The Health Files: Ethics

The Office of Inspector General (OIG) and the US Department of Health and Human Services (HHS) has been focusing on practice of skilled nursing facilities (SNFs) more closely for over a decade; however, since the 2009 report summarized heavy resource utilization groups (RUGs) overbilling, things have gone downhill. Unfortunately, despite attempts to place greater focus on skilled nursing care and outcome measures by reformulating RUGs, PEPPER reports tracking benchmarks and introducing G codes to track functional outcomes, Medicare payments during 2012 and 2013 have risen continuously, resulting in a staggering $1.1 billion. According to the OIG, almost 80% of that increase is due to “ultrahigh” RUGs. In fact, according to OIG’s 2015 Semiannual Report, the agency recouped $3.35 billion from Medicare overpayments. So who is billing ultra-high RUGs with no apparent improvement in outcomes?  Let’s go to the source.

Rehabilitation professionals are prescribing therapy intensity, duration, frequency and mode. I love my profession, but I am troubled to look into the future because many employers continue to stress high benchmarks for therapy utilization groups, case mix index (CMI) and daily productivity which may be influencing prescription of therapy. The ethical values of our profession are being stretched thinner and thinner.

Despite the spike in ultrahigh RUG utilization, quality of therapy has not changed in most organizations, nor have patients’ functional outcome measures.  Many therapists still do not even use standardized tests and measures to quantify data. An obvious gap exists between quality and quantity of services provided. Regardless of the flaws in the system, we, therapists, are part of this dilemma. The organizations that hire therapists set expectations and we are “forced” to comply. Or are we not? Do we question if expectations are ethical and if so, what’s next? Do we lose the job or pass on a promotion? When a therapist functions both as a clinician and a financial manager, who has revenue integrity in mind, making ethical decisions can be even more difficult. I am not looking to blame or point fingers, but let’s face it: The bottom line is that prescribing quantity and quality of skilled therapy is in our hands, and patients’ outcomes as well as outcomes of this debate affect the future of this profession.

CMS announced last year a new ACO payment initiative called the Next Generation ACO Model, designed for entities experienced in coordinating care for populations of patients. Next Generation ACOs reflect CMS’ commitment to exploring different Medicare payment arrangements that encourage providers to assume higher levels of financial risk and reward while delivering quality care, as this ACO Model is focused even more on value-based contracting2. As the healthcare model changes from reimbursing for services provided to reimbursing for quality of services provided I can’t help but question if most SNFs will continue with the same rehabilitation practices? Will they have new metrics for measuring therapy outcomes? Will reimbursement to those SNFs that change nothing be negatively affected? Will RUGs be still utilized in collaboration with quality metrics to determine reimbursement? As many already know, in 1998, RUGs were introduced as mutually exclusive categories that reflect levels of resource used in long-term care settings. Standard order or hierarchy exists and each RUG is associated with relative weighting factors and respective reimbursement. Similarly, case mix index (CMI), is used to determine the allocation of resources to care for patients in SNFs. Yes, resident and patient acuity (health and functional status) has a major impact on facility resources requirements (CNA, Nursing and Medical staff staffing), but many SNFs and rehabilitation companies work backwards, by setting benchmarks to be met. In addition to setting benchmarks for therapy utilizations, therapists have productivity benchmarks to meet, which do not take into consideration patient transportation, family consultation, case conferences, and viable clinical documentation. No doubt the cost structure must be reevaluated, so worth of value can be redirected from volume to value. As Chris Hayhurst pointed out in PT inMotion magazine published on July2015 that many therapists are “… frustrated with the disconnect between measuring performance and productivity by volume only and missing the “value” part of the equation.”

CMS is moving forward with the new payment and rewards model. In January 2016, the HHS announced that by the end of 2016, it aims to link 30% of Medicare reimbursements to the “quality or value” of providers’ services, and 50% by the end of 2018. According to HHS Secretary Sylvia Burwell, the goal is “to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients3.”

According to CMS, the Health Care Payment Learning and Action Network will perform the following functions:

  • Serve as a convening body to facilitate joint implementation of new models of payment and care delivery,
  • Identify areas of agreement around movement toward alternative payment models and define how best to report on these new payment models,
  • Collaborate to generate evidence, share approaches, and remove barriers,
  • Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, quality and performance measurement, risk adjustment, and other topics raised for discussion, and
  • Create implementation guides for payers, purchasers, providers, and consumers.

Despite major glitches in the system, the show must go on. Some therapists are vocal about making changes in this system. Others are complacent with salary and expectations, but on daily basis, most therapists are faced with ethical dilemmas to stay compliant with productivity, RUG and CMI expectations all while making goals to improve patient outcomes. Despite the fact that many rehabilitation professional organizations joined in to publish a “Consensus statement on clinical judgment in healthcare settings,” which discusses how “decisions regarding patient/client care should be made by clinicians in accordance with their clinical judgment1,” many therapists continue to normalize a routine of seeing most patients for 720min/week and doing house-wide patient screens two weeks prior to CMI assessment period. It surely boosts the reimbursement, but is this normal, ethical, accepted? One solution I found to work is development of specialized programs. As part of specialized program protocols it is paramount to use evidence-based protocols to document progress as well as focus on staff and leadership growth.


  1. Link to: Consensus statement on clinical judgment in healthcare settings
  2. Next Generation ACO Model, Centers for Medicare & Medicaid Services.
  3. Link:

About The Author