Tag: medicare

Matthew J. Mullaney
1918 - 1997

What my Dad knew

Matthew J. Mullaney 1918 - 1997
Matthew J. Mullaney
1918 – 1997

My Dad worked for 37 years at a job he loved. He worked at Boston City Hospital in the TB Control Department. His job was to do the intake and keep the records of all the outpatients being treated for active TB. If somebody failed to come in for scheduled treatment, he would alert the public health nurse who would go track the person down and bring them in for care. His department approached the public health crisis, which was swamping the nation, one patient at a time to save a city from an epidemic. Dad was proud of his work and the lives saved and the city that invested manpower and resources in the “general welfare” for the public health of the City of Boston.

It was toward the end of his career, his faith in healthcare was shattered. He watched helplessly as politicians declared the TB epidemic over, closed TB hospitals and merged departments under a larger Infectious Disease umbrella.

“We almost wiped it out. They stopped before it was completely gone. TB will be back. It’s too opportunistic to give it a chance to get away from us again,” Dad said to me after reading another chronic care hospital was closing.

Dad died shortly before it became evident TB was on the rise once again in the US and stronger than ever. Which means, Dad missed the total politicalization of healthcare. I’m glad he didn’t live to see the disgrace we have made of a once noble profession. Work where we worried about saving the world one life at a time.

Healthcare has become a system where decisions are made based on insurance type dictating care dispensed, the duty to die versus being a long term financial drain on a buckling system, and state legislatures and congress deciding what women and their doctors must discuss regarding their most personal care. Do no harm is very low on the decision tree for most providers these days.

The constant strain of doing more with less, generating revenue and cutting costs has shifted our collective focus from the person needing care and the professionals providing care to a bottom line mentality. Politicians and insurance companies are now standing between the ill and their caregivers. They have become the self appointed gatekeepers holding the purse strings.

Politicians and TV’s talking heads have stated as a matter of fact that fixing healthcare means cutting costs. For some reason, most of the public choose to believe this. The truth is closer to these being two separate problems which may be mutually exclusive. Fixing healthcare means getting people the care they need before they are in need of emergency treatment and educating/retaining enough professionals to fill the huge gaps we have in caregiver coverage. Cutting the cost of healthcare means getting serious about fraud, kickback schemes, rethinking for profit healthcare, and equitable prescription drug costs.

Each day the system seems to collapse another millimeter. We professionals grow more callous every time we see the darkness shrouding health squeeze the hope out of the next desperately ill patient on our ever growing list of treats to be seen in 8 hours. People have become IDC9’s and are dealt with in billable units greater than 8 minutes per HCPCS code.

It all sounds so terribly hopeless, doesn’t it? Most days, it feels that way too. But, the solution is really very simple. It is the approach my father and his colleagues used to wrestle the TB epidemic in the 1950’s. You treat one patient at a time, regardless of ability to pay, to arrest the spread of the disease and save your patient. This ensures the general welfare of the public and you save your city one life at a time.…

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Enduring Nemo

Enduring Nemo

A blizzard by any other name

Here in New England there are certain things which are expected. Snow in the winter is one such thing. We understand it will happen and prepare for it by getting snow tires and shovels. Blizzards, from time to time, are expectations too. We don’t deal with blizzards quite as well. Perhaps because, you can’t prepare adequately enough for all the things that can happen with a storm that can last for days dumping snow with wind whipped freezing temperatures and a measure of thunder and lightning to punctuate our vulnerability to nature. It is a meeting of all the elements we have absolutely no control over and it is pretty scary regardless of how many times we live through it. 

Blizzard 2013 is finished and the digging out has begun. The tallies are impressive enough to put it into the top 5 of our all time snow storms. I road the storm out in my little town by the sea. We are surrounded by water on three sides. So, we had the extra fun of flooding to deal with. As unbelievable as it seems, my power was out for only about four hours. We have our own municipal power company with windmills. The team there does an amazing job keeping us lit through the worst nature hurls at us. How they achieved what they did last night completely confounds me. My house was literally rocking and remains encased in ice today. Yet, some brave folks were out in the teeth of that storm trying to hook up wires. And, Nancy Helm-Estabrook said speech pathologists have the hardest job in the world.

Why am I spending time writing about yet another New England storm when there have been so many before and there will be so many more to come? Because, the Blizzard reminded me of Medicare.

Having worked in Healthcare all my life, I should expect the blizzard of changes Medicare dishes out yearly. It should be second nature to hospitals and healthcare professionals to weather reimbursement storms which descend on us from a congress that has no idea what it takes to keep people alive, healthy, and coping with their illnesses. A congress which does not participate in the healthcare system it regulates.

But, each year I’m stunned by the changes. The companies I’ve worked for have been stunned. Many collapsed. In fact, over the years, I have worked for  fifteen different companies. Nine no longer exist. All the closed business hit their breaking points around some Medicare cut or other.  PPS alone  knocked the coffin nails in on five of them.

The question that keeps bothering me is, did any of the changes really save any money? Or, where they really just a blizzard of hot air with two foot deep drifts of paper and booming rheotoric?…

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When Rehab Came to Long-Term Care

When Rehab Came to Long-Term Care

For this entry of REFLECTIONS, the founders of this website decided to take a moment to reflect on our own careers in the field of Speech Language Pathology, particularly that portion that brought us together.

Way back in the very late 1980s/very early 1990s, we were both moonlighting as contractors in long-term care.  We had both come from in-patient rehab settings working with brain-injured adults and were looking to expand our skills.  Back then, SLP’s were required only on an ‘as needed’ basis in nursing homes. PT’s were required 6 hours a month and OTs were regulated to 4 hours.  There were no rehab teams, because rehab didn’t happen in nursing homes.  Nursing homes were for custodial nursing care.  If a patient had a problem, the home would call us. We would swoop in, do an evaluation and leave a long (sometimes very long) list of recommendations for the nurses to carry out.  We didn’t treat the problem.  Follow up was PRN – at the request of the nurse – if the problem didn’t resolve, given our extensive recommendations.  Thinking back, it is shocking how much we didn’t do.  Even more surprising was the fact that the head injury facility where one of us worked full time (in a department that included two other full time SLPs and two full-time SLP-As) actually occupied three wings of a four wing long-term care facility, and in five years of providing full time care, our department was called to the nursing home wing only once.

Then things changed.  In order to cut costs and defer care away from high priced hospitals, insurance companies and the federal government’s medical insurance plan, Medicare, began to reimburse nursing homes for rehabilitative care.  It was pretty much a pass through arrangement which allowed nursing homes to charge a fee for rehabilitation services which Medicare then paid.  This opened up huge opportunities for nursing homes and contract rehabilitation companies that provided rehab staff
(PTs, OTs and SLPs) to nursing homes.  This was now the mid 1990s and we found ourselves setting up departments and policies and feeding programs and language therapy in facilities that had never had them.

A population we always thought we’d just dabble in, in a setting no one ever liked, we began to love.  And then we started to teach other people (students and CFYs) to love it.  Senior citizens are awesome.  They are wise and hilarious and generous and aggravating. They allowed us into their home (the nursing facility) so that we could care for them.  It was a joy to see them improve, heartbreaking when they didn’t and an honor to shepherd them through difficult times as they approached the end of life.  The process transformed traditional nursing homes where people went to die into skilled care facilities where people lived, got better, sometimes went home or stayed and lived their lives in a place they could call home.

Then came more change.  Enter the Balanced Budget Act of 1997.  The Balanced Budget Act of 1997 was an omnibus legislative package enacted to balance the federal budget by 2002.  The Act resulted in $160 billion in spending reductions between 1998 and 2002 with Medicare cuts responsible for $112 billion of that total.  This became the real test of our love of long-term care.  We now of course, had to do more with less, but this is also when our programs started to grow and coordinate with nursing and our fellow rehab professionals.  We were a smaller more mobile band of therapists working hard to treat a population that viewed the nursing home as a short-term stop on their road to recovery. Before our entry into rehab in long-term care, no one would have ever thought that a patient would return to the community once they entered a nursing home.  Now today, most rehabilitation following surgery, strokes or general hospitalization happens in nursing homes for people over 55.

As we look back/reflect on this part of our careers, we are pleased to have been a part of the group of professionals who changed how healthcare was provided in the US. Our work extended care to millions of neglected older Americans warehoused in institutions. We improved their lives in terms of survival and opportunities to return home. In fact, you would be hard pressed to find a nursing home in the U.S., accepting Medicare dollars that does not have an SLP as part of their team. It has been our privilege to participate in this leap forward in service delivery to provide a better quality of life for our Nation’s most valuable living treasures: our parents and grandparents.

About the Authors

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.  Contact Marguerite at mullaneycccslp@comcast.net.

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

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Unreasonable and Senseless

Unreasonable and Senseless

By Marguerite Mullaney

Unreasonable and Senseless

The cornerstone words in all rehabilitation treatment plans are reasonable and necessary. They have been the yardsticks by which our Medicare reimbursement intermediaries retroactively determine if a claim for service is covered under the Medicare A benefit or Medicare B plan. Seventeen years ago when I first walked into a nursing home and began to learn the rules for providing rehabilitation services in a Skilled Nursing Facility (SNF), reasonable and necessary were applied to every goal of each individualized treatment plan written for our patients.

I might mention, those plans were handwritten by the evaluating therapists. The goals were often agonized over to be sure they fit the reasonable and necessary parameters and could be measured should proof be needed of the final outcome. Way back in the 90’s, the therapist writing the goal was more than likely to be the person carrying it to completion. PTA’s and COTA’s were utilized as an additional resource but not the primary therapist responsible for weekly updates, monthly recertification, home evaluations, and discharge summaries. In short, they assisted the registered clinician in carrying the caseload. Then as now, Speech Language Pathologist cannot use an SLP assistant at SNF level and receive Medicare reimbursement as our PT/OT colleagues can. This means an SLP carries a caseload in much the same way he/she did almost two decades ago.

The rules changed in January 1999. The Prospective Payment System arrived! It was designed to cut Medicare waste and fraud. It was marketed as a means to control the spending at the SNF level which was rocketing out of control. Many inside the industry puffed about the system forcing ‘smaller players’ out of the market thereby cutting the ‘glut’ of skilled beds. We were being told at the time there were 1000 too many skilled beds here in Massachusetts. The extra beds were alleged to be driving up the cost of care.

I have a question: Our entire economy is based on supply and demand. Has there ever been another industry that drove the costs of services up when the supply was greater than the demand?

We are on the eve of adjustments to the reimbursement system. I’ve been told the regulations are going to get even tighter. To be honest, other than knowing rules will be added in October 2010, my knowledge of the changes are very limited. However, I feel qualified based on almost two decades practicing in SNF’s to make a prediction: Nationally based For Profit Corporations will become the primary providors of skilled care beds across the United States.

I have a second question: Large, nationally based for-profit corporations are created to make money and increase profits for their investors. Who will be paying the biggest piece of that revenue? Individuals? Private Health Insurance Companies? The US Government via Medicare/Medicaid?

I might mention here that regardless of clinical setting, the best reimbursement source for an inpatient rehabilitation stay is Medicare. Yes, the same system that was redesigned to control costs in January 1999. It is the system For-Profit Healthcare Providers want well-represented in their case mix. More than want, they rely on Medicare to make their bottom-line.

Here’s a rhetorical question for those who think I’m overstating the value of Medicare A and B to SNF’s: When was the last time anybody heard an Admission’s Director say they needed to fill more beds with Medicaid recipients?

I’ve watched over the last few years as the terms reasonable and necessary have been morphed into new packaging. Many rehab providers are using software systems that have goals listed and waiting to be plugged into an evaluation. Some software triggers the goal a therapist should pick. There are courses with watch words and buzz words to prep therapist to avoid writing an evaluation or a note with a RED FLAG. I’m a realist. I know those types of formulaic programming are a natural outcome of Intermediary Help Letters, Denials, and the dreaded RAC Audits. There is nothing wrong with giving therapists tools to practice within reimbursement guidelines.

But, something more insidious happened while I was distracted watching the major changes. A phrase entered the continuum of care very casually. In fact, it sounded like a good thing on first blush. It wasn’t until it was applied against the stark white of reality, that I truly understood the danger of the concept.

“We treat all our new admissions as ultra highs until they show us differently.”

It doesn’t sound bad. It actually captures the spirit of America. Everybody gets a fair and equal shot at their bite of the apple. Makes you think the care providers don’t pre-judge based on gender, race, sexual orientation, age, or ability. Sounds like equal protection. But, this is exactly the point where everything goes wrong.

We do an evaluation so we can pre-judge and prescribe the appropriate amount of treatment. Our recommendations are supposed to be based on what the patient is able to do during the evaluation. We must take into account their general health prior to illness, their premorbid level of daily activity, the course of their illness, their age, their family’s goals, and their own hopes for their recovery. We adjust the patient’s goals as the treatment plan succeeds or fails. Weekly notes and monthly recerts are there to keep us and the patient focused on progress, or lack thereof.

However, if the expectation walking in the door before we even lay eyes on the patient is that this very sick individual who has been in acute care for at least 3 midnights is to be able to tolerate a minimum of 35 minutes of treatment per day by 3 disciplines over 7 days with 3 hours of group time being evenly divided among disciplines, then the evaluation is completely superfluous.

Most nurses and aides and family members already know a patient cannot walk, eat, talk, or care for themselves. The therapists’ evaluation is meant to provide a means of rehabilitation and a plan of implementation. Computers are able to generate goals based on assessment data of strength/weakness. Assistants for PT/OT carry out most of the plans of care. And, now registered therapists have pretty much lost their authority to determine how much time is needed per day and how many days in a row are necessary to reach functional potentials.

I fear, we registered therapists across disciplines have just become rubber stamps for a plan of care designed, programmed, and packaged to meet the standards of a reimbursement system extracting the maximum dollar amount for care provided to any patient, regardless of their reasonable and necessary needs.

About the author

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.

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Why we need to show up

Why we need to show up

By Lisa Yauch-Cadden

“Why we need to show up”

As we mentioned in our welcome to this website, Speech Language Pathology can be a profession of great joy, and great loneliness. Often, as sole practioners in schools, hospitals, rehab centers, medical/private offices, and home care settings, we may be the only source of speech and language services available to a child or adult in our community. I have personally worked in hospitals, with no out-patient treatment services, skilled nursing facilities with no/poor access to home care services, schools where families cannot afford additional services through out-patient clinics, and in out-patient settings, where support from the school system has been limited. I have also known clinicians who, all by themselves are the hospital based SLP, the homecare SLP, the school therapist and the out-patient provider. In these situations, we have a huge responsibility to our patients. We may be the only one to diagnose and treat a patient’s problem, or provide a family or physician with needed information. Yet, over the past several years, I have noticed more and more therapists, not taking these responsibilities so seriously.

I have known therapists to cancel appointments for convenience or to avoid a patient with behaviors, therapists that utilize the same treatment approach with multiple patients regardless of individual needs, and utilize the same treatment materials with the same patient, over and over, and then blame the patient when he/she doesn’t make progress. I have worked in facilities where staffing required multiple SLPs to service the same patient on different days, and because no single SLP felt responsibility for the patient, (they were “just covering”, after all), the patient failed to make progress. I have met with indignant therapists, astonished that a payor source would require accountability, prior to paying for services, and I have seen talented therapists leave the field, because they did not want to play by a new set of rules.

In all of these instances, I am reminded that, while as therapists, we think that Speech Language Pathology is about us – our skills, our expertise, our credentials. It is not. It is about the patient. Every client that crosses our path is referred to us, because someone who cares about that person has a question or a concern that needs to be addressed. Someone in that patient’s family, desperately wants them to get better, and often we are the only ones to whom they can turn. We cannot phone it in. We have to show up.

When Mrs. Jones sends her 3 year old autistic son to the school or the out-patient clinic, she is putting her baby in our hands, and hoping for progress. When the homecare clinician sends her patient for an MBS/FEES, she is looking for specific information on the nature of that patient’s dysphagia, as well as recommendations for intervention. When Mr. Smith, an 88 year old man enters the skilled nursing facility for rehab, he is relying on us to understand his Medicare benefit, and entrusting us get him the services he deserves. When we think it is beneath us to be told to provide 35 minutes of care or make sure that we see a patient on Thursday vs. Friday, or write a note that conveys an appropriate level of service, we only hurt the patient, and put them at risk for losing the services, to which they are entitled. And when we cover multiple facilities/multiple patients with multiple clinicians, we need to be responsible for our session, and advance the treatment plan. It is our responsibility to understand our patients’ problems and their payor source and provide skilled intervention to meet their goals.

Now, I know it is hard to bring your ‘A’ game every day, and there are lots of forces that conspire against us (family, kids, traffic, heavy caseloads, limited access to materials, uncaring bosses, budget cuts, etc.). Sometimes patients are needy and families are unrealistic, and our caseloads are unending, and on some days, we have to leave by 3:00 p.m., no questions asked, but we owe it to our patients to try our best, everyday, and honor the implied trust between us. If the situation were reversed, we would expect nothing less.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

If you have something to say, please submit your article for consideration to lycslp@gmail.com.…

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