James M. Berklan

As if therapy providers haven’t been squirming enough like 6-year-olds in wet, itchy sweaters during the run-up to the PDPM era, now comes research that could add a few porcupine quills to their discomfort.

Scientists are publicizing study results questioning the use of productivity goals. The implications, to put it politely, are not good.

The key finding is that physical therapists whose employers emphasized productivity goals over evidence-based practice were six times more likely to report “high frequency of observed unethical behavior.”

Overall, 89% of the 3,400-plus respondents said they observed unethical behavior of some kind. On the plus side, most (69%) reported it happening “rarely” or “never.”

But it’s not good for skilled nursing respondents, the biggest sub-group (754) of respondents. Most were Texas PTs and assistant PTs filling out an online survey.

Clinicians in SNF settings were four times more likely to report high frequencies of unethical behavior than all other settings, said lead researcher Justin E. Tammany, PT, DPT, SCD, MBA, an assistant professor of therapy at the Holland School of Mathematics and Sciences at Hardin-Simmons University.

Tammany said he hopes that shining a light on results will help eradicate questionable practices.

“It’s kind of the dirty little secret that everybody knows is going on,” he told me this week. “But clinicians are feeling powerless to do anything about it. Maybe it will help with some data on it. Clinicians can be in a tough spot if they [superiors] tell you, you have to [make a quota].”

Three-fourths (74%) of all respondents had a formal goal set by an employer. That meant measurements by units-per-billable hour for 85% of them. Moreover, 83% said that productivity goals influenced their clinical decision-making.

Tammany said his undergraduate work was in psychology so he was fascinated about learning the motivation behind some troubling therapy practices. He also said he wanted to get findings out in the open before the Patient-Driven Payment Model goes into effect October 1. PDPM eliminates therapy being paid by the minute, something Tammany said has compelled a lot of bad behavior.

SNF therapists registered the highest levels of bad behavior in every category, although only by a narrow margin in “allowing an employee to perform tasks outside scope of practice” (34%).

On average, they were the worst, and twice the median average of seven other settings, in “Inappropriate frequency, intensity or duration of services” (86%). It was nearly as bad for “Counting treatment time that is not permitted by payer sources” (75.6%). SNFs also were the worst at “Discharging patients inappropriately” (88%), “placing patients on caseload who do not meet skilled criteria (88%) and “Falsifying or changing documentation” (51%).

“The skilled nursing specialists tended to report the highest rates across the board, and they also have the highest productivity standards,” Tammany noted. He said the number one complaint from physical therapists is the imposition of such standards, and the fact that PTs have little or no say in setting the standards, which they usually see as too high.

Ending the dollar-chasing

He noted that “a lot” of previous studies have already shown that PT utilization has closely followed reimbursement incentives. In other words, prescribing has changed based on reimbursement structure. He expects it will happen again under PDPM, though regulators say they will be watching closely to discourage such behavior.

To skeptics, Tammany and colleagues’ findings simply put another log on the bonfire. It’s a blaze that has helped burn fee-for-service as payment model — as well as numerous therapy providers and their leaders who have wrongly exploited the system. There have been numerous notorious cases of suspect or downright unscrupulous therapy operators who have performed services under some kind of quota or productivity rewards system, and not necessarily what’s in the best of the patient.

The black eye to the industry, and that means the broader long-term care rehab and therapy environment, has been a blot that has driven many regulatory changes. Heads must be nodding throughout the halls of the Centers for Medicare & Medicaid Services over this study’s findings.

“Hopefully, by adding evidence, it will stop incentivizing purely on the quantity of treatments,” Tammany said. “You have quality when there’s not so much pressure to see everything at the Ultra-High rate all the time.”

Of course, with PDPM stripping away the minutes-for-dollars structure, the pressure should naturally be much less to breach ethical norms. But Tammany maintains that due to a dearth of quantifiable information, his study — “Are productivity goals in rehabilitation practice associated with unethical behaviors?” — is not a case of coming late to the party with unneeded information.

(It was discussed in a poster presentation in late January at the American Physical Therapy Association meeting and is currently under production to appear in the Archives of Rehabilitation Research & Clinical Translation, an open access journal produced by the American Congress of Rehabilitation Medicine. In the meantime, a submitted version is available online here.)

The goal is to improve for the future. “Interventions should be targeted at the organizational level, since this and other studies have found that organizational culture is the top antecedent to unethical behavior and is also the most easily changeable component,” study authors noted.

The solution might lie with therapists themselves.

“Ultimately,” Tammany said, “it may come down to clinicians putting down their foot and saying they’re not going to follow these organizations rules that are clearly unethical or not in the best interest of patients.”

While PDPM could be the antidote, it’s also no time to back off on vigilance against unethical behavior, Tammany said.

“Part of the issue is anytime reimbursement changes, we come up with a new rate and fudge data or do a workaround to increase reimbursement,” he explained. “It would be a great thing when that’s not an issue any more and there’s more of a push for quality-based reimbursement.

“I work with students and we tell them to listen for how much a company brings up productivity standards and how much they bring up the idea of productivity in a job interview, especially those involved in skilled nursing.

“We want them to go in with their eyes wide open.”

Follow Editor James M. Berklan @JimBerklan.