Like many speech-language pathologists, Rachel Wynn took up the profession because she wanted to work with adults who needed her help. It wasn’t her first career—but when she discovered she’d need a master’s degree to continue in her original career of university admissions, she looked for a new field. She’d always enjoyed getting to know people, finding out about their difficulties, and guiding them toward personalized solutions that would improve their lives in meaningful ways. So speech-language pathology—with its focus on one-on-one treatment—seemed like the perfect choice.

But what Wynn experienced in the first week of her clinical fellowship at a skilled nursing facility stood in stark contrast to the work she’d imagined—and forever altered her view of the profession.

“When I graduated, I had no idea what to expect working at a skilled nursing facility,” Wynn says. “I was told I would have a week of observation and training. I actually had about a day. I saw patients the next day … and by day three was working like any other therapist on staff. I was completely unprepared.”

Soon it became apparent that Wynn’s employer expected her to complete documentation on her own time, and spend her time on the clock working to meet the facility’s 85 percent productivity requirement (85 percent of time on the clock must be spent in face-to-face treatment). Every patient was categorized as needing the highest level of rehabilitation services; all patients received speech therapy—whether they needed it or not, in Wynn’s clinical judgment; and managers overturned Wynn’s decisions not to treat certain patients, altered therapy minutes in Wynn’s documentation, and asked her to limit her evaluation time. Managers even denied her recommendation to discharge a dying patient.

Wynn may have been a novice clinician, but she wasn’t wired to wilt under organizational pressures, however concerted they appeared. When her protests went unanswered at the facility, she contacted ASHA ethics staff, as well as the Medicare fraud hotline and Texas Wage and Hour Board. (She was later advised by her U.S. congressional representative that despite the lack of response from Medicare, the agency does collect and record these complaints.)

Unfortunately, there was little either organization could do to help—beyond recommending that Wynn hold tightly to her professional ethics in all such situations. So Wynn took a drastic step: She quit her clinical fellowship two-thirds of the way through and finished it at another facility.

But she often thought of the patients with whom she worked. The one she’d twice attempted to discharge, only to have the patient be reinstated by her managers both times. The patients nearing the ends of their lives who’d been given therapy regardless.

“It’s appalling,” Wynn said, “that we’re treating elders this way.”

Payment and productivity

Why are treatment conditions so appalling—in Wynn’s parlance—in some skilled nursing facilities? The push to provide high levels of speech-language treatment and occupational and physical therapy stems from Medicare’s reimbursement system. SNFs receive reimbursement for therapy services under Medicare Part A (covering inpatient services and hospital stays) or Medicare Part B (covering medical or outpatient services), depending on the patient’s status.

Part A (which covers a significant number of SNF patients) pays facilities a daily rate that covers all patient expenses, including speech-language and other therapy. In this system, each patient is classified into a “resource utilization group”—known as a RUG—based on an assessment of how much therapy and other services the patient needs. The patient’s RUG determines the daily reimbursement rate. More therapy and other services equal a higher RUG which, in turn, equals a higher daily fee to the facility.

Only face-to-face treatment time counts toward the patient’s prescribed therapy minutes. (See “How Medicare Reimbursement Works in SNFs” for more explanation.)

Medicare instituted this system in 1998 to control upwardly spiraling costs. But third party-evaluations reveal flaws: A 2012 Urban Institute report to the Medicare Payment Advisory Commission notes that “the system did not accurately pay for nontherapy ancillary services [and] encouraged facilities to provide therapy services for financial, not clinical, reasons.” And as early as 2001, an Institute of Medicine report on the overall U.S. health care delivery system found “substantial evidence documenting overuse of many services—services for which the potential risk of harm outweighs the potential benefits” (see sidebar).

SLPs and other therapists see the effects of this payment system daily in some SNFs. Many report pressures to provide services to patients who don’t need or want them, and to maintain prescribed productivity levels that may approach 100 percent. “Productivity” includes only face-to-face time with patients, because other activities do not count as “therapy minutes” under the Medicare RUG system. SLPs must complete thorough documentation to justify treatment, plan treatment, consult with other health care professionals, educate family members, get from one patient to the next, even use the restroom in the remaining time. In an eight-hour day, a productivity requirement of 85 percent—common in many facilities—leaves 72 minutes for all these activities.

Some SNFs are trying new models to ease productivity pressures, but given the economic incentives, productivity is king in many SNFs.

The rule, not the exception

Wynn isn’t the only SLP in a skilled nursing facility experiencing pressures and frustration—far from it. In October 2013 she started a blog, now incorporated into her Gray Matter Therapy website, and in November spearheaded a letter-writing campaign to ASHA, state organizations, legislators, company ombudsmen—anyone who would listen. “It’s not an isolated problem,” Wynn said. “It’s the rule, not the exception.”

Lending weight to Wynn’s claim, physical and occupational therapists also report feeling productivity pressures. Maureen Peterson, chief professional affairs officer of the American Occupational Therapy Association, and Anita Bemis-Dougherty, clinical practice director of the American Physical Therapy Association, have received a host of similar concerns from their members.

Wynn drafted a form letter for other SLPs to draw from that outlines general concerns with SNF working conditions: lack of respect for SLPs’ clinical judgment, productivity demands, decreased compensation and increased expectation to provide one’s own materials. Wynn encouraged letter-writers to note that many SLPs are quitting their jobs—with no other employment—and clinical fellows are being hired to fill the positions.

The letters ASHA received describe situations that run the gamut from illegal to unethical to inappropriate—but all bear an uncomfortable similarity to Wynn’s travails during her clinical fellowship.

“My soon-to-be-former employer rejects my requests to discharge patients who have met their therapeutic potential or who are simply no longer candidates for therapy.”

“I have to treat every patient at an ultra-high minute level, and less minutes are not an option … and then, ultimately, I can only accept a patient refusal if the patient is dead.”

“I—as well as the occupational therapist and physical therapist—was forced to see a patient who was unconscious and dying for hour-long sessions.”

“I confirmed that my manager had increased my minutes on a patient to bump that patient from a ‘very high’ to ‘ultra’ billing category. Luckily, I was able to switch the minutes back myself and avoid any fraudulent billing.”

Productivity demands

Unrealistically high productivity expectations—often 85–100 percent—are a major concern among letter-writers. According to Wynn’s letter, the time does not include necessary nonbillable services including conducting Medicare A evaluations, speaking to nurses, calling families, consulting with colleagues, charting, and conducting and attending in-services and meetings. Employers are increasing productivity expectations and tying them to pay, noted some letter-writers, but these employers don’t provide sufficient resources to make the expectations feasible. Specific instances include:

“They determine how long each patient will be seen each day—and it varies greatly from day to day—based upon how many minutes each discipline needs in order to keep each therapist ‘productive’ at a 90–92 percent expectation for an eight-hour work day, while keeping each patient at the highest possible reimbursement level.”

“Rather than dealing with daily reprimands about productivity, I usually clock out to do documentation, make family phone calls, and even go to the bathroom. Working off the clock is disrespectful to the profession as a whole, though it’s the choice some of us feel forced to make.”

“I have responded to the increasing pressures by putting in more hours off the clock to complete all of the job requirements that simply are not contemplated in my employer’s definition of 92 percent productivity.”

“I was reprimanded at one facility when I did not meet their 85 percent productivity standards because I took 40 minutes on the clock to read therapy and chart notes on the seven patients I was treating that day in order to give them the best treatment possible.”

In response to the letters, ASHA hosted an online chat on Dec. 12, 2013, “Employment Issues in Long-Term Care: Productivity, Ethics, and Fraud”. More than 200 SLPs logged in to express their concerns; the flood of more than 650 comments was too great for the moderator to post them all. The chat had been replayed on ASHA’s website 425 times by the end of March.

Although not all chat participants expressed productivity concerns, most did, and they voiced frustration at not being able to find help. Addressing this concern, Janet Brown, ASHA director of health care services in speech-language pathology, noted that the association “is not a union and cannot arbitrate on [members’] behalf. However, we develop resources that are on the Web, and are happy to consult with you on the phone or via e-mail” (see sidebar).

In March an extensive thread sprang up on the Special Interest Group 13 discussion board on the ASHA Community, with nearly 50 health-care–based SLPs chiming in to recount their experiences completing documentation off the clock, being asked to provide inappropriate services, or otherwise grappling with their facilities’ high productivity requirements. Again, not all of the posted experiences were negative, but the responses paint a less-than-rosy picture of therapy services—primarily in skilled nursing facilities.

These complaints aren’t merely anecdotal: At least two lawsuits allege that companies filed fraudulent Medicare claims based on artificially high therapy targets—Life Care Centers of America in 2008 and Aegis Therapies Inc. in 2010.

According to court records from the Aegis suit, whistleblower Ricia Johnson said she “witnessed Aegis’s physical therapists negotiating over who would get to claim Johnson’s time as their own that day in order to meet Aegis-established individual productivity goals.”

Court documents also indicate that Life Care set aggressive targets for “ultra high” therapy levels “that were completely unrelated to its beneficiaries’ actual conditions, diagnoses or needs.” The company allegedly pressured therapists to reach the targets through corporate presentations, visits from top company officials and action plans for underperforming facilities.

Productivity perspectives

Given health care’s ultimate goal of improved care and the recent push toward patient-centered care and measurable patient outcomes, many ask whether higher productivity requirements are the best way to achieve these goals. Experts and professionals weighing in on the issue, however, have opinions that range from total rejection of productivity measures to enthusiastic support, albeit with a few caveats.

Medicare doesn’t issue productivity guidelines or recommendations; the facility or its rehab contractor set them. At their best, productivity requirements increase efficiency and are calculated to allow therapists time for other tasks in the building—consultation with professionals and families, documentation and so forth. But when productivity requirements rise as high as 100 percent, therapists state that they cannot provide the best treatment possible for the patient.

SLP Michael Hoeft maintains that the debate itself is useless. “As long as skilled nursing facilities see productivity as a good thing,” said Hoeft, director of rehabilitation at Redington Fairview General Hospital in Skowhegan, Maine, “you can’t win,” even if you include other tasks in the productivity formula.

“The industry is in a death spiral,” Hoeft said. “To get productivity up, managers cut hours, and send therapists home based on the patient census. It’s wrong for the staff: It kills morale, because therapists never know how much money they’re going to make. It’s wrong for the organization: Employees leave because they don’t like the work environment, and then capacity drops,” he said.

The bottom line? “It’s dangerous to look at labor as a variable cost,” said Hoeft. “People are not variables. People are your programs.”

Garry Pezzano, Genesis Rehab Services senior vice president for clinical practice, disagrees. “Productivity as a measure is not new to any service organization,” he said. “The asset is staff, the product is service, and one measure of performance is productivity.”

Pezzano, an SLP and president of the National Association for the Support of Long-Term Care, says that Genesis—which provides therapy services to 1,600 facilities in 46 states—doesn’t have a published productivity requirement. “The expectation is, on average, 75 to 77 percent. We have invested in electronic documentation and handheld devices to make bedside documentation more feasible. There’s a communication system built into that so that therapists don’t have to make as many return trips in between patients. We don’t measure or hold people to productivity levels, but we do have a guide for best practices.”

However, Pezzano also notes that Genesis department managers receive bonuses based, in part, on their staff’s productivity.

But Genesis also has demonstrated commitment to measuring patient outcomes: It is the first health care provider to participate system-wide in ASHA’s National Outcomes Measurement System. Genesis has embedded the NOMS data collection elements—including functional communication measures—in its internal system, and is working with ASHA to build a mechanism to export the data into NOMS.

To economist Gail Wilensky, a senior fellow at Project HOPE and former senior health and welfare adviser to President George H.W. Bush, productivity’s benefits or disadvantages are an empirical issue that depends on how the requirements affect quality of care. “What metrics do we have to show that increased productivity requirements lead to declines in quality?” Wilensky asks. “Productivity can be improved and result in improved quality of care.”

With health care reform calling for even greater reimbursement reductions, Wilensky sums up the health care environment as “tough ... doable but tough.” And although she supports productivity measures as a means to provide better quality care, she cautions that the way each facility sets up its practices has a big effect on outcomes.

Costs and quality aren’t necessarily trade-offs, Wilensky says, and it makes sense for facilities to measure productivity to improve care. “But,” she adds, “you must include outcomes.” Looking for improvements and decrements in outcomes, and adjusting for health risks, are crucial. The question, Wilensky says, is “How do we have the process function efficiently, yet encourage the best health outcomes?”

But to Hoeft, productivity does not necessarily equal efficiency, especially in a service-oriented field such as health care. “I have never seen an organization be highly successful—in terms of patient and public perception and financials—by turning to a productivity approach,” he said. “Productivity requirements are arbitrary figures. Why specify a [productivity] number? There’s no math formula that defines which is best. It sounds like more is better, but that’s the first mistake: Productivity does not equal efficiency. Productivity numbers don’t correlate with anything.”

Carving a new model

Recently, several organizations have partnered, chisels in hand, to effect change. In 2013, the Centers for Medicare and Medicaid Services contracted Acumen LLC and the Brookings Institution—an independent D.C. research and policy think tank—to help them explore alternate payment systems for skilled nursing facility therapy services. The recently released Acumen report identifies two payment model concepts for development and analysis.

The first, the resident characteristics model, uses existing practice patterns to develop an empirical model of the relationship between resident characteristics and expected costs of therapy care. The second, the hybrid model, uses a case-mix classification system but combined with a resource-based pricing adjustment.

When contacted, the CMS press office declined to answer questions about how nonbillable patient-related tasks and Medicare documentation burdens affect productivity, and whether the SNF reimbursement system incentivizes facilities to classify patients in higher RUGs than appropriate.

Some providers already do things differently, based on the concept that better patient care—not productivity requirements—leads to better outcomes, which in turn lead to satisfied patients who recommend the facility to others, driving up revenue. Janet Mahoney—CEO and founder of health care start-up Arete Rehabilitation in Amesbury, Mass.—is recruiting therapists, and so far she has been “inundated with applications from SLPs who want to work with a different philosophy,” one that values the highest-quality services over the amount of time spent with patients.

Arete Rehabilitation contracts with skilled nursing facilities—one, so far—to provide therapists. The contract is based on staffing needs and patient census over the past 12 to 24 months. “As volume ramps up,” Mahoney said, “our cost remains the same, allowing the facility to make money.” Mahoney believes facilities will achieve growth, not in spite of her therapists’ increased ability to spend on nonbillable clinical tasks—but because of it.

For Mahoney, professionals of varied fields collaborating on the best-quality care is a better efficiency indicator than artificial productivity requirements that are, Mahoney said, “a detriment to quality, to patients, to the facility. Patients don’t receive the highest quality services we can provide.”

Other facilities’ stories bear out Mahoney’s philosophy. Michael Hoeft of Redington Fairview General Hospital said that, “Regardless of payer source, the factors of financial success are completely dependent on the success of being able to create—in the patients’ perspective—a high-quality institution and, therefore, a high-quality therapy program. You’ve got to get the patients in the door, and they have to exit saying, ‘I had a good experience, and I’m going to tell everyone about it.’ You don’t want negative comments, which spread 10 times more quickly than positive ones.” Hoeft took that very pitch to Redington Fairview’s administration and convinced them they could make more money without a productivity requirement than with one.

The results were even more positive than Hoeft anticipated: The hospital’s therapy department has seen good financial returns by focusing on building a stable, long-term, high-quality therapy program—one that focuses on retaining talented staff and providing outstanding patient outcomes. The therapy staff has grown from six to 40, and they’ve seen steady growth in patient volume and customer satisfaction scores. Hoeft explained, “You recruit good therapists by creating a good home for them. Give them the tools and atmosphere to do the great work they’re trained to do. No productivity requirements—just happy patients—will make money. Excellence is the key.”

Loretta Wright, director of rehabilitation at Frasier Meadows retirement community in Boulder, Colo., is encouraged that SLPs are voicing their concerns so strenuously. With regard to service provision, “in the last 10 to 11 years,” she said, “the amount of arm-twisting in long-term care has ramped up markedly.”

When Frasier Meadows considered bringing in a management company to handle therapy services, Wright and her co-director presented an alternate plan. They would hire a full-time SLP and set their own productivity guideline, with the understanding that hitting a given productivity number wasn’t always feasible. As a result, revenue tripled, and they were able to bring in more Part A patients. Among patients, Frasier remains a sought-after facility—maintaining, on average, a 95–98 percent census—with low staff turnover.

“People who are discharged from Frasier Meadows tell other people about their care. And when those other people land in the hospital, they tell the discharge planners that they want to go to Frasier,” Wright said. “There are a lot of [skilled nursing] choices here, but we’re always full.” The gains made by individual facilities may be heartening, but they don’t help the SLPs working under productivity pressures who have bills to pay and families to support. In some locations, the facility might be the only source of SLP employment. And some SLPs are hesitant to complain about such policies, fearing they’ll be fired. What can you do if your facility is the only game in town?

“Go for the low-hanging fruit,” Wynn suggests. “Take on one thing each month: I’m going to do full evaluations, or I’m not going to work off the clock, or I’m not going to provide therapy to someone who doesn’t need it. It’s a huge problem, and we need to chip away at one little block at a time.”

Why Some SLPs Work Off the Clock Because of productivity expectations, some SLPs complete tasks on their own time. At 85 percent productivity SLPs must provide direct treatment for 408 minutes in an eight-hour day, leaving 72 minutes to complete nonbillable tasks. At 90 percent productivity SLPs must provide direct treatment for 432 minutes in an eight-hour day, leaving 48 minutes to complete nonbillable tasks. At 95 percent productivity SLPs must provide direct treatment for 456 minutes in an eight-hour day, leaving 24 minutes to complete nonbillable tasks. Nonbillable tasks Gather materials and walk to each patient’s room.

Persuade patients to agree to come to the treatment session.

Call families for status updates and discharge planning recommendations.

Attend care plan meetings with families, nurses, social worker, physician and others.

Screen new patients or those flagged by nurses.

Complete documentation for evaluations, treatment sessions, discharge summaries, weekly progress notes, 30-day recertifications and other patient activities.

File copies of documentation in paper charts.

Attend therapy team meetings to collaborate to improve patient outcomes.

Consult with other professionals about complex patient cases.

Educate nurses and assistants about diet texture changes.

Review patient reports from modified barium swallow studies, prior speech-language treatment, gastroenterology, otolaryngology and other specialists.

Solve problematic behavior and communication challenges, and train nurses and assistants to implement strategies.

Conduct staff in-service training to ensure appropriate referrals and provide appropriate cueing and assistance to maximize safety and independence.

Troubleshoot computer and documentation software issues.

Copy and prepare materials for treatment.

Read e-mail and written notes from managers.

A Call for Health Care Change Concerns about U.S. health care delivery are not limited to rehabilitation or to skilled nursing facilities. The delivery system has “floundered in its ability to provide consistently high-quality care to all Americans,” stated a far-reaching and pivotal report from the Institute of Medicine in 2001. “Between the health care we have and the care we could have lies not just a gap, but a chasm.” The Institute of Medicine is an independent, nonprofit organization that provides advice to decision makers and the public. The 2001 document, “Crossing the Quality Chasm: A New Health System for the 21st Century” called for fundamental change to close the quality gap and recommended a redesign of the American health care system to one that is safe, effective, patient-centered, timely, efficient and equitable. In one of its five agenda items, the report calls for a framework that better aligns payment and accountability incentives with improvement in quality, noting there is “substantial evidence documenting overuse of many services—services for which the potential risk of harm outweighs the potential benefits.” Any new payment framework should reward high-quality care and foster value-based, effective care—regardless of whether the care environment is competitive or regulated. Payment systems should be patient-centered, evidence-based and systems-based, and should: Provide fair payment for good clinical management of the types of patients seen.

Allow providers to share in the benefits of quality improvement.

Allow consumers and purchasers to recognize quality differences in health care and direct their decisions accordingly.

Align financial incentives with the implementation of care processes based on best practices and the achievement of better patient outcomes.

Reduce fragmentation of care. The report noted that incremental improvements could strengthen quality in existing payment method but that real change will come only through more significant reform. “With this conclusion, the Institute of Medicine explicitly recognized—more than a decade ago—that financial incentives need to be aligned with achieving high-quality patient outcomes,” said Margaret Rogers, ASHA chief staff officer for science and research. “Under this type of pay-for-performance system, there would be no incentive to provide services that may be unnecessary or ineffective, as is unfortunately encouraged in current fee-for-service systems.” — Carol Polovoy

ASHA Efforts and Resources Inflexible productivity requirements affect more and more clinicians in health care and pose a potential threat to patient care and clinician satisfaction. ASHA is working to raise awareness of the risks of excessive productivity requirements on quality health care. For more information on these issues and a host of helpful resources, see “The Push to Preserve Clinical Judgment,” The ASHA Leader, Feb. 2014 and “Audit-Proof Your Documentation,” The ASHA Leader, Aug. 2013.

Author Notes