We’ve all heard the Nietszche quote: “He who fights with monsters should be careful lest he thereby become a monster. And if thou gaze long into an abyss, the abyss will also gaze into thee.”
When those at the mercy of the healthcare system stare into their own abyss, what do they see?
Do they see their immediate mortality, defined and determined by third-parties, or do they see their future full of promise and extended functional mobility, resumption of independent living, and renewal of their prior life styles?
Various insurances have compelled rehabilitation services to focus on Prior Level of Function when determining the value of the services provided. Sometimes a patient can’t achieve PLOF, but what if your patient can exceed PLOF if given the opportunity and the optimum care?
The problem is that there are currently insurers who will allow rehabilitation to continue up to and only until the PLOF is regained.
For example, let’s look at Mrs. Johnson. She lived alone in her two-story home for the last 25 years. Her husband is gone, the children grew up, and she now lives in her recliner, with a bedside commode right next to her. She has her TV remote. She has her light switch. She has a walker that she uses only to transfer to the bedside commode.
This patient, who was “independent” at home has become dehydrated and her electrolytes are awry. She has rhabdomyolysis from inactivity and is in acute renal failure. Of course, don’t forget about the bilateral knee replacements she had four years ago.
Now that she’s in the hospital, she’s getting therapy every day for three days. She’s about to become our SNF patient, and her treatment diagnosis is debility. Between the extended inactivity at home and the three-day hospital stay, along with all the comorbidities and weakness, she’s going to need at least four weeks of therapy.
After three weeks of therapy, she has regained her PLOF. That’s correct: She can transfer from the recliner to the bedside commode. She can even take a few steps. Her insurance, which is a National Company of Good Repute with Shiny TV Commercials (aka The Abyss) has decided she’s done with therapy. Mrs. Johnson has paid her premiums for the last 40 years, and The Abyss, once stared into, has stared back with 21 days of therapy.
When Mrs. Johnson requests more time because she’s actually making gains that she hasn’t seen in 10 years, and her son is so pleased with her progress that he’s promised to take her to church and out to dinner for the first time in 15 years, Abyss Insurance has decided it’s time to stop.
We comply and stop the therapy. We have “become the monster.”
It has been my position to advocate for our patients to exceed their PLOF. The determinant of PLOF is not based on the health and welfare of the insurance company’s clients. It’s based on financial gain for the insurance company. I have personally made the calls, appealed the denials (all phases and steps including ALJ), scheduled and defended the Peer to Peer Reviews, and even (with my employer’s approval) continued the therapy to make gains for the patient without considering financial gain for our SNF.
Yes, sometimes we’ve offered free therapy. If someone needs it and can benefit, we’re doing it.
In this world of RACs, ADRs, denials and incentivized payback demands, it behooves us as providers to stare back at The Abyss and defy the illogical and irrational edicts of “PLOF” as the determining factor for payment. We have to ensure the health and safety of everyone we touch, and make sure that ethos and determination persists in the future for our loved ones, and eventually for us.
Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.
