Last week I heard a statistic about obesity in the United States. Currently 36% of all Americans are obese, with the number higher in the older population, according to a recent survey. I don't know if the number is accurate but it's probably close. That is a scary number for PTs since the majority of our patient population falls into the older category.
Obesity has become more and more common in our patients. Treating obese patients requires special equipment, extra staff and more time. All of those are becoming harder and harder to come by in the PT world. Hospitals have no choice but to purchase "big boy" beds. "Big boy" wheelchairs and RWs are a different matter. The last two facilities I've worked at had one of each.
If getting the equipment is difficult, actually performing the therapy is worse. It isn't that they are awful patients. If you're obese and you go to a rehab facility, you aren't going to get the same therapy as your slimmer roommate. We don't have the equipment or staff to aggressively mobilize you.
This problem is going to get worse as the older population increases. And it won't get solved. It's pretty clear what's coming. There will be no additional resources available but the demands will increase.
I've evaluated hundreds of SNF patients. They are always shocked when they realize the difference between what they expected and what they are receiving. The perception seems to be, "The rehab facility will have everything I need waiting for me." This includes medications that can't be ordered until the patient arrives.
Now add in the obesity factor. There are so many ways it can go bad. We PTs will do what we always do and give our patients the best care possible with what we have. It will just be harder.
"No good deed goes unpunished."
I learned this week how true that saying is. A couple of weeks ago I gave a new graduate therapist a piece of advice. I thought I was telling it to him in confidence. I didn't think much about it. I didn't want him to get caught up in a situation at the facility.
It seemed so simple and unimportant. In fact I forgot I had said anything until I received a call from the company HR department. It seems the person I spoke to shared what I said to others. One of those others didn't like it and complained about me. Now I'm the one in hot water.
Actually scalding, boiling water is a better description. There was no malicious intent in what I said. I might have worded it differently but the intent was to be helpful. Somehow this has been turned around and I am the bad guy.
Maybe we're beyond the water analogy. Last Saturday, I had to put down my beautiful horse Allie because of an infection in the bones of her hoof. We waited until the weekend so I could be there. The decision was made the day before that fateful phone call. When it came, I wasn't in a place where I could handle more drama. I doubt I was very likable on the phone.
I made a mistake. The price is going to be high.
|Toni's Horse "R Ms Chips" AKA "Allie"
Today the answer is yes, particularly if the patient is a resident of the facility who went out with a medical problem. Not only do these patients need therapy, they need to be on caseload as long as possible. It is the only way a SNF can survive.
Years ago, what I refer to as "back in the day," we had the same scenario. We were encouraged to pick up all Part A patients. The difference was they weren't on caseload very long. Today we're pressured not only to pick them up but to keep treating them as long as possible. Doing so helps the financials.
The facility I'm working at right now is barely surviving. Several residents have developed medical problems resulting in hospitalizations. I wouldn't say the reaction is gleeful when someone goes out, but there is a sigh of relief. They might actually make budget this month.
Obviously decisions about who to put on caseload and for how long are based on clinical judgment, or should be. It's beyond troubling that our current reimbursement structure produces an environment where staying solvent is so difficult. Everything has been cut to the minimum and SNFs still lose money. It won't be too long before current employees have their salaries reduced.
It's causing a conflict of interest. I decide who is on caseload and how long. My salary is dependent on the facility not losing money. If I pick up everyone for therapy for as long as possible then I keep my salary, which might not be in the patient's best interest. If I maintain the caseload based on what's best for the patient, my salary is in danger.
I don't think the situation has gotten that severe yet, but we can't survive much longer as we are now.
My post last month, "The DPT: How Did They Miss This?" has generated numerous comments on the ADVANCE website, almost entirely from readers who agreed with its content. One exception, however, was an assistant professor of physical therapy who stated that making the DPT a mandatory entry-level degree was necessary for the pursuit of autonomous practice.
Our friend Dean Metz, a former ADVANCE blogger who now lives in the United Kingdom, responded better than I ever could have. The following is a partial quote from his posted comment: "As for the assistant professor from Nevada, if it was all about autonomous practice, then why has the UK had direct access for nearly four decades while graduates still have bachelor's degrees? Membership in the CSP (the UK version of the APTA) is at 98% and is non-mandatory."
He makes valid points that no one seems to be addressing. I have one to add. Why are we so focused on autonomous practice, when even if we got it today nothing would change? The general public doesn't know what PTs do and payers wouldn't reimburse us.
Obviously there is something else going on. I have never understood why we put all our efforts into direct access. Wouldn't it be better to work on the payers to secure payment for direct access? We should also be putting more effort into educating the public. If the public demands direct access, lawmakers will notice.
Every Texas Physical Therapy Association meeting that I attend includes encouragement to get our patients to contact lawmakers. We're told one of the reasons we don't get traction from lawmakers is lack of public support.
If autonomous practice is really the goal, then our strategic planners got things backward. The UK is a good example. Why do we need doctorate degrees to obtain something they have achieved with bachelor's degrees? Someone needs to step back and ask what the real issues are. Autonomous practice is a nice idea but probably not what your average PT and PTA care about.
Besides volunteering recently at the Texas Physical Therapy Association (TPTA) annual conference, I also had a chance to meet with both professionals and students. It turned out the number of PT schools is a hot topic in the profession. The answer depends on who you ask.
Students and would-be students both think there aren't enough schools. They complain about how hard it is to be accepted. Some of the locations aren't ideal. They believe more schools would increase the chances of being accepted.
Those in academia also seem to think more schools are needed. They cite geographic areas unable to find enough PTs. They say the acceptance criteria have risen so much that many applicants who would make wonderful PTs never get past the first round. PT schools bring money to universities, so the more of them, the better.
Newer graduates didn't seem to have an opinion. Generally they thought more schools were a good idea but lacked a specific reason why.
The one group against the idea is made up of PTs who have been practicing for a while. To a person, they complain of minimal job opportunities and low salaries. Some of them are planning to leave the profession because it has changed too much. Others can't find full-time employment or can't change jobs because there are no other options.
Several more experienced therapists talked about the new graduate revolving door. Facilities want to hire new graduates because their salaries are lower. As those PTs gain experience and move up the salary scale, they are replaced with other new graduates. The practice is used to keep costs down. It will only work as long as there is a steady supply of new graduates.
I think we have plenty of PT schools, but in the wrong locations. There are so many within 4 hours of each other here in Texas that the entire southeastern part of the state is oversaturated. We aren't the only area with this problem. The current schools aren't going to move, but we really don't need more in oversaturated areas. Every one of the schools in Houston has difficulty finding clinical education slots.
I don't understand how cranking out new graduates at such an accelerated rate helps the profession. It doesn't help our patients either if there is constant staff turnover. I'm sorry that would-be PTs have such a struggle to get in. I just don't think more schools are the answer.
Last weekend was the Texas Physical Therapy Association annual conference. Before the conference began, I attended a board meeting. Among the items on the agenda was a nomination to the APTA. Being curious, I asked what the process was to be nominated to run for a national office.
The process is long. In order to run for a national office, a candidate must be nominated by either the chief delegate of the state or by the PT Board of the state. Either of these entities can nominate more than one person, but only one person per office. They do not have to nominate someone from their state but the nomination is considered endorsement of that candidate by the state.
To be considered for such a nomination, the person must be known to the board and have served previously in other offices, particularly the House of Delegates. It helps to have been a previous chapter president or vice president. District presidency is the usual stepping stone to a chapter presidency.
Realistically it will take at least 10 years to establish the name recognition in the state to even be considered to be nominated. Winning on the national level requires name recognition outside of the state, which is generally obtained by serving three or four terms in the state's House of Delegates, although there are other options.
Getting elected at the state level is difficult but possible. It just might require running in election after election. From what I've seen, it takes two or three tries to get elected to the state House of Delegates for the first time. Only the chapter president and chief delegate go to the national House of Delegates.
Those of us who want to see changes have a long road ahead of us before we can get into a position with the power to influence what decisions are made. The House of Delegates has some ability to make decisions but can only vote on what is presented to them. Policy comes from above.
Even if a nomination is secured, there is one last problem. Most of the people in the higher positions have been there for years and have become entrenched. Unseating them is not easy.
The more I talk to therapists around the country, the more I get the impression very few of us think that requiring the DPT as the entry-level degree for the profession was a good idea. Taken apart from other issues, the DPT is a good thing. But as the required degree, it created a problem. The market did not and does not support it.
Several years ago when the rollout was being planned, the APTA told us it wouldn't matter. There would be plenty of jobs. The market would recognize the value of the degree and salaries would increase to match it. PTs were encouraged not only to get the DPT but also to sit for one of the specialty exams because specialists would be needed.
They were wrong on all three counts. The market, or rather reimbursement trends, is going in the opposite direction. For as long as I've been practicing, there have been cuts in reimbursement. In turn, decreased reimbursement drives down everything. I can't imagine anyone would think that trend will suddenly reverse.
There are four possible explanations. Those doing the planning didn't take this into consideration. Or they didn't think it would make a difference. Or their calculations were completely off. Or they didn't care. Any of those explanations implies lack of understanding of how the world operates.
The problems we face now aren't solely a result of the DPT, but it did significantly exacerbate them. In response, a new trend is developing. Experienced therapists are leaving the profession. The positions they leave are either filled by new grads or disappear. Experience matters, but not in a good way as no one wants to pay for it.
I, and many others, have figured this out. How did someone not think of this a few years ago?
I just got back from a teaching trip in two larger cities near Lake Erie. I was lucky in that I was able to eat lunch with some of the attendees. Both times the discussion eventually turned to concerns about our profession. They had a different perspective than I do.
In that area, new graduates don't hold out for more money. They accept jobs that pay less, which I was told drives down salaries across the board. Because facilities can hire new graduates for less, they don't want to pay too much more for experience. Anyone who wants to work has to accept what is offered to have a job. I can see that trend spreading nationwide.
Both groups independently brought up the belief there are fewer jobs for PTs overall. They felt the job market is shrinking. I agree. I'm seeing the same thing here. Everyone agrees facilities are using less staff to accomplish the same work. But I think there are also fewer patients.
Censuses are down everywhere in Houston. I was told the same is true in the cities where I was teaching. I'm not sure what the problem is. There are fewer patients in facilities, but is that because there are fewer people requiring services or because payers are limiting stays, or because we have an overabundance of facilities compared to demand? I don't know.
Meanwhile, the supply of PTs is ever-growing. I don't think it is as bad for PTAs. When I check the employment ads, there are still more opportunities for PTAs than PTs. But then you can hire two PTAs for the cost of one PT with experience.
I won't even lay this at the feet of the APTA, although they bear some responsibility. Employment opportunities follow the economy and that is reimbursement-based. There are plenty of people who want PT but aren't able to get it. What is sad it that no one seems to care.
On my way home from work today, I stopped at the grocery store. As I was walking to the front door, a woman stopped me. She had one of those electric shopping carts and asked if I would please drive it back into the store for her. I must have looked shocked but after a quick driving lesson, I got the thing into the store.
I was kind of embarrassed as I was driving. I obviously didn't need to use one. Then it occurred to me. If the woman had driven the cart back into the store, she would have had to walk back out to her car. She didn't want to walk the extra distance.
We've all seen the carts in various stores. I never thought about how the system works. You walk into the store, grab a cart and shop. You use the cart to take your groceries to the car. Then the cart has to make it back into the store. The only way to do that is for someone to drive it back to the store, and then walk to the car. That's a lot of walking for someone with mobility issues.
I think the woman asked me because I was wearing scrubs. She must have associated scrubs with healthcare professionals and assumed I would understand. I did. And really, I've always wanted to try driving one of those things. They're much easier to manage than an electric wheelchair or scooter, but they're not a lot of fun.
My hospital serves a large population of non-English-speaking patients. At any given time, one-third to one-half of my caseload speaks Spanish. As a result, the Interpreter Services Department was created. They either employ or contract for interpreters in almost every language. This includes sign language. We are supposed to use these translators or a telephone-based language line whenever we work with a non-English-speaking person.
The problem is there aren't enough translators. Because they are in such demand, it is hard to schedule a translator. When one is available, it is for only a limited time and not always at a convenient time. Usually I end up having my tech translate for me. He isn't a certified translator but speaks fluent Spanish. According to hospital policy, I shouldn't be using him. If I don't, I can't treat those patients.
Obviously using a family member may not be a good idea, since you never know what they are actually telling or asking the patient. Sometimes patients don't want family members to know everything, so that could also violate HIPPA. I speak some Spanish. I'm able to ask the basic questions and perform a simple evaluation in Spanish. If I strictly adhere to hospital policy, I should be using a translator.
I know the hospital has reasons for that policy. Translators are necessary when doctors are communicating important information and discussing plan-of-care alternatives. They should also be used when discussing financial arrangements, home care and all important medical decisions. I think there is a big difference between those situations and asking someone his name and where he lives in Spanish.
I trust my tech to translate correctly what I am saying or asking. I am getting better with the language so I often understand words and phrases. Therefore even though my translator is translating, I also comprehend some of what is being said. I'm not sure that really violates hospital policy. I am asking for basic information, not discussing code status.
This is a slippery slope. I know I'm not the only one in the department who has this problem. Nor is the problem unique to our department. The hospital isn't going to hire more translators any time soon. So I go with the compromise I am most comfortable with, using my tech. It isn't ideal but I'm able to provide good care in the language most comfortable to the patient while maintaining confidentiality.
I wish someone could explain this to me. The baby boomers are aging. Each year, millions more of them will become eligible for Medicare. Instead of increasing funding to cover everyone at current levels, the government is decreasing the funding. Everyone will still get funding but with less coverage.
As physical therapists, we know the aging population will need our services. Years ago we talked about the job security that would come with the aging of the baby boomers. It was simple math. More older people means more people will need therapy. It didn't happen.
Yes, there are more people on Medicare. Yes, they need therapy. But Medicare went managed care. Patients still need therapy but fewer visits are approved. There might be more patients but they're on caseload for less time. Combine that with ever-decreasing reimbursement and we find ourselves struggling.
This is true of outpatient, inpatient and skilled nursing. Patients who used to stay 90 days at a SNF now stay 20 days or less. Inpatient rehab stays are under two weeks. Outpatient and home health patients might get scripts for three times a week for four weeks but it doesn't happen.
How is this better? No one is getting adequate therapy. Why cut reimbursement? Why not leave it at the same levels? You would have more people getting less therapy but it would have been more than they get now. Demand is not driving this equation. In every other industry, increased demand means more products or services.
In healthcare we are asked to do more with less, in less time and be paid less money to do so. Less is not more. I don't understand.
This week I thought I'd follow up on my friend's job search. She graduated the same year I did and lost her job last month. I'm tracking her progress because the plight of experienced therapists seeking work is completely overshadowed by how new grads are doing.
As of last Friday, she had three interviews. Within three days, one told her no. It wasn't a good fit so she wasn't upset. The second keeps telling her no decision has been paid but has reposted the position twice. The third one apologized for having her interview as the position had already been offered to someone else.
That is the total of her success following one month of searching and applying. Granted she's being somewhat picky. In doesn't matter what city you live in, location matters. So does setting to some extent. I didn't ask but would be surprised if there wasn't at least one facility with a questionable reputation no one wants to work for.
She hasn't limited herself to full-time opportunities. Some of the positions she applied for were prn. She thought she'd have better luck with prn jobs since the pay rate is the same for everyone. They aren't calling her back either.
I think new grads are doing better with finding work. The ones I've spoken to recently were all working either prn by choice or full-time.
Economics are definitely playing a role in this and not just in therapy. At my LTAC, there are probably five of us over age 50 and only a few more over 40. One night nurse with 20-plus years of experience has been looking for a year without luck. She feels trapped. She doesn't like her current job but has nowhere else to go. I wonder how many PTs feel the same way.
I hope my friend finds something soon but I doubt it. The pressure to save money isn't going away and salaries are the low-hanging fruit for that.
Wisdom comes to us in many ways. Last week one of my patients told me not to get old. Being an old lady is hard on you.
I've never heard it put any better.
Last week I was involved in a discussion regarding membership in the APTA. For once the topic wasn't new graduates but therapists who were members but no longer are. The question was, what would it take to bring them back in? What do they value? I responded by describing how a SNF functions. Fix that chaos and they'll return.
SNFs are unique. Their purpose is to provide rehab for patients who can't tolerate three hours of therapy and can't return home. They are usually part of a nursing home because those patients also require nursing. The crux of this dilemma is for those patients, therapy is a priority and reimbursement is based on therapy.
Maybe in the beginning it worked. Now we have the bare minimum of staff doing the best they can to provide quality care. SNFs are staffed heavily with PTAs. The PT primarily does evals, re-evals and therapist summary notes. Productivity requirements hover around 90%. That doesn't leave adequate time for documentation.
Some facilities do point-of-service charting, which basically means spending time inputting data into a device rather than with the patient. Some payers don't want point-of-service documentation because they are paying for therapy time, not documentation time. I worked, briefly, at one place where the only way to meet the various demands was to work off the clock, which is illegal. Thus why I say I only worked there briefly.
Equipment in SNFs is limited. There is little capital budget for purchases. If something breaks, there often isn't money to replace it. DME for patients is also problematic. If the patient's insurance can't be billed, the patient will either receive something off the shelf or have to wait until going onto Medicare part B. No facility wants to pay for DME or equipment out of their reimbursement.
SNFs do not pay staff well. This is true of both nursing and therapy, although therapy fares a little better. Lower salaries aren't going to attract quality workers. Nursing care suffers. Medicine and medical supply levels are strictly monitored.
Changing this means changing legislation. The APTA would have to lobby, and lobby hard, for those changes and that costs money. Currently those lobbyists and that money are focused elsewhere.
The problem is SNFs are only one piece of the puzzle. Similar issues exist for home health, pediatrics, inpatient rehab and everywhere else PTs work. Thus we have one very large reason PTs and PTAs drop their membership in the APTA. They don't see any value.
Previously I've written about the financial burden on newly graduated DPTs. If undergraduate costs are included, a new graduate could be as much as $100,000 in debt. The debt is driving decisions about jobs, salaries and benefits. Until last week, I hadn't considered the effect this is having on more experienced therapists.
A friend of mine from another state called me. She lost her job. She wanted advice. She has been filling out applications and sending out resumes. She's had a few interviews but says they didn't go well. She put on her best face but felt like the facilities weren't really interested in her as much as going through the motions. One sent her an email the next day stating another candidate had been selected. The rest haven't contacted her.
She lost her job because the facility downsized. It was losing money and had been for a while, so they cut staff to reduce the cost of salaries. She thinks she was laid off because she had the highest salary of everyone in the department. I'm not sure if that is legal but she is probably right. Salaries are one of the biggest expenses in healthcare.
Facilities don't want to pay for experience. It's been a long time since experience mattered. Everyone wants a revolving door of new grads. Hire a new grad and replace him with another when he moves on. If the same position is constantly held by PTs with little or no experience, the salary remains near the bottom of scale. Even at prn rates, the facilities save money.
This means those of us from back in the day are at a disadvantage. Changing jobs becomes problematic. It might mean staying in a job you hate just to have a job. Or accepting another job you don't really want with a pay cut for the same reason. Or you could work prn at several places and make more money but lack benefits.
This truly concerns me. There is no hope the situation will change in the near future. I just have to hope that I don't experience it.