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  • Too Much Focus on Productivity Increases Risk of Unethical Behavior, Say Researchers

    Employers that overemphasize productivity goals over evidence-based practice (EBP) may inadvertently set the stage for unethical behaviors by physical therapists (PTs) and physical therapist assistants (PTAs), say authors of an unedited new study published ahead of print in Archives of Rehabilitation Research and Clinical Translation. Organizational culture, say authors, is "the most easily changeable" factor in promoting ethical behavior.

    In an email survey, researchers asked licensed PTs and PTAs in the state of Texas about their practice settings, their employers' use of productivity goals, and observed unethical behaviors, such as inappropriately discharging patients or falsifying or changing documentation.

    The majority of the 3,446 respondents were women (70.5%) and had been practicing an average of 15 years. One-third of respondents were PTAs. The most-represented practice settings were skilled nursing facilities (SNFs) (23.1%) and private outpatient clinics (17.7%).

    Their findings include:

    The majority of employers set formal productivity goals. Of the respondents, 73.9% said their employers set productivity goals for them. Of that group, 85.1% indicated that the goal was based on billable units per hour. However, 54.5% said they had no input into the goal-setting process.

    The use of productivity goals varied by setting. SNF clinicians were most likely (97.1%) to report having productivity goals, while school system PTs and PTAs were least likely (13.2%). [Editor's note: an accompanying table in the unedited article includes different percentages.]

    As the rate of expected productivity increased, so did the rate of observed unethical behaviors. Of all respondents, 53.3% indicated their productivity goals were difficult or very difficult to meet, and 60.2% felt they were high or much too high. Most clinicians said that productivity goals influenced their clinical decision making.

    SNFs had the highest prevalence of observed unethical behavior as well as the highest frequency of each behavior. PTs and PTAs in SNFs were 4 times more likely as those in other settings to report having observed unethical behavior.

    Overall, unethical behavior is not widespread. While a majority of respondents had observed unethical behavior, 68.6% reported observing it "rarely" or "never."

    However, workplace cultures emphasizing ethics are not common, either. Only 38.9% of respondents said their organization's culture emphasized ethical practice, far below the business average of 66%.

    Focusing on ethics and evidence-based practice may discourage unethical behaviors. The degrees to which an organization emphasizes ethical and evidence-based practice were negatively associated with observed unethical behavior. Employees whose organizations emphasized productivity over EBP and ethical practice were, respectively, 6 times and 3.39 times more likely to have observed unethical behaviors.

    One of the contributing factors to unethical care is a payment environment that results in patients and clinicians being "disconnected from negative consequences" over overutilization, say authors. They write, "Historically, utilization of rehabilitation has been highly influenced by financial incentives, with significant variances in factors unrelated to caseload such as geographic location and payer source."

    Authors explain that business pressures toward overutilization often are accompanied by a gradual shift in the attitudes of clinicians, who "justify overutilization of rehabilitation services by portraying it as meeting their patients' desires or sustaining their own livelihood." This "moral re-construal" in turn paves the way for unethical behavior, with clinicians and patients seldom experiencing the results of overutilization, given the typical health care system with its long gaps between service delivery and payment.

    Given the ways business decisions can set the stage for unethical behavior, change must take place at the organizational level, which also happens to be "the most easily changeable component," researchers write. Among their recommendations: Survey employees about the ethical climate and organizational behavior; avoid the use of productivity standards based on billable units; and involve clinicians in developing productivity goals.

    "Use of productivity standards measured solely by the quantity of billable units is not advised," authors write. "We recommend that clinicians are involved in the setting of productivity standards."

    APTA members Justin Tammany, PT, DPT, MBA, ScD; and Janelle O'Connell, PT, DPT, PhD, were among the authors of the study.

    The issue of productivity pressures is at the heart of a "Consensus Statement on Clinical Judgment in Health Care Settings (.pdf)" collaboratively created by APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. For more on productivity, check out "Measuring by Value, Not Volume," in PT in Motion magazine.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • I hope this paper gets some real editing before any more re-post/print. The headline is extremely misleading without any clear stats to back it up. When there are stats in the article their meaning is skewed towards the article title in a sensational manner. Posting this article with this title misrepresents what the vast majority of PTs do and how they behave. I am disappointed the APTA would publish this on their website without a full edit or even a basic statistical check or interpretation.

      Posted by Nick Weber, PT on 3/23/2019 8:51 AM

    • What is going to be done about this situation? SNF's want the PTA's to be 90% productive. This is extremely unethical. Rehab companies are only concerned about how much money they can make. They do not care about the clients and workers.

      Posted by Ivyrose Goswick on 3/23/2019 9:39 AM

    • Finally, someone is bringing attention to this problem! The APTA needs to protect all practitioners from being used as cash cows. We also need standards for the number of PTA’s one PT can supervise. Today’s productivity requirements do not allow a PT to do all that is necessary to complete their job ie chart reviews, attend family conferences, review PTA charts etc. Nonbillable necessities! Most LTC therapists are clocking out and staying late to complete documentation. I LOVE LTC and is the reason I became a therapist 33 years ago. I left LTC because of observed unethical behaviors..in fact, therapists don’t help each other out as much (with a tough transfer, or gait) because they can’t account for their time (nonbillable). I have loved my profession, but given the changing culture, I’m glad I’m not entering the profession today. I have 4 children, none of whom are PTs. Thank you for this article!

      Posted by Sharon Kanz on 3/23/2019 11:14 AM

    • I applaud this work. As chair of the Value/Productivity Task Force of the Academy of Acute Care Physical Therapy, I have had many calls from colleagues related to this. The academy has a position statement that these kind of measures are not accurate. That productivity in healthcare is different and must be blended with cost effective outcomes

      Posted by James Dunleavy PT DPT MS on 3/23/2019 2:12 PM

    • I hope talking about this continues. Several years ago as a travel PT, I had an assignment in SNF to which I ended up leaving early because of unethical behavior. It went so far as to be fradulent with the PTA documenting “in” times before she was even in the building! I reported two therapists to the board and Medicare but there was nothing done as far as I can tell by looking up their licenses. So it won’t get better unless there is accountability. And this behavior was fueled by the “100%” productivity standard.

      Posted by Christine on 3/27/2019 5:07 PM

    • Overall, I must agree with Nick Weber. And in addition, do you know or have you studied the other side of the issue. As a staff therapist, I see other staff rush to clock in, then slowly doff their winter boots and coats, donn their shoes, put their lunch in the fridge down the hall only to return to check in about last nights personal happenings with any of the other 9 staff members who will listen. And leaving the facility in the same reverse manner. None of which is patient care or caring related. We get paid a hefty fee to work and to help improve systems not drag them down. Wasting 30-40 minutes of an 8 hour day plus our breaks are hard to watch. The liabliity risks and the overhead to provide us with updated inservicing and necessary electronics and support costs money. There are many sides to why some have low productivity.

      Posted by Karlene Guay, PT, MS on 3/27/2019 5:43 PM

    • I agree with Nick that the title of this article is misleading, inflammatory and, basically not true. What this article really says it that payment structures influence specific settings and business models to put undue pressure on therapist to provide inappropriate care. The title of this article makes it seem like holding therapists accountable to patient care as the primary focus of their time at work is in-appropriate. I would challenge any worker in any industry not to have a baseline measure of what quantity of work is expected of them. That is the real world!

      Posted by Karen Green on 3/27/2019 6:39 PM

    • As the primary author of this manuscript, I can say that the title of this article and summary accurately reflect the findings of the study. Please follow the link to the journal above to read a more in-depth analysis of the research methods and findings. Thank you to the APTA for sharing.

      Posted by Justin Tammany on 3/28/2019 12:31 PM

    • This has been a blight on our profession for years! I am glad to see it is finally being brought to light. Too often this encourages over billing, up coding and extended off visits that aren't necessary. I believe moving towards a case rate system with assurances to achieve a certain outcome level is needed to begin changing this behavior.

      Posted by Kay Scanlon on 3/28/2019 12:48 PM

    • Interesting article. I recently wrote my state board with an ethical concern regarding a prevalent practice pattern to reduce the PT:PTA ratio. In the area where I work, there are rehabilitation contractors who dictate that a PT will evaluate the patient and be treated by PTA(s). This practice precludes that the patient does not require the expertise of a PT. Patients are treated like a number. This practice pattern violates the “soul” of the APTA’s principles.

      Posted by Nona Sheridan, PT, DPT on 3/28/2019 6:41 PM

    • We definitely need to look at this issue more seriously, and I am happy it is getting more exposure in print. We do not work with widgets, and we should not categorize patient treatments according to a recipe of treatment procedures and the amount of time we spend with each patient. If we are to be truly autonomous-our judgments need to be based on what we see and what the patient may or may not be able to tolerate-whether it is in OP, acute or LTC. We understand businesses and hospitals need to make money in order to survive, but basing what we do on what we see and what EBM says about treatments is much more ethical than saying patient "x" needs 60 minutes of treatment every time they come is not necessarily evidence based. Please keep monitoring this issue and keep us informed on your findings.

      Posted by Gerald Pica on 3/29/2019 1:45 PM

    • As an owner of a small PT clinic in a small town for 19 years I see my expenses go up, reimbursements go down. I certainly dont want a practitioner coming in and wasting time. In order to make payroll and pay the bills you must have a productivity rate. Employees should understand the expenses and bottom line. Salaries based on productivity are an excellent idea, with proper oversight on ethical billing etc. PT is a challenging field and requires hard working work ethic. Where we have gone wrong is getting rid of PT techs who can provide ancillary assistance. I still use them, mainly for cleaning, setups and taking patient's throug exercise though unable to bill for this. They are almost always kinesiology or other science based students so very motivatedm. Insurance companies would rather we always use higher paid professionals meanwhile decreasing reimbursements. We are going the wrong direction. Anyone who thinks there is cash cowing going on is not in upper managment or involved with the with the finance side. PT while it used to be a profitable business, is less likely so and you must be frugal with every dime you spend. It should be profitable, to ensure all employees are paid as they deserve. Office staff included.

      Posted by Suzanne Graves on 3/29/2019 8:28 PM

    • I agree with the article. Finally, someone started to talk about it. Productivity?! It kills the profession of Physical Therapy. Moreover, what it means is very often scheduling four or three patients per hour and expecting to bill for skilled therapy service ( read time-based CPT codes) more than 1 units minimum for each patient. Perhaps in addition to auditing overutilization of service, auditors should also look for disconnection from the number of patients scheduled during the day and numbers of time-based units billed by single PT/PTA. Is this still the elephant in the room?

      Posted by Greg on 3/30/2019 5:13 PM

    • I work in home care for the last 28 years. I’m seeing more demands in documentation and the same reimbursement to the clinicians. This process with productivity standards makes the practioners unable to put hands on as much if the treatment blocks are barely 30 minutes with vital signs, medication reviews, and ER or fall reporting as we are required by CMS. Im not sure what the answers are, but I hope it comes from within the profession. I’m stsrting to feel like a robot.

      Posted by Claire MullinPT,DOT on 3/30/2019 6:36 PM

    • As a SPTA who has had the opportunity to work in a SNF, I have have already witnessed individuals billing/using certain codes just to meet productivity standards and because, “if I don’t, they (their boss/company) will find someone else who will). I believe this is something that not only needs to be addressed by us (PTs/PTAs), but needs to be taken to the insurance level. Also, to comment on a remark that was made earlier, I don’t think this is leading to pt.’s being treated as numbers (the PT/PTA who does that is going to regardless of productivity guidelines). Thanks for reading :)

      Posted by Rhoads, Jacob on 3/31/2019 12:25 AM

    • I was in the hospital three times in 2018. I am a physical therapist but I do not practice. I am 83 years old. At one hospital I had the meanest and angriest therapist Ive ever seen . I was afraid of him. At another hospital, and after I had had a mild stroke, a very tiny PT came to see me. She asked me to walk with her. No evaluation, no questions. I was afraid to walk with her. I was very, very weak. I asked for a walker. I asked for an itemized bill when I was discharged. I was charged for $400, for a PT evaluation. All of my experiences were negative. I had a positive experience with a PTA from the Visiting Nurse. I could provide other examples equally as disappointing and sad. this is a complicated problem. It starts with the institutions starting PT schools to generate financial resources. There is a severe faculty shortage. if a mediocre program begins and admits mediocre students, the graduates are mediocre. there is more but I'm finished. Thank you for the article. Lets "shine a light on iI " as we used to say when I was a health poilcy analysist with Senator Kennedy, in the United States Senate.

      Posted by Patricia Yarbrough on 4/1/2019 2:42 PM

    • I agree with Sharon Kanz comments. I've have been a PT for 33 years and in the last 5 years or more I have seen these changes where productivity and bottom line are more important than patient care. I've mostly worked in outpatient rehab clinics and it's happening there as well as hospitals and SNFs. It is appalling that we are forced to do 1/2 hour evals now heaven forbid the patient is late or is a complicated case and see 3-4 patient's an hour who are see the majority of the time by the aid because the therapist is too busy and maybe can give 10 mins on hands treatment. Yet bill for an hour eval and 45 min follow ups. I was laid off from my last employer after a merger who implemented these policies and gave incentive bonus to the PTs at the end of the month for meeting there productivity. The problem with that is the patients don't benefit with unethical care and billing, only the company does plus the therapist are run ragged now in this mill type environment. This unfortunately has become the norm and the new grads don't know any better and except this type of practice now in PT. Unfortunately the majority of the public is not aware of this either and also thinks this is the normal of how to be cared for from a PT. It saddens me that this has happened because I loved being a PT but would not recommend this profession with the current changes I have seen. I wish we had a union through the APTA so this abuse would be put to a stop for the PTs and hold employers accountable for uneithical practices.

      Posted by Cathy Boppert on 4/2/2019 11:39 AM

    • I'm pleased this article is sparking conversation. I have been treating patients for the last 18 years as a physical therapist, with the last 8 years in my own private practice. All that time I paid my employees, and my clinic bills, but was unable to afford to pay myself when I was the one working seeing all the patients. Thank God for my husband who had a very good job and paid the bills at home. Why do it? Because I LOVE what I do. I also have the unusual background of having worked for an insurance carrier, processing claims and investigating fraud, for 10 years prior to entering PT school. Not much has changed since then. Physical therapists have not had an increase in reimbursable codes (97140, 97112, 97110..etc.) since the late 80's. Evaluations, the most important part of treatment, have been drastically cut. We need to wake up! Private practices are having trouble making ends meet because of constantly decreasing reimbursement. Reimbursement is driving this crazy train, my friends. Direct Access is a very good thing, but we need to increase worth for our services in dollars though negotiating reasonable payment for our services. We also need to refuse participation with carriers that pay cut rate fees. Medicare should be the gold standard for payment, and yet some practices accept 50-60% less to see patients. The hole we are letting them dig for us is getting deeper. I can tell you, from experience, that insurance carriers have meetings every day on how to make their investors happy and give bonuses to their corporate leaders; a portion of this involves cutting PT payments; each code is gradually going down in value before our eyes. One dollar here, a 5 dollar decrease per visit there, I could go on. It all adds up. I happens every year. Since I have been submitting my own billing I noticed the gradual decline in reimbursement per code, and this has become a very sad and scary trend over the last 8 years. It has been happening longer than that. Most PT's are not aware of this, but it is very real. PT's should be paid based on the skill they bring to the office, not on productivity. If working part time, they should be paid for the hours they are working, not on how many patients they see. Trust me when I tell you that payment based on productivity encourages insurance fraud, and you won't know about it until that certified audit letter is received. The PT, even as the employee, is held accountable if they signed that treatment note, because they hold a professional license to practice and services were billed under their name. I'm not advocating support of employees that punch the clock and waste time, that is a separate issue and is a behavior that must be addressed because it hurts everyone. Paying a licensed professional based on productivity, however, is not fair to the patient, and the resulting care contradicts the reason we became PT's in the first place.

      Posted by Marie Francis on 4/2/2019 11:51 AM

    • These comments are a welcome sight: others are seeing it too. I've been a PT for 49 years, and some of my recent observations make me seethe. Productivity is only a small part of what is happening at the LTC rehab department where I occasionally work per diem. No details here, but it's awful sometimes. I'm sorry to see the results of this research, and sad to think about some professionals who worship the almighty dollar. We need more ideas for change, and the willingness for some of us to push for it!

      Posted by Barbara Melinek on 4/5/2019 5:15 PM

    • Marie Francis- you hit the nail on the head- your comments above are exactly what is driving this issue.

      Posted by Kim Gerling on 4/8/2019 9:57 AM

    • The system is unethical, because the circumstances are unreasonable. Evidence based care is no longer the driving force behind PT, because reimbursement and restrictions in patient care time and models limit care delivery. We're forced into a 45 minute intervention by CMS on fear of OIG investigations and that just isn't enough time. We're forced to spend more time on documentation than at any time in history. We're forced to receive full payment for only the first 15 minutes of care. As a profession, we've seen nothing but declines in reimbursement since the early 1990's. Since 2005, reimbursement has declined by at least 50%. Rehab delivery is a financial loss to be managed by nearly every business in medicine. It didn't use to be that way back in the 70's and 80's. Apparently, we aren't valued by society. That is the story.

      Posted by Brian P. D'Orazio on 4/14/2019 10:10 AM

    • Kudos to the authors of this article for bringing forth this festering problem in our profession. I have been a PT for 30 years and work as part clinician and part management at a subacute rehabilitation and SNF. I have loved every moment of my professional life and continue to enjoy my work. Sad to say that over the years I have seen a decline in the way healthcare is delivered in our field with the ever growing burden of documentation required in LTC setting and unrealistic productivity standards set by employers. The other very big price we pay as professionals is the personal stress level that we as therapists experience in meeting these guidelines. I feel that innately as professionals our hearts and minds are in the right direction and most of us are passionate about our profession as seen by the comments and feedback above. The personal stress arises from constant inner turmoil of meeting unrealistic expectations of productivity, the passion to do right by our patients and meeting our own internal moral and ethical compass on a day to day basis. The question arises on how should the performance of a therapist be judged? Just by numbers churned out or by the quality of care and patient outcomes? Are other healthcare professionals judged by the same parameters? Are we going to end up as machines churning numbers at the risk of providing “run of the mill” Care ? or as true clinicians and professionals who would pay the price by burning the candle on both ends, using personal time to complete documentation or other duties (that were done by our ancillary staff) and feel that we are “not efficient enough”? With due respect to business owners and managers , to run a successful viable organization, accountability from the employees and standards of productivity are important and needed without which patient care would also suffer. It would be interesting to know the beliefs of clincians on realistic productivity guidelines in the LTC and subacute rehab settings. Productivity guidelines set by corporate level managers who are not hands on and donot experience day to day hurdles and challenges will tend to be unrealistic as when remote decisions are made there is always a sense of dissociation from reality. Would having employers use the feedback of their frontline staff in setting productivity standards help in reaching a happy medium?And finally, what will happen to our profession if students, new graduates and older therapists like me get disillusioned and change professions or settings and/ or advise their loved ones not to pursue PT as a career? Our patients will pay the price in the future. I agree with the comments from Sharon Kanz, Nona Sheridan, Cathy Boppert and Marie Francis and feel that something at an organizational level or as a standard for the LTC industry needs to be established to ensure our well being as professionals and for patient care. Radhika Gandhi, PT, DPT

      Posted by Radhika Gandhi on 4/15/2019 11:09 PM

    • I support the comments by my colleagues here. Bringing these issues to light I hope will bring appropriate change for the best interest of our clients and professionals. We need to continue our efforts in research, promoting and delivering best practices with our current evidence, and demonstrating effective outcomes and recognizing those colleagues who work hard at these daily in all practice settings. Mary Ellen Pellman, PT, DPT

      Posted by Mary Ellen Pellman, PT, DPT on 4/16/2019 7:40 AM

    • I had my own practice for almost 30 years and have now joined corporate PT. The biggest change I see is that patients are slid into whatever clinician slot is available. There is virtually no continuity of care. The advice and guidance of a single PT/PTA is not carried over treatment to treatment, and, of course, what the patient says one day is different from what they tell the PT the next day. In my very long experience it takes regular treatment to treatment advice and supervision to ensure a patient is reaching optimal rehabilitation.

      Posted by Bruce on 4/23/2019 6:38 AM

    • I agree with so many of the comments above including those from Marie Francis, Sharon Kranz, Cathy Boppert, Brian D'Orazio, and Radhika Gandhi. I loved my profession with a passion and always strove to be the very best. Probably spent a couple hundred thousand dollars on courses, books, journals, videos, etc. over my 41 years in practice to develop and refine my knowledge and skills. But reimbursements have gone down, down, down while insurance CEOs and executive board compensation packages have gone up, up, up. As long as we're willing to be doormats, we will be walked on. We need to organize, fight back, and oppose this financial tyranny like the unions did in the early 20th century. Those unions organizing led to the rise of the middle class in this country and one of the highest standards of living in all of human history. Unfortunately, APTA has been of shockingly little help in opposing the tyranny. They teach us and prepare us for how to adapt to it but not how to overthrow it. As for me personally, I'm done. I retired two days ago. And I can't tell you what an unbelievably fantastic feeling it is to know I'll never have to deal with this soul sucking bureaucratic nonsense and spend evenings and weekends doing mind numbing paperwork ever again. I used to wholeheartedly recommend PT as a career. I don't any more. It's a crying shame. And apathy on the part of so many therapists is partly to blame.

      Posted by Brian Miller on 5/31/2019 11:28 PM

    • I saw a similar article in 2014 and NOTHING has been done about it. Crooked companies is the new America but I want my slice of the pie without working through lunch! This field sucks anymore.BURNED OUT!!!

      Posted by Amy Bevard on 7/5/2019 6:12 AM

    • So now, in some places, 120% productivity is being required with some Rehab companies. I haven't seen how The APTA has improved any Therapist Work Life. I've been waiting to join. There's no proof of improvement. Where are the Lobbyists?

      Posted by TC on 9/28/2019 3:22 PM

    • Acute care facility I work at is asking 100% or more actually cause we have to cover for the techs that are included in our productivity???

      Posted by CS on 10/18/2019 5:07 AM

    • Unethical behavior is encouraged in SNFs. High productivity standards, low levels of support staff, and supervisors who are “strongly encouraged” to achieve high RUG levels(no longer, thank the lord), and high productivity. The fraud runs deep on all levels.

      Posted by Harry on 12/4/2019 12:02 AM

    • Before the new payment model (PDPM) was introduced rehab companies wanted to bill as many minutes as possible so they could make more money. They would say whatever they needed to justify billing more minutes. Then when PDPM was introduced the rehab companies all of sudden wanted to justify spending as few minutes as possible because payment was not related to minutes spent.

      Posted by Andrew on 2/7/2020 5:13 PM

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