Joined: December 22, 2007
I thought I'd get some insight from those around the country (and beyond) on this one. I've been working in corporate-based outpatient practice since I graduated. The productivity standards have varied slightly between companies but remain pretty consistent. The "metrics" are as follows:
4.0 units per visit 10-12 visits per referral 10-14 visits per day
I have a few questions for the group. Firstly, are these typical of your productivity standards? Secondly, although I believe I already know the answer, do you believe these metrics to be business driven or clinically driven? I had a colleague mention they were partially based on the APTA Guide, but I haven't had the stomach to purchase that cookbook.
I'm trying to understand productivity in a clinical context and running into some ethical barriers. It comes on the heals of some pretty heated exchanges and listing to the author of Worried Sick: A Prescription for Health in an Overtreated America. Baring my soul here a bit, I sometimes feel my productivity standards are like an ideal gas expanding to fit reimbursement, rather than what is clinically reasonable for the patient.
I'm trying to look at this from the greater perspective here. Money is tight for many individuals. Tweaking things to make a buck might be ethically acceptable for a lawnmower repairman, but should it be ok for health care providers? At the same time, our profession is standing up to demand a greater share of the public trust by becoming autonomous providers. Will our efforts be worthy of this trust? I believe given the opportunity for a greater patient load, our productivity standards might suddenly change, again causing our treatment plans to fill the money provided.
I'm about as right-wing capitalist as you can imagine, but I have deep concerns about the tail wagging the dog and it's implications for the future of our practice.
< Message edited by TexasOrtho -- November 15, 2008 9:11:12 PM >
Joined: May 11, 2004
From national claims data, proportedly analyzed by Ingenix (not sure how trustworthy/credible the data is whenever I know Ingenix is involved)... but it appears mean service units per visit is maybe 3.5 or something like that (the bar graph in the report sent to me doesn't have enough lines for me to be accurate in my guess). Nationally, it appears that per visit almost 2 units of exercise are provided, maybe .75 units of modality and maybe .75 units of manual therapy. (Again, I can't read the table chart perfectly.) It appears on a line graph that average visits/episode are about 7.5. I do tend to believe that mean service units/visit - from my experience in a few different companies and the expectations of management, that bar graph seems like an accurate portrayal. I don't believe the 7.5 visits/episode of care though. Without a sharing of the breakdown of the type of benefit policies and the percentage of the various benefit policies, the visits could be highly based on limited benefits and without standard deviations or information on quality of care (such as pain level changes and functional changes), the 7.5 value has limited meaning to me.
The number of visits can't be based on The Guide - the guide is so darn general and the duration of the episode of care and the number of visit recommendations are stated in a very large range - I'd be willing to bet that every single physical therapist could meet the expectations in the guide. The reason the guide has to be so broad is because the guide has a very broad classification system (for lack of a better word). As you read research, you learn to value subgrouping patients and targeting the appropriate interventions for that subgroup of patients to improve both your efficiency and your effectiveness. The guide isn't even close to being the type of document that can really guide our practice.
I don't think anyone in any profession, no matter what is is they do - from a plumber to a physical therapist should tweak things to make a buck. (As a consumer, that is the worst feeling one can have -when you feel like you've been taken for a ride. You never go back...) If we can identify ourselves, differentiate ourselves and provide a story as to the relevance of our services that is palatable to consumers, we'll be on the right track. Consumers will determine the level of trust we are warranted by our performance. The consumers are the only ones who can determine whether our brand is trustworthy, consistent, and valuable. With the amount of rules and regulations upon us right now, productivity standards aren't going to change too much - we're boxed in by the definition of the CPT codes and their association with time (minutes). IF regulations changed to be more open and the current fee schedule no longer existed and a different payment system was created and regulated for us to follow, then you'll see change.
Edit: Actually, what you might see if there was a change in our role to becoming potentially more involved with something like primary care, you'll see more of a "consultant" type of a role with a "managing" of the condition. Probably not the 2-3x/week frequency, but a potential for telehealth and contact with the patient at a different level with probably a higher emphasis on education and progression with activities to get the person back to life because the physician might not be involved with prescribing meds and doing the "wait and see" approach. If our role changes to something like that, we may or may not be functioning the majority of our day in a clinic as clinics now look - I would forsee that the physical layout of clinics would change to accommodate the change in our role.
< Message edited by SJBird55 -- November 15, 2008 5:55:35 PM >
I too work in a corporate outpatient clinic and my standards are similar.
As long as we continue to be driven by a business (the insurance companies) we as PTs will continue to have clinic practice patterns driven by business economics. I think it is sad but that is where we are stuck for the time being.
Based on how units are reimbursed my clinic has decided 40 minutes is an ideal time to schedule patients. Because we are scheduling patients based on unit reimbursment we will always be driven by the business side and at times at the sake of patient care.
If I have 5-6 patient a day that might truly only need 30 minutes of care as opposed to the scheduled 40 it is in the clinics best interest that I stretch this to 40 so I can bill maximum units. Otherwise I will have a failed business model. Is this unethical or just a byproduct of insurance company regulations?
Of course, even if didn't have insurance regulation in practice one would still run into similar problems. Anytime you have a business model which is appointment driven you have to come up with a standard length of time for the appointment. Just seeing the patient as long as they need to be seen would never work b/c you would either have a lot of unhappy folks waiting forever, or large gaps in your day.
How will this change, I don't know. Hopefully folks out there a lot smarter than I am will figure it out.
"Is this unethical or just a byproduct of insurance company regulations? "
absolutely unethical. Ethically we are to provide care in the best interst of the patient, regardless of our bottom line! Not only is this part of our practice act, not doing so would be unethical of just about every healthcare practitioner I can think of.
Do people treat by the numbers? yes, but that doesn't make it right.
I also work for a large rehab company. My expectations are about 3.3 units per pt, 12 visits per. I have told my supervisor that I will do whatever is in the best interest of my patient. I also have made it clear that if I am disciplined for not seeing a patient for 3.3 units or less that 12 visits, and I feel that not meating those numbers was in the best interest of my patient, I would consider this asking me to do something I feel is unethical.
So far the answer has been "... we wouldn't want you to do anything unethical."
I see far to many PT's treating to the numbers, and it really saddens and angers me. Like SBJ said, how would you like it if you were getting taken advantage of everytime you needed a service? Worse yet, unlike a plumber or a mechanic, when someone comes into our clinic, they are putting their trust in us that we have their best interest in mind.
When I first started working for this company I had to wrestle with the same questions. As a matter of fact I posted questions on it as well. I came to the conclusion that I would abide by the golden rule ( and I know this sounds corny)"do one to others ....." and let the chips fall where they may.
Is it scary in these economic times? yes, especially with recently buying a house, having a 1 year old, and another child on the way, but I feel good about the fact I do for my pts what I hope someone would do for me if situations were reversed.
If we are affraid to treat our patients ethically and give them the care they need, and not the care we need to meet a budget, I for one don't believe we deserve the autonomy direct access access would provide.
Sorry about the rant, but I'm really passionate about this. To continue on TexasOrtho's example, I'll never understand how everyone would sue someone if they were sold a new engine bc the windshield washer fluid was low, but think that doing the same thing as a PT is OK!
I just hope I am not in the minority, or I may end up having to work at a garage or as the lawnmower guy!
< Message edited by laptma -- November 16, 2008 4:38:04 AM >
okay so I just made a long reply and realized I was not signed in and don't have time to rehash so I'll be short.
I agree with most of what you say. I think you misunderstood what I was saying. I don't treat the person for 30 and bill for 40 minutes nor do I just try to fill dead air. The client gets 40 minutes of skilled, quality care.
I too get frustrated that it seems b/c of insurance and things like the 8 minute rule we are trying to fit patients all into the same box by scheduling appointments. But I don't know a better way around the problem.
If I have a 40 minute business model and treat 70 percent of my patients and bill for 30 minues then I have a problem. I can't just say to a manager, well that is what the patient needed so deal with it. I would need to come up with a solution of how to treat some patient for 30 minues and some for 40 and still make a profit. Right now I don't know the answer as to how to do so.
I do know that PT is a business that needs to be profitable and many PTs don't understand this is the case. I am not saying we needed to sacrafice care for the sake of the numbers but one does need an understanding of what it takes to make a clinic profitable. Otherwise all we end up with is a failing business and then would be unable to...
"provide care in the best interst of the patient, regardless of our bottom line!"
Joined: December 22, 2007
I appreciate the replies and agree. The standards of care should not be dictated by the business model, but rather the other way around. I understand the need for metrics as they are a reflection of some measure of control the company has over its revenue. Every company must have them and I get that. I was more interested in how you all perceive the productivity standards and how you reconcile them your personal standards.
The main reason I'm asking this is that I took on another clinic recently and will be in charge of more PT's and PTA's. I've been counselled on my metric management from my superviser before. My charges tend to average 3.7-3.9 but the company standard is 4. As a single PT clinic right now, I see 15+ patients per day and have some difficulty balancing the higher volumes with the kind of care I'd prefer to deliver. With two new grad PT's coming on board, I want to set the right examples for them. At the same time, I don't want to be "that guy" hen-pecking his employees that they really need to take their producivity from 3.9 to 4. I get why the business does it, I just don't want to turn into Bill Lumberg.
On a more personal note, there are things I'd like to do better as a clinician in the interests of quality care. The last thing I want to do is look back on my career and measure success by the number of patients I saw. At the same time, I do want to drive a successful business. I'm trying reach that balance. As with most issues, it will most likely be another work in progress.
I did not mean to say that you bill for more time than you treated, my problem in general is this keeping anyone longer than they would need if namagement was not giving you "quotas" they would like you to meet.
I go back to the point that if your treatment is not in the best interest, weather more or less, it is not ethical, regarless of the business needs.
I certainly understand the business concerns, but if your talking about the ethics of it, it's just not ethical!
I would like anyone who thinks it is not unethical to treat to budget to please give me your reasoning.
Joined: May 11, 2004
There are different ways to problem solve the issue. Of course there are various interpretations by various payors on the time of the unit. You know that Medicare has the 8-23 minutes for one unit rule. Treatments for patients might truly range from 20-40 minutes per session depending on what the patient needed. I am going to speak very generally to help think differently... Medicare's perspective is that 20 minutes would be one unit of service, but for most payors, 20 minutes are 2 units of service. These differing rules do create difficulty in addressing productivity because spending 20 minutes of one-on-one time with one payor leads to higher productivity. From my interpretation of what I'm reading in this discussion, some of you are pigeon-holed into being told how long time slots are supposed to be for returning patient visits. If the scheduling system could be broken down into 10 minute increments, as a PT you could exert more control into scheduling. From an administrative position, 10 minutes will always be one unit... 20 minutes will be 1 unit for Medicare but 2 units for most other payors... 30 minutes would be 2 units for all payors and 40 minutes would be 3 units for all payors (right)? Anyways, create a more flexible scheduling system so patient centered care can be included in the picture. I designed my system around 15 minute increments because that seems to work well for how I practice and the needs of the majority of the patients. Some patients have 15 minute visits... the majority have 30 minute visits... a few with balance deficits will have 45 minute visits. I have full control over the amount of time required for the visits and this occurs via communication with my office manager... I indicate the frequency 1, 2, or 3 times/week and the one-on-one time required to get the visit completed.
What I'm really hearing and interpretting from those of you sharing is that your hands are tied and you have no control over your schedule which is irritating and creates the impression that you are potentially getting yourselves into a situation you don't agree with ethically. My whole career, I have never allowed administration to tell me how long visits should be with patients... I have never allowed them to dictate to me when or how delegation occurs... and I have never allowed them to tell me the final number of visits per episode of care nor the duration of care. (Don't get me wrong, there was always a productivity requirement, I just could just ask all sorts of questions to my supervisors - questions that basically had no direct reply which left them leaving me alone and not hammering me on productivity if the numbers didn't come out the way they liked.) In the big hospital system, for myself and my patients, I created a little 1/2 sheet of paper that indicated the patients name and how I wanted the patient to be scheduled - on my schedule or with a PTA and when to begin PTA visits OR generally PTA for x amount of time then me for x amount of time on same visit. And if a patient was evaluated by me, since I've worked part time for lots and lots of years, I had a rule that the patient was not allowed to have return visits when I was not in the clinic unless the need for a visit outside of my clinic hours was cleared by me first. Sure it created waves... nope, no other physical therapist on staff (of about a dozen) were doing what I was doing... yep, it was more work for schedulers (job security for them is the way I saw it)... but reality was the patient was inherently my responsibility and I would be held accountable professionally and legally for the provided care.
What is it that administrators really want? 1) They want as much of your time with a patient and billing out for services that are reimbursed. 2) They want low cancel and no show statistics. I've never understood why administration fears allowing PTs to have full control of scheduling. A PT or a scheduler can see a hole in the schedule and knows that hole should be filled with some patient... What I get my panties in a bundle over are administrators that want and desire the PTs to have a full role of mainly performing evaluations... evaluations pay more than any other procedural code. When administrators require this, that means there will be heavy reliance on PTAs to be providing the bulk of return visit services. This also inherently means there will be a higher amount of PTAs in the department - which typically leads to poorer quality of care. The other thing that administration doesn't get is that procedural codes don't reimburse at the same rate - which means that technically, the way productivity is measured is really screwed because the productivity measurement doesn't assist administration in really knowing anything from a financial/business perspective. Think about it... if you decided to do hot pack, ultrasound, electrical stimulation for a visit, you got your productivity... but if you did 2 ther ex and a neuromusculo re ed, you still got your productivity. From a business perspective, which do you think gives you more profitability? Take it a step further, was the company reimbursed for the services provided and at what level were the services reimbursed? A therapist's payor mix will have a huge role on the financial aspect of the business. So, when you piece it all together, what exactly does 4.0 units/visit allow you to really know from a business perspective? It's a crap measurement in my opinion.
The best role a supervisor can have, in my opinion, is that of a leader versus a manager. The more a supervisor micromanages, the more dissatisfied those being micromanaged become. Lead, explain and problem-solve WITH those you are to be leading and I'm very sure the majority will give you 110%.
I think you don't need to be "that guy" with the new grads coming on. I would sit them down and discuss productivity standards one time. Explain to them that these are in place so the business in successfull and in turn the PT is financially successful.
Then I would center most company interactions/staff meetings around quality of care, evidenced based care, and improving delivery. When this approach happens the productivity standars usually fall into place.
I have been with the large corporate company where it seems like you meet every week to discuss how to improve billable units by .2 units an hour. Every meeting centered around this left a bad taste is my mouth.
Bottom line, the new grad needs to at least be educated about the business side and standards but as long as quaility of clinical care is the focus of most interactions everything works fine.
Joined: February 7, 2007
Interesting that you (and I bet many other corporate clinics) meet on a weekly basis to see how to increase billable units by 0.2. Get rid of the meetings (usually useless and waste of time, bad taste left, decrease staff morale, etc) and increase revenue that way.
Intersting posts - some great thoughts. You are all more articulate than I am on this subject.
My business concept is similar to SJBird. I generally tell the employees I manage to determine the time needed for patient care - 15 to 45 minutes. Then I expect those minutes with the patient to be productive from a business standpoint - that is chargeable units.
"When administrators require this, that means there will be heavy reliance on PTAs to be providing the bulk of return visit services. This also inherently means there will be a higher amount of PTAs in the department - which typically leads to poorer quality of care."
SJ, As a PTA I really take exception to this statement. I do not know what type of PTA's you have worked with but I can tell you that when I work with a patient they do not receive poor quality of care. What I can tell you as a PTA that it troubles me when I see PT's treat a patient for 15 minutes and then have a physical therapy technician take over for the rest of the treatment and then the PT bills for the entire "skilled" treatment. I completely understand your argument but please do not underestimate a PTA's education and dedication to providing good skilled care to patients.
Joined: May 11, 2004
Gail Jensen and Linda Resnik's work on "expert" and how "expert" therapists practice. Resnik also has 2 other published studies that were discussed over on the Evidence in Motion blog. One study looked at high utilization of PTAs and the other looked at the association of PTA utilization and state practice acts. There are now 3 or 4 studies that are alluding to poorer quality of care and increased number of visits if PTAs are utilized >50% of an episode of care. The issue not analyzed in any of the studies is how delegation occurs or the processes involved with PTA delegation. I have mixed feelings, poorer quality and increased number of visits could be related to factors involving not only the delegation process, but also the education of the PTA, whether the PTA competent in performing the activities delegated, whether the PTA is following the plan of care...
Rod, I don't have the literature here in front of me, but if you PM me, I can give you the specific references.