Ethical occupational therapy practice in nursing home care

I teach ethical decision making to occupational therapy students.  One of the most common concerns that I hear from students each year is the pressure that they experience regarding productivity and 'meeting minutes requirements' in skilled nursing facilities.  Nursing homes receive higher rates of reimbursement based on intensity of rehab services that are provided, so there is an incentive for facilities to provide as much 'high intensity' therapy as possible.

Typically, the students express ethical distress because they often believe that the recipients of these services are receiving marginal or no benefit from their participation.

As a population, OT students feel disempowered about expressing concerns in this area during their fieldwork experiences because

a) they perceive that they are 'just students' and don't want to make waves
b) they feel confused because their clinical preceptors are all engaging in the behavior
c) they have competing pragmatic concerns, like graduating on time, having to find a new fieldwork, etc

Students report that many practitioners 'go along' with the push for more therapy because they become concerned with job security or that they simply accept these practices as 'being the way things are done.'

The Wall Street Journal wrote an excellent investigative article on this issue that I encourage others to read fully and carefully.  The article can be found here:

The article describes massive increases in therapy that advantage Medicare payment rules:

"The ultrahigh-therapy rise stretches from small operators to chains. Genesis HealthCare Corp., among the largest nursing-home providers, cited ultrahigh therapy in 58% of days for which it billed the system in 2013, a Journal analysis of Medicare data shows, up from 8.1% in 2002.

Kindred Healthcare Inc., which runs nursing homes and provides therapy at other facilities through its RehabCare unit, did so 58% of the time in 2013 at its own facilities versus 7.6% in 2002. Kindred and Genesis declined to comment.

HCR billed for ultrahigh services 68% of the time in 2013, versus 8.8% in 2002. In December, the Justice Department joined a whistleblower lawsuit alleging HCR pressured employees to provide unnecessary therapy and overbilled Medicare."

The leaders of the speech, physical, and occupational therapy member associations responded to the article with this letter that can be found here:

The response pays appropriate concern to the problem, but I believe that the member associations need to do more than simply "dialogue with industry to address the issue of volume-based versus value-based care and to improve compliance" and "help clinicians navigate complex regulation and payment systems, emphasize their responsibility to report unethical care provision and promote value-based patient care."

Some therapy groups named in the Wall Street Journal Article declined to comment but they also have direct relationships with the member associations, including sponsorships, clinical affiliation agreements, and other opportunities where they 'partner' with the member associations.

I believe it is reasonable to suspend these kinds of partnership arrangements until there can be a more thorough investigation about the practices of these companies.  Membership associations can't claim to be concerned about possibly unethical or even possibly illegal practices that are discussed in the Wall Street Journal article while they are forming partnerships with these agencies at the same time.

Writing a letter in response to the article only pays lip service concern, particularly when partnership agreements with these agencies remain in force.  Temporarily suspending partnerships pending investigations is prudent and sends a much stronger message about the actual concerns of member associations.  Partnerships can be renewed if there is no wrongdoing.  If there is wrongdoing, the member associations should not be partnering with these groups.


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