December 10, 2014

An Interview Series by Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS

Today’s interview has a special focus on home care and skilled nursing home PT experiences. This is the actual transcript of the live interview.

Today we have the pleasure to meet with Kathy Miller, PT, who is a home care physical therapist with 30 years of experience in the Long Island, NY region.  Kathy has worked in multiple settings, including hospital, home care, private practice, skilled nursing, and more.  She has a unique insight into the current changes in the field of skilled nursing and home care PT. After all these years, she is still passionate about her career and making a significant difference in the lives of all she touches.  You will learn about current issues PTs face in home care and skilled nursing in the greater NY area, and about how one therapist manages to serve her patients well despite the challenges.

Theresa:  It is great to meet with you, Kathy.  Thank you for spending time with me today to share your experiences and your vision of physical therapy.  Tell us a little about your current practice.

Kathy:  I’m a home care therapist now with a large home care agency in Long Island, NY.

T: Do you love it?  What do you love the best?

K: I love it because it’s just my patient and I.  The bureaucracy is minimized.  I see my patient, they make progress, I put my notes in and for the most part nobody bothers me.

T:  How many patients do you typically see in a day?

K: I see a minimum of six to be considered full time because I am an employee. However the volume fluctuates.  I’ve seen as many as ten in a really long day.  Usually I average about 7-8.  It can vary quite a bit.

T: So do you get to spend the time you need to with the people?

K:  Oh yes.  I take the time.  I take what I need.  It varies from patient to patient.  There are patients that don’t tolerate much activity, so the sessions may start out short and get longer.  Then there are people that need more time and I just give them what they need.

T:  Do you get a referral from a physician?

K:  The physician usually calls into the agency and then they assign the case.  I treat in a certain geographic area.

T:  So you don’t actually get a physicians prescription dictating what to do you just get a referral saying Dr. Joe Smo ordered therapy.

K:  We get something called a patient profile.  That will have the doctor’s notes on it, but they mostly say the same thing, evaluate for home exercise program, disease process. The orders are very general unless it’s an unusual diagnosis or new procedure.

T:  How about x-ray reports and MRI’s, does that come with this profile?

K:  No, we usually get a weight bearing status in ortho cases.  You can always request more information, but you really just get bare bones.  Then you determine interventions, frequency etc.

T:  What does that say about physical therapy practice that you don’t get to see the rest of the medical records? especially the radiology and blood tests.

K:  You really don’t get much medical information at all.  A lot of times the information is wrong.  You get information usually from a secretary or family,  not a medical person. So of course they don’t know how complete or incomplete it is.  I have seen past medical histories that are very incomplete. For example, you can be talking to a patient and they tell you that they are on insulin and there is no diagnosis of diabetes on the profile. I’ve had many instances where significant diagnoses were left off.

T:  So you need to be on the ball, very independent. It says something about direct access.

K:  And you need to hope your patient is on the ball because if the patient is confused or demented they may not be able to relay an accurate history to you.  Then you need to rely on a family member.  It is amazing how many people are out there in the world who really can’t function very well be it cognitively physically or both and they don’t have a support system.

T:  What do you do when you come across that issue, a lack of support system?  Is there a certain protocol through the agency or is it something you kind of decide for yourself, like how do I get a better support system for this patient. 

K:  We would usually recommend a social work assessment because that is their area of expertise.  What community resources are available, what may be available through the government,  local churches, even food banks.  There are lending closets for durable medical equipment because for a lot of people their insurance does not pay for this so they would have to pay out of pocket.  You can actually borrow things like commodes walkers tub benches, as long as your return them.  Different towns have them. There is one in Smithtown, there is a Three Village Lending Closet, there is also one through the town of Brookhaven.  So all you have to do is pick it up and return it when you are done.

T:  How did you find out about these resources?

K:  The social worker.

T:  So the social worker lets you know and you pass it on to the patient.

K:  Right.  That is one thing I’ve picked up but the social worker also has information on day programs, senior social groups, etc. She helps people apply for things like Medicaid or other assistance programs.  Her knowledge is much more extensive than mine.  I just picked up that bit because we talk about DME with our patients so I learned about that resource from a nurse and I was able to get a list from the social worker.

T:  So do you interact with other health team members, like you mentioned the social worker and the nurse?

K:  A great deal because we have to coordinate care, which is a little challenging because we are on the road.  We have weekly case conference meetings and now we work on I-pads which is cool because you have the whole patient chart.  You don’t have the whole medical record, but you have their home care agency chart.  So you have all the nursing notes OT notes etc. We have email to an agency link, so if there is something pressing going on with a patient we can contact each other via cell phone or through the agency email.  I had to call a nurse today because I had a patient who was a little confused. I felt that his wife was also confused and that they might make errors in their medications. His wife has a breathing problem and she was supposed to see a pulmonologist .  When I saw her today she was telling me she was having a hard time breathing. So I asked her if she did her nebulizer and took her medication and she said yes.  I asked her what the pulmonologist said.  She said, “oh, I forgot to call him.”  She never went to see him.  I left a big note saying don’t forget to call the pulmonologist but I also contacted the nurse so that when she went in she could remind her as well. By the time I went back she had seen the pulmonologist and had her meds adjusted.  They need that kind of support sometimes when they are forgetful.

T:  So they really rely on you almost like a primary provider to bring people together, to bring other practitioners involved?

K:  For sure. We are the front line because we are in the house.  We are seeing these people, so if there is a status change…for example, our nurses do wound care.  So if you see a wound is getting infected and you are going in three times a week and they are seeing their doctor once a month you will pick up on that and hopefully get it under control before it takes off like wildfire.  These infections can get bad quickly.

T:  So this sounds like a very well coordinated system?

K:  We try to be, but it is hard because everyone is very busy.  Like you asked about number of visits.  If you are seeing 8 or 9 people in a day and the nurses I think see more because the nursing visits are shorter for the most part. Unless it is wound care they go in for medication management, checking vitals, sugars, etc so their visits may be a little shorter than a therapist.  Everybody is busy, so it is a challenge to coordinate, but it is something that absolutely has to be done.

T:  Do you supervise assistants as well?

K:  Yes, I have one assistant that I supervise.  I pass her cases, but they are only allowed to see Medicare patients.

T:  I wonder why they do not recognize PTAs. There is an issue I know with New York Physical Therapy Association in which we were trying to get a law passed, that requires insurance such as workers’ comp to allow treatment of a patient who is under workman’s’ comp by a PT Assistant.

K: They won’t allow it.  I just found out last week.  From a financial perspective you are better off being able to pass those cases on because they pay less then Medicare so you want to be able to pay your staff member less because your reimbursement is less. Much of this stuff is just the opposite of what it should be.

T: Well, PTAs used to be covered.  I have been in business for over 30 years and the last few years they stopped paying because they say physical therapist assistants are not written in the comp law specifically so now they refuse to pay.  But NY State law allows a physical therapist assistant to work under a PT and the insurance companies’ excuse is to refuse to pay and to limit care. We will continue advocating for patients with the NYPTA.

K: It’s all like a big stupid game.  It really is and it is very taxing, very trying, a lot of trivial rules that have nothing to do with patient care.  It’s all about we are going to take up your time and your brain cells to memorize these stupid arbitrary rules so that you can miss something and give us an excuse to take the money back.  Medicare is famous for that.  They are constantly… you learn the rules and they change them.  It’s an ongoing thing.

T:  But we are supposed to be giving people better care now. 

K:  Well hopefully most people who are in this field are not for the money. But in a way that’s what these people rely on. That you work yourself to death out of a sense of integrity and compassion and dollars is not your number one thing. Then they keep the dollars and they work you to death.  It’s a messed up situation.

T:  Has this problem changed your perception from when you first entered the field?  What was it like when you first became a physical therapist? 

K:  I think there was less expected of us in terms of generating revenue.  Now you are expected to see so many more patients, you are spread so much thinner.  I think there was less stress back then.  Documentation was certainly more lax.  That’s another thing now; Medicare finds excuses to deny if your documentation is not very tight.  There are certain things that they look at.

T:  Like what?  What would they deny on?

K:  I will give you an example about paperwork.  Doctor’s orders are big in therapy.  Like you were saying about the prescription, it’s not so much the prescription but once you get the order from the doctor you have to develop a plan of care and there are things that you have to check off.  If you check something off and you don’t document at some point that you did it, well you are out of compliance with the order because the doctor signs off on the order.  Now you are in trouble.  Not so much with Medicare, but when the state audits.  So say for example you put energy conservation.  You probably did it, but we all aren’t the greatest writers in the world. We went into this field to treat patients not to write notes.  So if you don’t write somewhere that you worked on energy conservation and you educated the patient on energy conservation and it is on the plan of care you are out of compliance.

T:  So you won’t get paid?

K:  Right, and you can also get dinged by the state for that.

T: The state audit is for Medicare?

K:  It actually is connected to Medicare because if you get enough “deficiency tags” of a high enough severity, then Medicare will not reimburse you for services. This is how they get you with the money.  What happens is say the state comes in… this relates more to SNFs then to home care. The state comes in to inspect.  If you have a certain number of severe tags, Medicare will deny payment. You can no longer admit anyone who has Medicare and they will not pay for any Medicare patients in your facility until they come back in three months and see if you corrected the deficiencies.

T: What is a deficiency?

K:  It can be anything.  It can be something they consider poor patient care.  Say the patient has a wound, they will go look in their record.  How are they treating?  How often are they documenting? Are they following the plan of care?  There is a certain standard of care that they are looking for..  They look at everything.   In terms of PT, it is really fun; you have to have a schedule of how often you clean the hydrocollator, how often you’ve check the temperature because it has to be in a certain range.  Same thing with paraffin, all kinds of equipment.  Things have to be calibrated on a yearly basis.

T:  That is standard policy anyhow.

K:  Yes, but you would be surprised, it is a lot to keep up with. I’ll give you an example… when I took over as chief of the SNF where I worked they didn’t have any of that documentation in place.  I had to put that all in place..  I don’t know if the state came in in the past and just didn’t look at that.  That’s another thing; they pick on certain things from one year to the next.  These SNF’s actually pay companies to track where the auditors are, what the emphasis is on that year and hopefully you have your ducks in a row when they walk into your facility.  They look at safety, they look at everything.  They look at documentation. They see the patients.  Another thing is restraints.  You are not allowed to restrain people, which is a good thing. There has to be extensive documentation if you are going to use a restraint. The doctor has to renew the order monthly and you have to have a “restraint reduction” program. You have to show that you are always trying to reduce the restraints.

T:  Well it doesn’t sound bad on the surface if they are checking safety and compliance. 

K:  That is what they are about.  But again, if you are not in compliance they take the money away.  I have been told that they withhold reimbursement for the patients that are there at the time and it takes forever to get it back.  They can really put you out of business.  A lot of people rely on Medicare as the highest payer.  If they close the doors for Medicare patients that is a big problem.  If you can’t take Medicare admissions that can be a big problem.

T:  Sounds on the surface the guys who are doing a bad job were being put out of business, which is a good thing.  

K:  I think it is a good thing too.  But there are a lot of rules that are counter intuitive or just stupid.

T:  Or onerous.

K:  Right.  I think the state is right. SNF’s have to post the number for the state; because if you are a resident in a facility and you are not happy you can call directly.  They will come in unannounced in response to a compliant and family members can call whenever.  If you go to a nursing home and you find your dad is laying in urine in the bed you call the state.

T:  That sounds like a good thing.

K:  Absolutely.

T:  Do you think anyone is getting paid off to pass?

K:  I hope not!.  Those state inspectors are brutal.  I have been questioned. It was terrible.  It was like I was waiting for the hot lights.  I was only involved in an indirect way.  Thank God I wasn’t directly involved, but it was a scary thing.  From what I have seen they are very strong patient advocates. They want the facilities run the right way.

T:  Is there any negative impact at all from all the excessive compliance and documentation or is it all a good thing?

K:  It is very time consuming, but I understand the purpose of it.  I think in terms of documentation, years ago you would see: subjective… no complaints, objective… treatment as above, assessment… tolerated well, plan… continue as above.  You could look in charts and see pages of that.  The demands are high, but I think rightfully so because if the insurance company is paying for this care they want to know that your treatment is goal directed, that they are making progress and if not why not.  If they are not making progress, therapy is not helping and they shouldn’t continue.  To me, if they want me to justify what I am doing, well I must be able to.  If I can justify what I am doing I should be able to convey it in writing.

T: What resource can you recommend, say I am in private practice and I decided to go into homecare with an agency or a skilled nursing facility.  I have no idea what their requirements are or their documentation or compliance regulations.  Where can you get training and information about this?

K:  I learned from the company I was working for.  For example,  the company I work for now just had a three hour lecture and it was all about objective findings.  What is the research staying these days, what are we emphasizing.  She shared a lot of results with us. Why are we doing what we are doing.  How we will get better outcomes and how to document what we are doing so our outcomes are better.

T:  Is that an outside web  resource they brought in or was it someone in the company?

K:  My agency apparently paid for a lot of research.  They went to this person, in Minnesota to do a big study with them and she said, “well if you like the results I am going to publish them all and tell everyone about it and if you don’t like the results I am going to publish them and tell everyone about it too.  That’s what you are getting when you come to me, whether you like it or not.”  That’s who you really want doing your research.  This is a very good company and I feel they are doing this to find out how we can improve quality care. What are we doing, what do we need to do better, and it comes down to research.  One thing she said, research shows the faster you walk the longer your live and I have said this to so many of my patients.

T:  That’s a great tidbit.  That can benefit anybody.

K:  We talk a lot about gait speed, because if you get them faster they are going to be better, balance is going to be better, everything is going to be better.

T:  Buildup the heart, buildup the muscles. 

K:   They have a lot of specialized programs in my agency.  They have a program called safe strides which targets people with unsteady gait. Fall prevention in the home is so important. The cost of hospitalizations following falls is huge. Not to mention the mortality rate.  What I found interesting is they did studies on patients in assistive living facilities versus patients out on the their own and they found the functional level was much higher with people on their own because they have to do more so they do more.  In an assistive living facility even if you can dress yourself the aid is going to do it for you because it is faster. What is the hurry, where are you going?  You see it with caregivers in the home.  We train them; if they can do it themselves let them do it.  It is one thing if you are in a rush for an appointment, you can help them, but if it takes them two hours to get dressed let them do it, because a week from now it will take them an hour and a half.  If you do it for them, they will lose that skill.

T:  That’s a great point.  What do you like most now about your current position?

K:  No one looking over my shoulder.  Doing what I want to do.  There is great flexibility.  Being able to provide the level of care that I want to provide.

T:  So even with all the regulations and compliance and documentation issues you can still determine your own type of treatment interventions for your patient. 

K:  Right.

T:  That’s great. 

K:  If one works in a skilled nursing facility or a private practice: because of the low reimbursement, to make money you have to see more patients because they are paying less and that is bound to impact quality.

T:  Do you think that will impact on homecare eventually that the fees will be lowered like the fees for all the other practitioners?

K:  Oh yes.  I did homecare 13 years ago and the fees are the same now as they were.  So how many people work for 13 years and make the same money?

T:  No raises.  New York State Workers comp and no fault fees didn’t go up for 25 years and now they are considering looking at the billing structure.  Imagine if the sanitation workers did not receive a raise, there would be garbage all over the streets.

K:  Which will take another 10 years?

T:  Right. 

K:  The other thing about homecare is the work load has quadrupled.    If it takes you four times longer to do a job at the same rate of pay, that’s a pay cut.

T:  What can we do about that?

K:  That’s a very good question because it is getting worse and worse.  I ran across an article, I actually was going online to a portal to look at my paycheck because everything is online now, and I stumbled on this article about the CEO of the agency:  his pay was cut by six million dollars from 43 million to 36 million.  That is where I think we can find the money.  I know this guy works hard, but honestly, I work hard too.  The many hours he puts in in a day, I probably put in close to the same because in order to see nine patients a day and provide quality care and all my paperwork is done in the evening in my home and on the weekends.  How many beautiful weekends have we had that I haven’t gone out.  I sit in my recliner and write notes from when I get home to when I go to bed.

T:  How does that impact your quality of life?  Are you exercising, spending time with your kids, are you taking care of yourself?

K:  No.  My yard, I showed you the weeds when we walked in.

T:  Why are you doing it? 

K:  Because I have to work.  I have to support my family and the part of it that I love well surpasses the part of it that I don’t love.  I can’t imagine doing anything else.  If you told me 30 years ago that I would be in the same profession I would have said, “you are crazy.”  I never would have thought that I would love it as much or that I still would get so excited when a patient makes progress.  I laugh with my patients that I am more excited than they are when they can do something.  They look at me like I am crazy.

T:  So you are very passionate about really helping people reach their goals.  Making changes, making a difference.  You make a big impact on people. 

K:  Yes.  That is why I do it.  It is so satisfying.

T:  Can you see another branch or division of physical therapy that you could work in where you could have that type of satisfaction? 

K:  Yes, well, I did manual therapy for a long time and that still is my favorite thing.  My plan was always to end my career in geriatrics because from when I was a student I loved older people.  I didn’t go directly into geriatrics because I felt there was a lot more to learn out there.  Geriatrics can be static in some ways although it is not as static as I thought it was way back then, but back then I said let me go and do everything else and at the end of my career work with the elderly.  So I did neuro, I did ortho, I did some peds, and then I really wanted to work in a rehab facility, but they were all so terrible, so I went from that to homecare. This is where I belong.

T:  Why were the rehab facilities terrible?

K:  They were all about making money.  I think they commit fraud every day and they should be in jail. Is that too negative?

T:  No.  This is honest reporting.  You had mentioned to me that when you were at certain facilities you were asked to do activities, shall we say, that were technically fraudulent.  Can you give me an example of one?

K:  Medicare pays different levels of reimbursement based on treatment minutes.  There is rehab low and no one is allowed to be on rehab low.  There is rehab medium, high and ultra high.  It corresponds with number of treatment minutes and it directly corresponds with reimbursement.  The more minutes a patient gets the more money the facility gets.  Therefore, everyone will be put on a ultra high level or as close to everyone as possible whether they are appropriate or not.  I’ve seen lengths of stay go on.  They keep people in these facilities when they are ready to go home weeks ago.  I saw one patient, I was doing per diem coverage on weekends, and I saw this woman, she was walking around making her own bed, taking her own shower and the aids loved it because she was completely independent and I thought wow, she really doesn’t need to be here.  I knew they were kind of stretching her stay, which is what happens.  I didn’t go back there for three weeks and three weeks later she was still there.  So you are talking about extending lengths of stay, not days but weeks.

T:  Who makes that decision?  Who actually is making that happen? I have heard this from numerous therapists across the country.

K:  The therapists are under a lot of pressure from the administrators.

T:  The administrators?

K:  Yes.  Now there are “management companies” that are coming in.  Years ago I think they called them efficiency experts.  There is a particular company on Long Island that I know that is trying very hard to buy entire nursing homes but when they can’t they will “go in and manage the rehab department.”  I heard from a headhunter that they went from owning about six facilities on Long Island to over thirty and that was several months ago.  Every time I turn around I hear that they bought another facility.

T:  Do you know the company name or would you rather not say?

K:  I wish I could say. I wish someone would stop them. I truly believe that they are criminals. (Name withheld.)

T:  I heard of them.

K:  I don’t know why I haven’t called the Medicare fraud line. Now that I am in homecare I hear stories of patients coming out of these facilities and it is just horrific.  Back when I started out people like them used to at least give lip service to quality care.  They used to talk about it.  They didn’t care if you really did it, but they used to talk about it.  Now they don’t even talk about it.  When I was the chief of this facility they would tell you right out they didn’t care.  They want length of stay, they want ultra highs, they want profits. They had no desire to even talk about patient care.  Forget about inserviceing or staff development.  Forget about all of that.

T:  Who owns this facility?

K:  The “rehab management “ company did not own the facility where I worked. The rehab staff all worked for the management company. The owner of the management company I believe is a therapist and he partnered with some business guy and started this company.  I heard from people who have had dealings with him that he is not very pleasant.  He gets up in your face and screams.  I heard about a director who got into it with him because a patient was not appropriate to be on program.

T:  What happens to a practitioner who blows the whistle at one of these types of facilities?

K:  I don’t know really that anyone has.  The sad thing is that when it is uncovered I’m afraid they are going to blame the therapist because the therapists are really forced to participate in this in order to make a living.  When I first started as Director of Rehab in this facility I was warned by several people not to take the job if it meant working for this management company. At the time they were in there as “consultants”. I was assured that I would be an employee of the facility. The facility was right around the corner from my house, it was like my dream job.  You and I went there and told them about your aunt with a broken hip, to check the place out.

T:  I remember.

K:    One woman told me to go and Google the name of the company because the state took like 13 million dollar back from one of their facilities upstate.  This is another thing, if the state found wrong doing in one of their facilities why don’t they put all their facilities under a microscope?

T:  Because no one is reporting it.

K:  But if the state discovered all of this fraud:  if you know that this facility is  fraudulent, why wouldn’t you go and checkout their other facilities?   This is what doesn’t make sense to me.  So I started working for the facility in June. The following Feb they took over the rehab department. I found out later that the administration knew they were taking over when they interviewed me. I hung in there until June, then I quit.

T:  What specifically did they ask you to do that made you feel like quitting, but not reporting?

K:  They came in and slashed everyone’s salary so they forced people to quit.  This was a little local facility.  It wasn’t really that big and most of the therapists had been there forever.  So they had worked their way up on the pay scale, with benefits and everything.  Then they slashed benefits.  One girl quit on the spot.  Then there were certain people that they knew they wanted out and they got them out.  So I said to my regional manager are you going to cut my salary and he said “no, you are market value.”  They viewed everyone as a commodity. Their attitude was “ if you don’t like it you can leave.”

T:  In business there would be a job action.  If there was a union involved and someone tried to get rid of a certain type of worker who sounded too many alarms there would be hell to pay.  But yet in healthcare we are not seeing that.  People don’t leave their jobs and they tolerate mistreatment regularly and I just don’t understand it.  Therapists allow business managers to walk all over them and accept their demands to produce fraudulent records. I hear it all the time when I travel all over the US.

K:  A lot of it is complacency.  In this place they had been there for so long and I think people are afraid to change.  I had an OT who was worth her weight in gold and I would tell her there is such a demand for OT’s right now in skilled nursing facilities, I used to tell her you are crazy to stay here.  That’s another thing; they do not value skill or experience.  They want warm bodies.  They don’t care if you are providing quality of care or lousy care.  As long as you are doing the length of stay and keeping them at an ultra high that’s all they care about. They don’t care about quality of care.  There is no loyalty, there is no anything.

T:  What about the patients?  Doesn’t anyone complain with their families?

K:  Patient’s complain.  It’s human nature.  You say, write a letter and complain. I have patients say to me “I don’t want to get anyone in trouble.”  I tell them, “they should be in trouble if they were neglectful to you or they say they are providing care to you that they aren’t .”  People then go home and they forget about it.  I had a patient tell me her roommate hired a lawyer to get her out of the facility because they wouldn’t let her go home and she was perfectly capable of going home.  This specific woman, and it was ironic because this was the facility where I was the director, went to her “care plan” meeting after two weeks. She had had a hip replacement.  She said “I figured out how to get myself out of bed and into the bathroom because every time I rang for an aide, nobody came so it was either get myself into the bathroom or pee the bed.”  So out of necessity she was doing everything for herself.  So after two weeks she was basically ready to go home.  Her daughter comes into the family meeting and they’re saying well we are going to keep her for another 30 days and she says, “what the hell for?”  Because according to the therapy notes you need mod assistance.  The therapy notes were completely false.

T:  What therapist wrote false notes?

K:  I don’t know. I wasn’t the director anymore. I heard this from a homecare patient..  So the daughter said, “well you know I work for the state and I’m taking her out of here.”  This was a Wednesday.  So she went from needing another 30 days of rehab to going home Saturday.  And you know what, she was ready to go home.  They were charging her at an ultra high.  That’s another thing with Medicare.  You have to make certain benchmarks.  Remember I was telling you about the stupid rules, well the stupid rules in SNFs are there is a reimburse rate for 14 days, then you go to 30 days and then you go to 60 days.  If you don’t hit these benchmarks they lose money.  So if you make the 14 day, but you are there less than 30 you make less money than if they stay for 30.  So whether they need to be there for 30 days or not, you better keep them there for 30 days.

T:  Those rules require it, so those rules need to change.  That’s the bottom line. 

K:  People need to stop being crooked.  That’s what I mean, it’s all about the money.  If it was patient care driven they would make less money. It would cost Medicare less.  Now this is Medicare trying to keep people honest and they can’t.  Therapists are compassionate hardworking people.  If the owner of the facility came to the staff and said, “I can’t pay you more money, but we need you to do this much more because we really are trying to make ends meet.  We want to provide care for these patients” the therapists would give sweat and blood to give the patients what they need.  But these people are not cutting corners to make ends meet. They are making millions.  These people are making millions by cutting salaries and robbing Medicare. When I started out as a therapist if someone cut their finger there was a band aid in the drawer.  There are no more Band-Aids. There are no tissues.  If a patient has a runny nose you have to give them your first born child to get a box of tissues.  Everything is locked up.  There are no niceties.  There are no amenities.  Everything is counted.  Everything is cut to bare bones.

T: What about the beautiful décor?  The pictures and the fancy rugs? When I visit these facilities, it appears they hired interior decorators to polish them with new expensive furniture and paintings, but nothing special for patients.

K:  You know the government pays for a big part of that I found out.

T:  Do they? Do we?

K:  When I was at this facility, they were renovating and I thought these people are such cheapskates why are they spending all this.  That is when I found out the federal government gives them a certain amount.  Why should the federal government give a privately run for profit facility money to redecorate?

T: Was that a grant? 

K:  I think it is a period of every ten years or something they get money to redecorate.

T:  And it doesn’t go to patient care. Our taxes are taken out of our paychecks to pay for this!

K:  And it doesn’t go to patient care.  In addition, those people had no taste.  I don’t even want to tell you what they did, it was disgusting.

T:  Tell me about the story when you were walking the guy down the hall with dementia and there was a change in the color of the carpet because the decorator had no clue about what was required for people with low vision, dementia or comprehension issues. 

K: Right in the doorway they changed the color of the floor tile.

T:  What does that mean?

K:  Well people with Parkinson’s won’t cross the threshold. People with dementia won’t cross the threshold because they don’t know what that is.  Their depth perception gets affected and they don’t realize that it is just a change in the color of the flooring so they will stop.

T:  So someone came up with this grand idea to decorate and didn’t take the geriatrics requirements in mind. 

K:  And didn’t consult with the therapist.  They put in toilets that were too low.  You are redoing all the bathrooms.  Why not put in higher toilets so you don’t have to deal with commodes and all that other stuff.

T:  So the government (we) paid for this and it cost more in the long run. 

K: Yes, because they weren’t smart.

T:  OK, let’s go beyond this issue and think about if there is something in the field that along the way you found, wow, this person really inspired me or I was at this facility and there was something I picked up there I got really passionate about.  Or a certain mentor who was just amazing.  Tell me about a really peak experience in the field.  Maybe someone who guided you along the way or something you learned that you think would spark some passion in someone else.  What can you share of that real positive experience. 

K:  Well, you have been a great mentor to me.  I think you are my main mentor.  You and Jodie in terms of manual therapy and really seeing good results.  Just being very effective.  Seeing good carryover.  I think that in terms of my clinical skills I learned the most from you guys.  Then I had a regional manager when I worked for a reputable management company who was so knowledgeable in Medicare ways and was a great resource and was very very smart.  She was a great therapist also.  They were really driven by how do we get the most for our patients.  They were not financially driven.  They were driven by patient care.  So they put it back into staff development and were constantly looking at things.  But they wanted to learn how to play the game so to speak and their philosophy was well you guys are working really hard and should get paid for it.  In that company it did trickle down to the employees.  Whereas a lot of the other companies are putting it in their pockets.  So that was good in terms of morals and ethics.  They were a good company and she was very good.  They also did a lot with inservicing on documentation and fighting Medicare denials.  These companies pay people to fight and they take it to the courts.  They appeal to Medicare and if Medicare denies you, you go to the next level and you get to the point where you go before a judge.  That’s her job now.  She is not a regional any more.  She talks to the judges.

T:  It must cost an awful lot in legal fees to go to that level to appeal?

K:  Well their philosophy is first of all we are going to get paid for what we do regardless of what your stupid rules are.  They don’t let anything go.  They fight every denial because they feel if they hear the company name enough, and the company wins 93 or 95% of their appeals, they will leave us alone.  Ultimately that is what their goal is.

T:  Tell me what you think about evidence based research and the need for the so called best practice and how all the professions are supposed to be getting in line behind what the evidence says is the best way to treat.  Do you think that is a good thing?  Is there a up or down side to following simply protocol and evidence, clinical prediction rules?

K:  I think it is absolutely necessary.  I think it is a way to justify what we do but on the other hand it is not all about statistics.  As we were saying you can skew things and if it is not a good study your findings can be invalid, but I think research is also important because it does point us to what we should be doing and why we should be doing it.  We need the research, but we also need to rely on things that are almost intuitive. Some people call it lunatic fringe.  Some of these things are things that have not been quantified yet.

T:  So the art and the science.

K:  Exactly.  There has to be a balance.  But the science absolutely because it does help to give us direction in terms of the most sound way of doing things, the most effective interventions..

T:  Makes sense. 

K:  We do a lot with compliant surfaces, stimulating balance reactions because falls in the elderly are so huge and they find that these techniques are very effective.  The safe strides program is a lot about working on compliant surfaces stimulating those balance reactions.  If you have the data, 60% fewer falls in people in this age group who have participated in the program. Well that is good to know.  You want to know that you are being effective.  You know, we’re not going in there to have tea with these people, we are going in there to help them.  It is nice to have some information to guide you because you don’t want to be doing something that ultimately is not effective.  It is a waste of your time.  They are not benefiting, so research is good for everybody.

T:  Very good.  How do you feel about continuing education.  I hear from therapists around the country complaints about our continuing ed used to be paid by our job and they cut our benefits and we don’t want to have to pay for it yet the states are now requiring mandatory continuing ed hours.  Do you feel that that’s a benefit in our profession and are people really learning in these seminars when they have to go?

K:  I don’t think that the fight can be mandated.  I think that’s something that you either feel you need to do or you don’t.  I think quite frankly everybody should feel that they need to do it because medicine is always advancing.  I have rarely been reimbursed for continuing ed. And I have taken a lot of courses. I just have an internal desire to better myself, to better the care that I am providing.  I think they make these rules, again good intention, but there are a lot of fluff courses out there.  Haven’t you heard of the courses for the MDs where it’s in Hawaii for a week and you mostly play golf and you put down that you took this course?  People that are taking continuing ed for learning sake and to advance themselves are going to do it whether it is mandated or not.

T:  How do you feel about web based or internet based home study continuing ed versus going to a live seminar? 

K:  Depends on the topic.  Certainly if you are going to a joint mobilization or soft tissue mobilization course you have to have the lab, you have to have that guidance, that mentoring.  For other things, like research studies, you can certainly do online.  I think we need both.  Also with these mandates, let’s face it, it’s hard to find the time for a lot of people and if your job isn’t paying for it, it is expensive to go even if it is just for a day.  You have to get there, you have to take the day off, it gets to be a lot.  I think it is important to take those hands on courses but to fill all your CEUs in that way would be hard.  Again, it is nice to have a mix and do something online.  That might encourage more people to do it and maybe get to some of those people that otherwise wouldn’t do it if it is made more accessible and more affordable.

T:  Can you make some comments on alternative and complementary medicine.  With so many patients who used to have a physical therapy benefit like even outside of Medicare or Medicare might cut their benefits at a certain point, certain yearly dollar value and there are a certain number of visits, so patient’s are reaching out, looking for care to help them feel better or function better and they are going to acupuncturists, they are going for nutrition, they are going to raki healers, they are going for massage.  One of the big complaints I hear in my private practice group is that we are getting paid less by insurance for physical therapy skilled care with a doctorate degree then the personal trainers that are getting our patients when insurance cuts them off or the patient’s decide, I don’t want to pay a 50 dollar copay, I’ll just go to a personal trainer at a $75-100 a visit and they are paying them but they are not paying us and yet we have the skill that they lack for medical care?

K:  Why are they willing to pay a trainer a $100 dollars and they are only willing to pay PT $50?

T:  That’s a good question. 

K:  They’re setting the values. Maybe they feel like they are getting more benefit from the personal trainer.  Maybe that’s what we need to look at too.

T:  What could they possibly be getting more benefit from in a person who has no medical training?

K:  Who knows, but if they are paying double the price for it they are getting something.  Makes sense to me, right.  Why would I pay more and get less?

T:  Well it is interesting that if in the case of private practice Medicare, a private practitioner physical therapist is only allowed to bill along the same rates or I think it is 5% greater than Medicare rates so even if you are doing a super specialty practice and a patient is extremely wealthy and wants to come for physical therapy to buy a three hour visit you are not allowed to bill them more then that Medicare allowed rate even if you are a non participating provider. 

K:  So if you treat them privately  1:1 and get paid “appropriately” you may jeopardize your license?

T:  Right, unless you are billing the Medicare allowed rate.  But, why should one bill the Medicare allowed rate if you are giving much more time, more hands on, one on one and something that they might not be able to get through Medicare.

K:  Well that’s something, the law has to change because if a person wants to above and beyond I think they should.  It’s their business, their money.

T:  We have a bill in the house of representatives now, but they said they are going to strike it down, allowing a physical therapist to opt out of the non participating provider, to be able to charge what they want.  Hey, if I’m Howard Hughes or the head of Microsoft, Bill Gates and I want to pay top dollar for physical therapy once I’m on Medicare I’m not allowed to bill at my own rates.  I’m not allowed to choose that board-certified level therapist for extended care and pay appropriately.

K:  This is the government’s attempt to level the field, like you shouldn’t be allowed to have better care because you are rich.

T: So everyone can have mediocrity. 

K: That’s where the problem is.

T:  Interesting.

K:  And I personally, I don’t think I believe in that.  I think it is my money and I’m going to do what I want with it.  I have patients all the time want me to see them privately.  But it could cost me my license if something goes wrong.

T:  So there is a place for these patients to go using alternates such as personal trainers or massage therapists.

K:  I usually tell my cardiac patients to go to cardiac rehab. I often recommend that certain patients work with a trainer for a month or two because I don’t want these people going from homecare to the gym unsupervised.  So a lot of times that is a nice segue.  Go to a cardiac rehab so you will continue to be monitored, but on equipment.   What I do is have people run the stairs, which works great.  Literally I have one woman who is in one of these elderly complexes and there are no steps anywhere which I have a problem with because if you don’t use it you lose it.  The woman was saying I really want to work on the steps, she went to the club house and there are no steps anywhere.

T:  Let’s get back on track.

K:  So we were talking about Medicare regulations and homecare and how you have to reassess on a certain visit, if you miss that visit by one they take back all the money from that visit back.

T:  How far back?

K:  Say the reassessment was the 13th visit and you missed it any visits you do after that until the reassessment they don’t pay for.  So you have to realize you missed the visit and get in and do the reassessment as quickly as possible.  That’s when they take off from when it should be done to when it was actually done.  Which can sometimes be 3 or 4 visits.

T:  So it doesn’t go all the way back?

K:  I don’t think so. I think it goes back to when the reassessment was due.  So now I’m a PT and I pass this case to a PTA, so she’s in there, the OT passes the case to a COTA.  So now you have 4 people trying to coordinate. So this is a text for me from a COTA: “when are you doing a reassessment on such and such patient because Joanna will be the 17th visit, and I’ll be 18 Thursday. I’ve got to get in by 19.  So Brian the OT would have to get in before PT next week.  But if you don’t do it this week we will be out of compliance.  So you are trying to coordinate because only the PT and the OT can do reassessments, so the assistants have to convey to us that we need to get in on this certain day.

T:  That requires some coordinating.

K:  And it’s stupid stuff.  So I do it the 20th visit.  What’s the difference? We spend a lot of time making sure these assessments are right.

T:  So a great deal of your personal time is spent emailing and texting and communicating back and forth, counting visits when you could be either treating patients, working with your family, it doesn’t make any sense that you have to coordinate at that level. 

K:  When I was the director of the SNF you spent all your time counting minutes.  They used to joke and call us minute counters because the benchmarks are by treatment minutes.

T:  Wouldn’t it be easier just to say that every thirty days or something to that affect and separately for each profession?

K:  Yes, and I agree in terms of Medicare patients that they should be reassessed at regular intervals.

T :  It used to be every 30 days in private practice. 

K: Right.  And I don’t think it has to be exactly on the19th visit or we’ll take the money back, but that’s how they work in SNF’s too.  You have what they call a look back period and if the minutes don’t add up for that period you lose that level of reimbursement.  They call them MDS books. There is a 14 day a 30 day and a 60 day and if you don’t have enough minutes in the 30 day you lose that reimbursement level for the whole month. If you miss the 14th day you only lose it for two weeks.

T: But then there is a reason that these therapists are told by the administrator they have to add the minutes that they didn’t actually do, otherwise they physically can’t stay in business. It is still fraud.

K:  And they’ll say things to you like well you put 15 minutes but didn’t you really do 20? And it’s all on the surface.  Could you remember that you did an extra 5 minutes that day?  This is how it goes.  We talk about the crooked company I worked for but all these companies are like that to one degree or another. I was doing per diem at this facility in Nassau County. They give me this patient to see, she’s an ultra high which means 60 minutes of PT and 60 minutes of OT six days a week.  I go to see this patient. She is schizophrenic and developmentally disabled and 54 years old.  She has self abusive behavior and she strikes out at staff.  She was in a group home walking without a device, fully mobile, slipped on a wet floor and broke her patella.  So she is immobilized in full extension, but she can weight bear as tolerated.  They want her standing. They want you to try and walk her.  Well you have to see this woman. She is in a high back recliner and all day long she sits bashing her head back  into the headrest.  You try to get near her and she punches, scratches, tries to bite you.  She’s pulling her own hair.  I got her to stand maybe three times.  She hit me in the chest, she hit me right in the sternum.  So this woman is getting two hours of therapy six days a week. You are billing Medicare at a ultra high level.  And so I went back to the gym, and I said to the Director you know what, I’ve been a chief, I know what it’s like “couldn’t you get another 5 minutes out of this person?”  “Can’t you stretch it, can’t you this, can’t you that?”  I know there are alot a lot of gray areas, but this is fraud.

T:  How many minutes could you actually get working with her?

K: Less than 5.  She stood 3 times. She stood less than a minute each time, so maybe 5 minutes.

T: But you had to document an hour.

K:  I told this story to my former chief, my former regional at the reputable company and she said if they’re striking out at you, you bill them for upper extremity exercises.  That’s how they try to get around this.  Pathetic.

T:  Otherwise if they don’t do that they can’t get paid enough to keep the door open.  So what is the solution?

 K: It’s a pie in the sky attitude but I think if people stop cheating, robbing from the system, I think there is more than enough money for everyone to get what they need, but you have to take out human nature.  You have to take out greed.  I’ve have patients say “ I’m going to take these services even if I don’t need them because I paid for this.”  If everybody took what they needed there would be enough for everyone. If there were people who settled for hundreds of thousands of dollars instead of millions of dollars. But then again if I ruled the world everyday would be the first day of spring.

T:  I love it.

K:  And that’s a quote from another song that you probably don’t know.

T:  I think I’m going to end it right there because that is a good one.  Thank you for your thoughtful comments, Kathy. Hopefully you provided some inspiration for therapists out there who are experiencing the same issues, in SNFs, home care and general practice. Perhaps they will now recognize that there is a reason to challenge the system to make positive changes.  Therapists are not alone in facing these issues.  We can advocate for our patients and work together to make our profession better for the people we serve and the greater good overall. Thank you for giving us an bird’s eye view of current practice, and for inspiring us to step up to demand improvements in the health care system.

To learn more about how to make a significant difference in your practice and in the lives of people you work with, visit www.educise.com.  Contact Dr. Schmidt if you would like to share your successful experiences in PT with us. 

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