Employer Demands in Health Care
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
Employer Perspective
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.
ASHA Code of Ethics
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."
Legal Issues
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
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.
The ASHA Leader Article
Ethics and Patient Management: ASHA Guidelines Support Clinicians' Choices