Twisted Sister sings to me as I research the history of changes in rehabilitation services under Medicare. The more I research, the more validation I am finding in my experience and opinions. And the more I feel the importance of speaking out…
We’ve got the right to choose it
There ain’t no way we’ll lose it
This is our life, this is our song…
I have worked in the “health care system” for over 27 years, known to many of my like-minded friends as the “sick- care system”.
My career has been taken over by government entities who have changed the reimbursement system for skilled therapy services for the second time in 20 years.
The insurance industry is the one who runs the show and now decides how long the patients need therapy services.
When I began my career, after graduating from a certified and well respected Occupational Therapy program at Elizabethtown College, part of my role as an evaluating therapist was/is to determine the need for skilled Occupational Therapy, set goals, monitor progress, and determine when there is no longer the need for skilled services.
I now have very little say in how long someone receives therapy services in adult and geriatric rehab under Medicare Part A services, at skilled nursing facilities where most of short term rehabilitation now happens.
Twenty-seven years ago, physical rehabilitation began at rehabilitation hospitals. Now, most people can no longer head from the hospital to an acute care rehab hospital, as the changes in PPS in 1999/2000 changed the criteria for admission to acute rehabilitation facilities pushing people to go for rehabilitation at nursing homes, with the new tittle of “sub acute rehab”.
Why did this happen?
From my perspective as an Occupational Therapist who has been practicing for 27 years and has lived through these changes, the mighty dollar has taken higher priority than quality patient care.
Sure, the people involved in establishing these changes, the branch of government now known as The Centers for Medicare and Medicaid Services, CMS, including the head of the organization who is appointed by the president, would argue that it is to stop fraud and to improve patient care.
On November 29, 2016, President-elect Donald Trump nominated Verma to serve as administrator of the Centers for Medicare and Medicaid Services, the Health Department agency that oversees Medicare, Medicaid, and the insurance markets.[16] On March 13, 2017, the United States Senate confirmed her nomination in a 55–43 vote.[17] One of her first actions was to send a letter to the nation’s governors urging them to impose insurance premiums for Medicaid, charge Medicaid recipients for emergency room visits, and encourage recipients to get jobs or job training.
Patient’s Over Paperwork:
Taken directly from the CMS.gov website:
Reduce unnecessary regulatory burden to allow providers to concentrate on their primary mission: improving patient health outcomes.
• CMS Administrator Seema Verma launched the “Patients over Paperwork” initiative in 2017, in accord with President Trump’s Executive Order that directs federal agencies to cut the red tape. This helps patients by allowing doctors and non-physician practitioners to focus on care instead of paperwork.
• CMS is eliminating overly-burdensome and unnecessary regulations and guidance to allow providers and suppliers to focus on their primary mission – improving their patients’ health.
• CMS is removing barriers to unleashing innovation.
• CMS is partnering with clinicians, providers and suppliers, administrators, support staff and beneficiaries to ensure we are focusing on the needs of patients.
I call “Bullshit!”
Suppliers and beneficiaries?
Is that code for health insurance companies?
I have MORE paperwork than I did 27 years ago and will have even more now with these new changes and have less time for actual patient care.
This is my favorite part of this information:
Our actions have delivered results
• Saved the healthcare system at least $5.7 billion through 2021.
• Eliminated at least 40 million hours of burden through 2021 giving that time back to providers and suppliers to spend with their patients and not on needless paperwork.
• Heard from over 2,000 clinicians, administrative staff and leaders, and beneficiaries through listening sessions and in-person visits throughout the country.
“Saved the healthcare system at least $5.7 billion through 2021”
Who have they saved $5.7 billion for?
THE INSURANCE COMPANIES!
And these changes both with PPS in 1999 and now in 2019 with PDPM have directly affected the lives of the healthcare professionals who provide these services.
There is a HUGE difference between rehabilitation services in 1992 and what is now happening in 2019.
I worked in an Acute Rehabilitation Hospital in 1992, my first job out of college. It was a great learning experience and an excellent facility. Sure, I hated many aspects of working for this large hospital system, yet I would not change beginning my career there. I left after three years to escape the strict schedule and stress of hospital policies.
I took a job in a Nursing home that had both long term care and “sub-acute care”, the new buzzword for rehabilitation services. My new job had flexible hours and a 35% pay increase. Yet, I soon found out that my role of being a skilled Occupational Therapist looked very different in this new setting and I had to spend less time being a skilled therapist and without the environment of a rehabilitation setting where the focus was on patient care and rehabilitation. And without all the necessary tools to do my job and the experienced professionals that I was surrounded by at my prior job.
I have been working in adult and geriatric physical rehabilitation since that time in various settings including nursing homes with “sub acute rehabs”, home health, and outpatient centers for assisted living and independent living residents.
When the PPS system was being developed, I agreed that there needed to be a change. Yet, the change was from one extreme to the other. The results were not better patient care, but less staff to patient ratios, a shift from quality of care to the number of minutes of therapy equating to a dollar amount, affecting not only the patients but also the staff whose job was to provide needed care for these patients.
Five years after I began working in nursing homes, I suffered a pay cut, reduction in benefits, and was shuffled to different facilities. My position moved from working 4 miles from my home with a 32 hour work week, hours reduced at my request to have time with my 2 year old child and still have full time benefits; to traveling to 2 different facilities in one day, traveling 147 miles round trip each day. I had an amazing boss at the time who negotiated some extra pay in addition to the standard pay for travel between the two facilities.
After traveling like this 5 days each week for a while, she then helped me to switch to working 4 days a week rather than 5 days to return to something closer to my “reduced 32 hour week”.
My other option, was to loose my job. Everyone was cutting staff. There weren’t many jobs to be found.
I spent 9 months searching for a new job. I eventually got a job offer for part time work in home health care which gave me more freedom in some ways but also evolved into traveling a larger area to see patients in 3 different NC counties, Stanley, Union, and Anson. I live in the corner of Mecklenburg county where it meets Stanley, Union, and Cabarrus Counties (see image below: Mecklenburg county is the pink county on far left)
Flash forward to 2019:
Over the past several months, everyone has been talking about the new reimbursement system, PDPM, Patient Driven Payment Model.
I wasn’t very worried about it, listening to my fellow therapists and co-workers “panic” and share the information they had from other employers and our mutual employer. I had gone through changes in the reimbursement system before. I have had issues with this system, and knew a change was needed. I wasn’t surprised that the change would be a pendulum swing to the opposite end of the spectrum.
For the second time in my career, my rate of pay is being reduced.
I had about a months notice for this pay reduction. 3% pay decrease starting October 1, 2019.
“This is minor compared to what I went through in 2000” I told my young coworkers.
From everything I heard, I was not too worried. It appeared that my employer was handling it calmer than other places. I felt secure because even though I am a prn employee, working on an as needed basis, I have had 30-40 hours of work lately because one full time therapist has been on medical leave. And, had plenty of hours before that happened. They needed me.
I knew I would likely have less hours. I was aware of the industry push to use less prn employees and have full timers flex hours and work weekends. This concept had affected me already at my last job less than 2 years ago.
I work primarily weekends because that his been my only semi-guaranteed way to get hours.
Because of the anticipated change, I had been working as many hours as needed while they were available. I typically worked between 15-25 hours before and now began working 30-40 hours. I had several weeks where I had to pay close attention to my hours so as not to go into overtime. Paying prn employees overtime is a big no-no in healthcare. As a prn employee, I have no benefits and so my rate of pay is higher than full time therapists. Yet, my higher rate of pay is the same prn rate as it was 22 years ago.
Flash forward to Monday, September 20, 2019:
11:16 am: I received a text saying I was not needed to come in for the 2-3 hours of work that I had agreed to on Friday. Not surprising, this happens all the time.
My reply:
OK, Hoping I will still be needed Friday with XXXXX having the day off, I had agreed to cover for her.
Working prn, my boss confirms if I am needed to work the next day. If I don’t hear, I check in to confirm I am needed to work. This has been the typical practice for years and across several employers. I have always been frustrated by last minute call-offs, but despite my efforts to change this, the best result I have gotten has been a confirmation text the day before. My current boss has been the most consistent with this practice and this employer has been my best experience working prn in a nursing home/rehab center.
I was then told that I would not be needed on Friday, And likely for the weekend as well.
There were changes that even my boss wasn’t expecting.
I like my current employer and am happy I am working for this company and not somewhere else. I share this because this is an across the board change affecting all of the Occupational, Physical, and Speech Language Therapists who work in rehabilitation where Medicare is the primary reimbursement system.
As is always the case, the need for prn coverage changes constantly and usually, how much help is needed, is not known until the day before because of fluctuations in the census.
This is good, I can now devote more time to the business my husband and I have recently started.
But wait, we are finally out of major credit care debt and I have been working extra hours to pay off debt and to build our savings.
This is good, Gina, the universe is telling you, once again, to pour your time and energy into your new business and writing pursuits.
Will I have any hours over the next week?
I have no idea.
Surely, they will need me once the census picks up.
Right?
We’ll fight the powers that be, just
Don’t pick our destiny ’cause
You don’t know us, you don’t belong
Oh, we’re not gonna take it
No, we ain’t gonna take it
Oh, we’re not gonna take it anymore
Oh, you’re so condescending
Your gall is never ending
We don’t want nothin’, not a thing from you
Your life is trite and jaded
Boring and confiscated
If that’s your best, your best won’t do
It will be ok, Gina, you can finally write more and work on the book that has been inside of you for so long.
It will be ok, Don and I have come along way with our new business and have speaking engagements set up and we are working with a business coach.
This is time to step up and dive in to a new chapter of my career as an Occupational Therapist. I can use my experience and talents in a new way and outside the healthcare system.