Over the course of the past 30–35 years, we have witnessed profound changes in the provision of our nation’s heath care services. In some respects, these transitions are similar to the economic revolution of 15th century Europe. From the late 1960s through the present, we have seen a gradual movement away from health care feudalism , where the economic power and decision-making was largely in the hands of individual physicians and independent facilities, to health care mercantilism, with provider networks, governmental regulations, market collectives, and greater dispersion of power across many different political and market forces.
These economic shifts, along with dramatic technologic advances, have led to a tension between cost expansion and cost containment forces, with providers and patients caught in the middle. Although this tension between "do more" and "do more with less" has created a great deal of uncertainty and stress, a more market-driven health care system has brought with it opportunities for nonphysician providers. The door has been opened for audiologists and speech-language pathologists to expand and solidify a more independent place within the health services community. We have witnessed a greatly expanded scope and access to skilled services for communication disorders, which have put pressure on our academic programs for competent entry-level professionals and for specialized training and clinical research. Although we have had to wrestle with the insecurities of a more open marketplace, the economies of our professions have benefited, directly and indirectly, from the changes in the health care industry.
But, like most good things, gaining access to the health care arena has brought with it some obligations—principally, we have had to ensure that our professional practices fit and align with the business practices of our employers. Making that reconciliation is difficult for many of us. However, learning to incorporate business practices into our day-to-day work does not mean engaging in unethical or deceptive practices. Understanding the business side of your profession does not imply sacrificing professional standards or ethics for the sake of the employer’s "bottom line." "Cost-effective" service does not equate to cutting any corners that ought not to be cut, nor should it mean charging for less than what the payer expected to get. Engaging in substandard, unethical, or inadequate clinical practices puts the provider facility or organization at risk and is not good for business. Simply put, good business practices in health care mean delivering excellent clinical services in an efficient and cost-effective manner to achieve satisfactory outcomes.
Survival of the Fittest
It is not an exaggeration to say that working in a health care setting today is a fiercely competitive "survival of the fittest" struggle. To remain competitive, we may have to make some changes in the way we do things and get actively involved in advocacy. To advocate effectively and to achieve a strong and respected position for the disciplines of audiology and speech-language pathology as service providers, we have to know what we are worth and then confidently communicate that worth to policy-makers. We have to know the costs and benefits (especially in comparison to other providers) of communication services.
Defining and communicating our worth requires a great deal of work on multiple levels: more research in the efficacy and effectiveness of our clinical practices, more outcomes and cost-benefit data, increased support for consumer awareness and consumer advocacy, and persistent advocacy with public policy-making bodies. These efforts should ultimately result in more evidence-based services (which means getting the "best bang for the buck"), better consumer access to our services, and a more level playing field for us among other providers.
None of us entered the disciplines of audiology or speech-language pathology expecting to get rich. We expect to be paid a fair wage, but the connection between our individual efficiencies and keeping the doors open to the facility where we work is not something to which we want to pay much attention. That lack of focus on the business side of our profession has some inherent risks. It risks the competitive edge of audiologists and SLPs in relation to other providers in the health care marketplace. It risks the financial viability of the organizations we work for. It risks jobs. It risks a loss of access for our patients to the quality of care we think they deserve. And, it risks placing clinicians at a disadvantage should they ever be requested to do something that is not consistent with ethical proscriptions. Knowledge can be the difference between becoming a victim or becoming a player.
Emphasis on efficiencies in clinical practices and knowing how to do your job within the constraints of an individual patient’s available resources cannot come too early in our clinical preparation. Entry-level clinicians today have to come with or acquire these skills quickly, or they are not going to be very happy in their jobs. To do that—to work within the patient’s coverage and the business practices of the organization—requires knowledge and skills.
ASHA’s Ad Hoc Committee on Business Practices for Speech-Language Pathologists in Health Care Settings has developed a draft knowledge and skills document that targets several focus areas of practice, including obtaining compensation, marketing your services, participating in your organization’s performance improvement, fitting into the business plan of your organization, maximizing use of technologies, maintaining ethical practices and compliance, and engaging in advocacy and activism.
The following topics reflect the core issues identified by the business practices committee.
Compensation is how the organization gets paid for your time and, consequently, how you get paid. Compensation comes from meeting the performance expectations of the organization in such a way as to ensure the organization can recover its costs and end up with some amount of profit. These performance expectations may be stated as "productivity," "target billings," "billable hours," "visits," "procedures," "the numbers," or some other euphemism for the unit of output that ultimately results in compensation.
Being productive is more than just staying busy doing clinically important activities. On any given day there are many things we do that typically will not be directly compensated (scheduling, phone calls, preparation time, patient care meetings, reviewing audio and video tapes, filing, report writing, etc.). Finding ways to do these things with as little ("nonbillable") time as possible is a key performance expectation. Similarly, it is not enough just to generate direct "billable time" with patients if that involves services no one will compensate you for (e.g., services that were not authorized or services that were not adequately documented). Oftentimes facilities have documentation requirements that incorporate many different reimbursement schemes and have to hire case managers, coders, and clerical support personnel to monitor authorization, coding, and documentation to ensure that those requirements are met. Adding those processes and personnel increases costs, of course, but they are essential to ensure compensation.
Imagine that your weekly salary came to you not as one check, but 40 different checks from 40 different payers, each compensating you for one hour of your time in a given workweek. These 40 payers are a mix of public and government agencies, insurance companies, and private entities, such that there are 40 different sets of regulations for you to follow to submit your timesheets to obtain your wages, and there are 40 different rates of compensation for your time, from 100% to zero. Some of these employers will pay you a fair compensation for an hour worked. Most pay you some percent less than a fair compensation for your time. Some may decide that only part of what you did fits their authorization stipulations, so only a fraction of the hour deserves payment. Some will decide to pay you nothing at all. Each week the size of your salary varies depending upon the mix of payers.
You get the idea. This scenario merely illustrates the problems faced by organizations when attempting to cover expenses when there are a variety of payer sources. The number of different payers the organization actually works with, in reality, could be fairly small or far greater than 40 (more like 140 in large organizations), and the rules and regulations will vary accordingly.
Marketing Your Services
Along with developing the knowledge and skills necessary to ensure compensation from a variety of payer types, it is important to know how to participate in the organization’s marketing activities and to understand exactly what marketing is. Marketing is not "advertising" or "sales" or recruiting referrals by setting up booths at health fairs. Marketing is a key business strategy in most health care organizations. Marketing includes what are commonly referred to as the "5 Ps"—promotion, pricing, place, position among competitors, and product. Each of these areas is integral to marketing success and all are interdependent. Without a quality product, promotion is a fairly empty enterprise. Our "product" is quality clinical outcomes that satisfy the expectations of our patients and their families. Balancing price and product means ensuring an excellent clinical service at a reasonable cost.
For various reasons, organizations do not always achieve consistently good outcomes (quality products). In those cases, the organization’s performance improvement analyses provide a way to identify, study, and achieve better outcomes. Targeting "better outcomes" can include efforts to have more effective clinical services, fewer complications and safer procedures, quicker response times, more patient-friendly service, practices that are more evidence-based, and so forth.
Organizational Business Plans
Another business skill set involves ensuring that your clinical services and work practices align with the business operations of the organization. Exactly what type and line of business is the organization in? Is your employer organization a nonprofit, not-for-profit, or for-profit organization? Is it in the business of providing primary care, secondary care, tertiary care, or quaternary care? These factors are important with regard to the regulations under which the organization operates, the governing or oversight of its financial operations, its profit reporting practices, and where the organization fits within the "care continuum."
To improve efficiencies, clinicians have to make good use of every available labor-saving and timesaving technology at their disposal. Any technology that merely creates more work is obviously not a welcome addition, but most organizations have acquired paperless processes that provide documentation formats easily adapted to our clinical services and computerized ways to capture billing. Anything that can be done to reduce the transfer of paper from one human being to another ultimately is a cost savings and a good business practice.
Ethical Practices and Compliance
Clinicians have to be keenly aware of what it means to practice ethically and work in compliance with all of the regulations and rules that apply to the organization. Ethical practice and compliance reduce risks to the organization. They are essential to good business practices.
Advocacy and Activism
Advocacy is key to both defining your worth within an organization and within the health care industry at large. Advocacy results in more favorable public policies. Without policies to provide a competitive edge, or at least a level playing ground, it won’t matter how efficiently we practice or how business-savvy we are. Policy-makers must recognize and acknowledge the benefits and worth of skilled services provided by well-trained audiologists and SLPs to reduce the physical, psychological, and social consequences of communication disorders. What is the cost and benefit of hearing, speech, language, or swallowing?
Audiologists and SLPs with knowledge and skills in business practices will help to protect the interests of our profession and our livelihood in the health services marketplace. There is fierce competition for dwindling resources in every setting in which we work, regardless of where the support or funding for the organization comes from. It is up to each of us to ensure our profession can successfully compete for those resources. Your profession is your business.