Productivity is Ruining Healthcare

There's a dirty little secret in the therapy world. Physical therapists, occupational therapists, and speech therapists are expected to be "productive" a certain percentage of their working hours. It doesn't sound too outlandish at first, but wait...there's more.

First, allow me to define "productive" as it pertains to this profession. One can only count productive minutes as those that are reimbursable by a payor source, or insurance and, namely, Medicare. The only activities that are reimbursable are the therapeutic ones performed on a patient. This includes strengthening, any functional training and any education or training that will lead to improving a patient's function or safety. What's not included is bringing the patient to therapy (which most often includes tracking down a patient not in their room), helping a patient become ready for therapy unless it is therapeutic (dressing, toileting, brushing hair), communicating with a patient's nurse, doctor or other therapist (although this is a requirement for every patient), or even documentation (even though the patient cannot receive benefits without clear and concise documentation ). So literally the only thing that counts towards productivity is therapy provided to the patient.

Many different settings require varied productivity standards for their therapists. For this blog, I am going to speak of the standards set forth in a skilled nursing facility (SNF) and short stay rehab. This is the type of setting your grandma or grandpa may go to after they've had a fall and need to return to a functional level where living at home is safe. Other settings like acute rehab, outpatient therapy, home health therapy, and acute hospital have their own standards, but I do not want to speak on a subject of which I have little experience. It is very common for a SNF and short stay rehab company to set their productivity standard between 90% and 95%, usually 92%. That means that, your grandma's therapist must be working with a patient in a manner to profit the company 92% of the time that therapist is clocked in at work. Which means 8% of their day while clocked in can be spent on pushing a wheelchair down the hall, communicating with the patient's nurse, helping the patient with some mundane task in their room to make them feel more comfortable in this unfamiliar setting (put water in their flower vase, hang up the picture their grandkids sent them, etc), documenting the patient's treatment in such detail that the payor source is confident in approving their stay, and relieving their own bladders. Actually, relieving their own bladder is the only thing listed that is allowed to not actually happen (can you say "chronic UTI"?) As you can see, it can be very easy to have one small moment go awry and set off a chain of events that leads to a day of low productivity, say only 89%.

What happens when a therapist does not reach productivity? Well that depends on the company. More often than not, the therapist is reprimanded. I recall a time when I was reprimanded in front of the entire therapy staff for not reaching productivity the day before and told I should "try to work harder". Had the manager bothered to ask she would have found out whomever made my schedule for that day (you heard that right, they didn't allow the therapists to make their own schedules) had placed me in three different buildings which made for a lot of walking between patients. One day of lower than acceptable productivity resulted in public shaming. Some therapists have their jobs threatened if they do not make productivity, stating they can be replaced at any moment. Try to give good patient care with that looming over your head. I once had a phone interview for a position in a SNF with a nationwide company. Their first question to me was, "Our productivity standard is 93%. Is that something you think you can do?" This threw up a red flag to me but I proceeded with the hiring process, mostly out of curiosity. At the in-person interview with a different manager, the first thing said to me was the productivity expectations are rigid, do not waste time with reviewing a patient's chart prior to treatment. I did not accept the job.

These unrealistic standards are ruining healthcare. They are forcing therapists to cut corners and sacrifice their own bodies in order to help the corporate company make a profit. And I say this as a business owner: I understand having to stay above water in order to stay open and provide any services at all, but at what cost? Therapists are quitting the field daily, unable to continue giving their ethics and own well being for the company's bottom line. No one goes into this line of work for the glamor and great pay. This is a selfless and often times thankless profession, but also an intrinsically rewarding and satisfying, fascinating career. It is a shame to push talented and dedicated workers to their breaking point.

And those that don't leave, are stuck trying to navigate in an environment that is impossible to understand. They are unable to provide the patient with the amount of attention and time they need in order to excel in their therapy goals. Therapists are clocking out while still working in order to not be reprimanded. They are skipping bathroom breaks and lunch breaks. They are coming home at night completely worn out, pained, and exhausted from performing the physically demanding jobs of two people (therapist and patient transporter) thus sacrificing quality time with their families. Productivity does not measure the efficiency of a therapist, but rather, the bottom line of a company.

Medicare is not run by a bunch of dummies. Regulations are ever evolving to avoid corners being cut at the cost of the patient. Documentation cannot be performed during patient care one day only to turn around and regulate documentation should only be performed during patient care; No group therapy, only one on one treatments; rest time cannot be counted towards billable units. If you can conceive it, it's been attempted. But these companies always find loopholes to make their productivity standards feasible. With the release of the most recent Medicare changes to reimbursement, called PDPM and PDGM, many companies have used the regulations as an excuse to resort to pay cuts to therapists. So not only are these highly trained specialists not making enough to pay their student loans, they are expected to work long hours until their bodies give out for less money.

I have worked in a couple areas that used productivity correctly: to measure the efficiency of the company's processes. If a therapist is able to meet reasonably set productivity standards regularly, the company has efficient processes in place. Period. If a therapist's productivity is low, why? Are there ways the therapist can be better supported by management? How can policies adjust to allow maximum productivity of therapists? If a therapist's productivity is high, why? Does more staff need to be hired? Can a therapist meeting productivity of 95% really be giving quality treatments to each patient? Patient outcomes should actually be the gold standard of a therapist's and company's efficacy. When choosing a facility to care for your loved one, are you more concerned with the outcomes of their former patients? Or how much profit the therapist makes for the company?

Things won't improve unless we demand improvement. How can you help? Therapists: demand better from these companies. If they are not treating you with full appreciation and supporting you, ask for better. If they don't provide that, find a better company. Obviously, that is not always an option. But in this day and age of limited benefits and no more pensions, it doesn't hurt to always have the feelers out there. Be in touch with your national organizations like APTA, ASHA, and AOTA. Join groups on social media dedicated to unionization of the profession. Get involved but most of all, stand up for yourself. Managers: people work hard for those that work hard for them. Every day that your employees show up to work is a miracle and you need to appreciate that miracle. Ask your staff, "How can management support you better?" then follow up. Consumers: many of you are probably unaware of how therapists are treated. I've had family members say to me "you have an easy job" while I was holding back tears from the back, knee and foot pain. When choosing a facility for you or your loved one, do your homework. Research a company's rating and patient outcomes. Patronize the companies with good ethical standards. And please grant your therapist some grace if they are 5-10 minutes late.