Ethical Considerations is a monthly series looking at ethics in elder care and therapy. Often ethics are talked about in hushed voices; however, ethical concerns are something worth speaking about. This series (occurring on the first Tuesday of each month) will update you on what is new in advocacy and offer recommendations for getting involved.
Managing the transition from volume to value: Productivity standards
I attended the “Managing the transition from volume to value: Productivity standards” webinar (April 2014) offered through the American Physical Therapy Association’s Learning Center. With my interest in SNF ethics and the current involvement of ASHA, AOTA, and APTA in addressing our concerns with SNF ethics, I expected different content in this webinar, but there was still some worthwhile information. Unfortunately only 8% of the attendees registered as SNF therapists, so I wasn’t the target audience. The webinar was led by two physical therapists. James Dunleavy spoke about the actions of the APTA Acute Care Section of the Productivity Task Force. Lynn Steffes spoke about changing the definition of value in the private practice setting, an inspirational webinar for private practice owners. I will focus on James Dunleavy’s section regarding acute care therapy for this month’s Ethical Considerations.
Dunleavy started the webinar with an example of “really good” productivity where services were provided in the highest quantity and fastest/efficient as possible, but in the end the patient dies. While this would be considered good productivity, it doesn’t consider patient outcomes at all. Dunleavy proposed changing our language and redefining the value therapists provide in the acute care setting.
“We have to blow up our perspective of productivity in acute care environments. We need to look at the healthcare system in new ways. We need to find points in the system that we can make a difference. And bring the concept of value and new definitions to the professional approach to this issue.” – James Dunleavy
I agree. Our language needs to change. Productivity has become a four letter word, meaning little to patient outcomes and much to company’s bottom lines. Both speakers in the webinar argued for a perspective of value generating care rather than revenue generating care, especially in the acute care setting where the Medicare payment structure doesn’t pay extra for services like therapy.
Dunleavy quotes Michael Porter’s article “What is value in healthcare?” from the New England Journal of Medicine (12/23/2010):
“Value should always be defined around the customer, and in a well-functioning health care system, the creation of value for patients should determine the rewards for all other actors in the system. Since value depends on results, not inputs, value in health care is measured by the outcomes achieved, not the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is value measured by the process of care used; process management and improvement are important tactics but not substitutes for measuring outcomes and costs.”
The Acute Care Section of the APTA Productivity Task Force has been working on a variety of goals including developing a new paradigm of acute care value measurement, creating a position statement on productivity in acute care, identifying the value of therapists within the health care system, and creating a tool that “integrates cost of service, patient severity, intensity of services, and patient outcome measures that produce a measurement of value to service to patients, facility, and healthcare system.”
The tool being developed by the APTA Productivity Task Force will help determine which patients we provide the greatest value to, which patients gain little from our services, and determine prognosis for patient function.
I would also like to note, I paid $99 to participate in this webinar, because I felt this was important information to share within the therapy community as we work together to improve elder care. I believe this information should be shared by APTA, AOTA, and ASHA with members as a part of our membership fee. After all, they are reporting on what associations are doing (with our member fees) for our professions.
Medicare Guidance for SLP Services in Skilled Nursing Facilities
If you haven’t had an opportunity to check out the resources that ASHA has been adding to the website, make sure you check out the Medicare Guidance for SLP Services in Skilled Nursing Facilities. This is the type of information I asked for when I met with ASHA staff members and board of directors at the members forum at the 2013 convention.
I encourage you to use this information as talking points with your employers to advocate for elder care. It is also a great resource for clinicians who don’t understand Medicare’s Prospective Payment System for part A benefits. At the beginning of the document ASHA writes:
“Medicare guidance for Part A services is found in the Resident Assessment Instrument (RAI) Version 3.0 Manual. The manual provides specific direction about therapy services in Chapter 3, Section O. Even when institutional policies are based on Medicare guidelines, the interpretation and implementation can differ from facility to facility or manager to manager. SLPs should become familiar with the manual rather than relying on interpretations from others.“
I know, I know. That’s the kind of thing that drives many of you crazy. We’re looking to ASHA for answers and ASHA tells us we’re responsible for familiarity with the manual “rather than relying on interpretations from others”. Are they just passing the onus onto us when we’ve asked for help? But let’s put managers, directors, corporate, etc. in the place of “others”. Now it makes sense, right?
And I agree with ASHA. We need to know Medicare guidelines and interpret them in a way that honors our practice and patients. Does anyone know of a good study guide or walk through to accompany reading the Medicare guidelines? Should I create one for you? I would love to hear your feedback before I get started on a guide.
Those who watch a spectacle share in the guilt of those who create it
I stumbled upon this post and knew I had to include it in this month’s Ethical Considerations. I must warn you. The introduction is beyond words. Disturbing is my best attempt. Some topics are hard to deal with, but read through to the end. It’s worth it. (Go ahead and read it then come back.)
Several things struck me. First, it made me question my inclination to donate my body to science. Second, when in doctoring/healthcare professions do we separate ourselves so much from our patients that we allow these types of things to happen? Third, are those that watch the spectacle of Medicare Fraud/Abuse and poor elder care share in the guilt of those who create it? In my personal experience the answer is yes. The guilt I felt working with some teams made me sick. When I found out that the administrators at one building celebrated when a patient reached 100 days under Medicare part A (therefore maximizing reimbursement from that patient), I felt sick to my stomach.
Stay tuned for the rest of the month as we discuss death and dying on the blog. A month focused to death and dying has been on my publication calendar for months and as it approached I found so many podcasts, articles, videos, etc. to really help us dive into this difficult topic.
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