Members in a variety of settings contact ASHA with concerns about employer demands. In fact, the most common reason members contact ASHA's ethics team is for issues related to employer demands. The following examples are excerpted from contacts made to the National Office:
"I was told that 'it was noticed that I [discharged] these patients sooner than other SLPs who had worked there' who had reportedly continued treating all their patients from beginning to end of their length of stay and had no difficulties meeting the productivity expectations. I questioned their policy of continuing to treat patients who had either: 1) reached their functional/maximum potential in skill recovery or 2) who were clearly not benefiting from continued therapy. I was told that, since these patients are billed on a DRG-based system, they would not be charged any more/less if I continued to treat them until the end of stay and that continuing to treat patients in either of the two scenarios would not "harm them". I was also told that (using these rationales), I should not feel as though I was compromising my ethics."
- ASHA member
"Rehab agencies are requiring therapists to be 80% productive or the therapist should go home for the remaining part of the day. In order for therapists to pay their rent, they have to rationalize taking on patients that are noncompliant or not appropriate for therapy or not appropriate for as much therapy as told by the facility and rehab agency. [In addition], patient's right to not have therapy is NOT taken into consideration. I know in regards to speech therapy, this means that patients sit mute and not imitating oral motor exercises for the entire therapy session so that Medicare dollars can be siphoned. Noncompliance is never noted for it would result in not getting the required amount of time for reimbursement."
- ASHA member
Employers experience financial pressures which they may transfer to clinical staff as pressure to include or keep patients on a caseload. Health care is a business and, as with any business, there is a bottom line. Reimbursement for medical services is the primary means by which facilities or agencies pay staff and cover overhead costs. As we are all aware, health care dollars are shrinking and payers are very stringent about what they will pay for and when. However, just because a payer will reimburse for a service does not mean that the service is appropriate and should be provided.
In addition, administrators may not completely understand the nature of speech-language pathology intervention and may set productivity levels higher than what is realistic for the SLP. Codes for SLP services are typically session-based rather than time-based. Therefore, while a PT may see a patient for one hour and bill for four units of one code, the SLP may only bill one time for the entire hour-long session. If administrators set productivity levels by "units," the SLP's productivity will suffer and there may be pressure to see more patients to improve the numbers. Again, keeping patients on caseload just to meet productivity demands is not appropriate and demands to do so may compromise the SLP professionally and ethically.
Principle of Ethics I of ASHA's Code of Ethics clearly states that "Individuals shall honor their responsibility to hold paramount the welfare of persons they serve." Rule G further clarifies that "Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected." In addition, Principle of Ethics IV, Rule G states that "Individuals shall not provide professional services without exercising independent professional judgment, regardless of referral source or prescription." Taking these three statements together, it is clear that the SLP's ethical responsibility is to the patient and that providing services when the patient will not benefit from them or because the SLP "was told to" is inappropriate.
As stated in the Issues in Ethics Statement, Prescription, "In all circumstances, it is incumbent on the speech-language pathologist or audiologist to determine when to accept limitations on professional responsibility. As long as the speech-language pathologist or audiologist maintains independence of judgment and preserves the professional prerogatives to plan and provide speech-language pathology or audiology services that are in the best interest of the individual client and accepts responsibility for the plan and services so provided, there is no violation of the Code of Ethics."
In addition to ethical issues, there are potential legal issues around fraudulent billing. Submitting for or accepting payment for services that are not clinically necessary or appropriate is illegal, regardless of the payer source or method of reimbursement (fee-for-service, Prospective Payment System, etc.). More information on this topic is available in the Issues in Ethics Statement, Representation of Services for Insurance Reimbursement of Funding.
Patient rights, as mentioned in the second member statement above, also must be considered. If patients have decision-making capacity and state that they do not want to receive treatment after being fully informed of all of the SLP's recommendations, this decision must be respected, regardless of what it might do to their health (in the case of refusing swallowing recommendations, for example) or the impact on the facility's bottom line. Patients who consistently refuse treatment, verbally or nonverbally, also may not be appropriate candidates for treatment. Continuing to see patients when they do not want to receive services is not appropriate. It may also constitute fraud to continue to see the patient and receive payment for services via direct billing or higher DRG categories if compliance issues are not documented and progress is implied.
Ethics and Patient Management: ASHA Guidelines Support Clinicians' Choices