term residents increased significantly. In 2002 much more short term rehab was done in hospital subacute rehab centers. We are seeing much more complicated, medically complex patients in SNFs now, and getting less and less money. The examples used in the Wall Street Journal were misleading to the general public. If your frail older demented father fell and broke his hip, would you want the SNF to say its not worth trying to rehab him? I've always given everyone the benefit of the doubt, if after a few weeks of good therapy there was no progress, then you have to discharge, but that time was not wasted. And sometimes it takes additional time to work with demented patients because they cannot follow directions as well. Dehydration is a common problem at end of life as systems are shutting down, would you have forced hydration into a dying man? I am saddened that it appears many therapists have had very bad experiences in SNFs. I would guess many of them worked for contract companies that have less investment in the patients of their clients and more investment in reimbursement. I've been very happy working in SNFs that employ their therapists directly. The PPS system has flaws, as did the fee for service programs. But, I'm more concerned about the games we may see played as outcome based reimbursement models develop. There are no easy answers.

      Posted by Sue Fitzgerald on 8/24/2015 5:33 PM

    • I TOTALLY DIAGREE WITH THE WSJ ARTICLE. I do agree that there is some abuse and it should be pursued and stopped. However, just as many of you probably would agree, I feel that therapy is a vital component to the recovery of a patient gaining their highest functional level and the large majority of therapists AND directors simply try to balance resources. Many patients could use more than 720-minutes/week but we are constrained by financial viability. The PPS 720 threshold tries to set the reimbursement for something that should be more fluid. CMS tried a more fluid system before when they had fee for service and patients would be treated 3+ hours per day with "abuse" viewed by non-therapy critics. Just like any resource, therapy has limits and value put on it. All we can do is try to be a patient advocate, treat appropriately, and push for proper reimbursement of our services.

      Posted by Curtis on 8/25/2015 2:48 PM

    • How about a more critical look at how the income of rehab managers may be enhanced by higher productivity? Isn't the employer at fault for creating this kind of conflict of interest, only few have the guts to stand up to for the sake of integrity? Very nice and well some rehab companies have shares and multiple managerial levels, but it's also a step up for those 'burned out clinicians' to do the minimum, receive a ridiculous pay, becuase they are allowed/ encouraged and choose to put others under productivity pressure in order to keep their positions. A lot of clinical PT's know that the RUG levels are stretched to the max and may very well either have a bad conscience or stand up to it. But people need a pay check, are on a workpermit and have greencards dangled in front of them on the condition that 'they play the game', because ambitious and/or unscrupulous rehab managers want them too. High time to look at the pyramid scam of rehab companies!

      Posted by ineke groenwold on 8/29/2015 1:07 AM

    • Do not discredit our profession and our patients. I think many of the nay sayers in this article are unhappy with their employers and as a result the patients may be paying the price. I have been a SNF and TCU therapist and manager for over 20 years because I love geriatrics. I truly believe that if you deliver the amount of therapy required to get the patient to the prior level of function without worrying about minutes or productivity it will always work to the patients advantage and the companies expectation. I work with a great group of interdisciplinary therapists that are ethical and are on top of their game. They have no problems calling me and our company out if we deviate slightly from an ethical practice. Many of them have been with us for decades and they are good at what they do. We continuously deliver over 850-900 minutes of therapy per patient per week if not more, and yet we know Medicare only pays for 720. We market on how we provide more therapy than what we get paid because we focus on results and a shorter length of stay. I don't ask the therapist to deliver that much therapy, they make their own clinical decision and we get consistent results. They also tell me when it's time to discharge a patient, when to give a Medicare denial, and when to recommend an alternate placement. Our productivity expectation is 75% and we hover around 74% for all disciplines combined. I recommend you focus on the well being of the patient and helping them return to a functional status. If you deliver quality care and evidence based care you should have no problem treating a patient for a one hour session per day. Medicare is paying for 24 hours of skilled nursing home care yet many of the comments are balking at 60 minutes of therapy per day. That is 1 hour out of 24 for your skill and professionalism and probably the reason they are there. How is that ethical? We should be providing more so they can leave the skilled service faster and ultimately save Medicare dollars by needing to stay fewer days. A good therapy session should last between 30 and 45 minutes twice a day, if the patient can tolerate it. Anything less you are just wasting time and achieving minimal outcomes. I do agree that some patients are not appropriate, but I also believe that most patients and their families would want to return to an independent level of care. Don't let your employer dictate the quality of care. Quantity can be trumped with quality easily. You all seem very experienced and knowledgeable. Focus on your patients; they need you as much as you need them.

      Posted by Henry Lozano on 10/15/2015 11:09 AM

    • Would I be able to simply say, this online journal is the thing that got me as the day progressed today.

      Posted by warmheartassistedliving.com on 11/1/2015 4:58 AM

    • School therapists are now being harrassed by advocates, teachers, administrators, and parents to provide unwarranted services in the educational setting where they would not benefit from the services nor is it educational but their expert opinion is ignored and a team of individuals who are not therapists are determining how you will practice that conflicts with the therapist's practice act. It is becoming epidemic. And if anyone says they want an advocate, no one supports the therapist and unethical services are being provided without question.

      Posted by so true, now infecting school based services grump on 1/12/2016 10:45 AM

    • We are missing the forest for the trees. The fundamental issue goes beyond providers to the health care environment in this country, i.e. health care for profit. These enormous productivity requirements are generated by the need for for-profit health care corporations to generate acceptable returns for their shareholders. Not only do we need to generate enough revenue for the company to survive and serve patients, but we need to enrich investors. Therein lies the reason for promoting nationalized health insurance: removing the investor from the equation!

      Posted by Norm on 1/18/2016 8:00 PM

    • High productivity demands in the nursing homes are driving therapists insane! The " make your 8 hrs or go home" mantra by rehab managers is putting a lot of pressure on PT's especially those who are the primary breadwinners of the family. You either end up using PTO to make up for lack in pay ( and resulting waste of vacation/personal/ sick days) or find a per diem position which isn't always available at the spur of the moment. A losing proposition for most PT's in nursing homes. Despite the nursing homes aversion to overtime, they refuse to have us paid as salaried employees instead paying us as per hr employees and taking advantage of the low census ( which happens more often now with intense competition among nursing homes) as an excuse to kick you to the curb every chance they can get. Take note this doesn't happen to nurses who are assigned shifts and stay the whole shift regardless how many patients are there. My advise is to get out and stay out of nursing homes!

      Posted by Joey Torres on 6/6/2016 8:33 PM

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