Author: Marguerite Mullaney



I’ll confess, since the bombing at the Boston Marathon, I have been very depressed. It is not the response demonstrated by the victims, first responders, healthcare workers, average citizens, or local media and politicians that has darkened my mood. It is the national failed leadership which has let me down. Instead of turning the conversation to what actually worked well, DC and the NRA and the right and the left have hijacked the event and sliced it to fit their own agendas. Their behavior is nearly as despicable as the bombers’ actions. They all try to use terror to force people to agree with them.

So, I want to use my web page, my forum, to look at the event for what it was. A crime. A pathetic, dirty crime committed by two arm chair terrorist. Raised in safety here in the US and supported by welfare funded by the same citizens they decided to kill. Two cowards who hid a bomb in a backpack and put it at the feet of children before running away to safe distance then hit the trigger. A reprehensible crime meant to kill and terrify.

Did it work? Did they succeed in their murderous endeavor? Well, they did kill. Four good people died because of these two angry men. Hundreds were maimed. Thousands saw their cities become a battlefield. Millions watch in horror unable to help. But, did they succeed in terrorizing the people of Boston? The citizens of the Commonwealth?


Do I have proof of my statement? Yes.

The video of the bombings shows panic and chaos for sure. But, then it shows ordinary people, obviously frightened but jumping into action to save lives. The victims requiring ambulances were evacuation from the scene in 18 minutes.

Hundreds of off duty doctors, nurses, police, fire, paramedics raced to the scene or their jobs to save lives. The first operating room in the city received the first blast victim 38 minutes after the explosion.

Neighborhoods mobilized, not just immobilizing with the shelter in place order. People connected on Facebook to relay info regarding locations. Funds were started for people effected. We did what we do best, we took care of each other.

The Boston Bruins National Anthem during the first home game after the bombing was played to a full Boston Garden captures the spirit of the city best. Nobody there was afraid to be there and sing that night.

Then, of course, there was Big Papi’s speech at Fenway. You might have to be from here to understand the love that goes with the comment, “it our fuckin’ city.” It is. He was staking a claim, making a warning. He wanted others to know not to mess with our city. They shouldn’t. Look what happened to the bombers – dead or apprehended within 110 hours of their crime against humanity.

For me, terrorism takes many shapes. The mad bombers. Wild eyed gun men. Screaming fanatics. And, snarky politicians, lobbyists, radio djs, and activists who would steal somebody else’s heartache for their own message of manipulation.

Boston is strong. We stick together. The nation should take that message and move forward with it. Don’t let any form of terrorism steal what is good and right and true about our country, our nation, our fuckin’ home.


The flag of the Commonwealth during the Hull MA candlelight memorial for the Boston bombing victims.
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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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To all our colleagues working in the schools, love and good thoughts to you today and in the coming days.

Your tasks are huge. Educating students to the 3 R’s isn’t enough anymore. You create a safe place with food and support and watch over them to ensure they are well physically and emotionally. Too often, you have to act on their behalf when those that love them do not. And, at least during the last election cycle, you listened to overpaid wind bags discuss how much you don’t contribute to the Nation’s bottom line.

Yesterday, we saw once again, how much teachers are willing to sacrifice to our Nation’s bottome line. They ran toward the children in their care when danger erupted. They shielded them with their own bodies. They hid them using what little tools they have available; closets, bathrooms and their own wits. And six, stayed with the children in their care and died with them.

To all our Clinical Colleagues in the Schools and teachers and school support staff, thank you for all that you do. You are saving our world one child at a time. I am proud of the work you do for all of us and so very grateful for your dedication.

peace and love and all that stuff,


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Sun sets on ASHA 2012

Sun sets on ASHA 2012

After all the planning and the travel and the drama.  ASHA 2012 has come to an end.  The closing ceremonies will be underway in a few hours.  However, I will be on a plan heading for Boston by then.  With a little luck Ill be asleep before take off.  ASHA was a wonder chance to connect but sleep was sorely neglected.

We learned a lot. Made good connections with therapists.  And, we were reminded why it is we do what we do.…

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ASHA 2012

ASHA 2012

Opening Ceremony ASHA 2012

We are minutes from the start of something big.  #ASHA12 begins.  And, returns to  ASHAConvfor the first time since 2010.  We have a new site that is easier to navigate and with more content.  But we continue to offer a SLP/AuD a place to gather and share or vent or laugh and cry or do all the above.

We are communication specialist.  Self expression is the most fundamental needs of humans.  It defines us.  It makes us happy.  It keeps us sane.  It is the single common human trait.  Our professional life is the care, nurturing and promotion of good communication. Yet we neglect our own needs to be heard. is here for you to express yourself.  Come Talk to Us!…

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more than half way through my life

more than half way through my life

i usually write out a few drafts of a post before i attempt to post it but today i feel reckless and free to make all sorts of mistakes.  the sun is shining for the first time in days and my belly is full from an amazing lunch with the beautiful Atlantic churning just beyond the sea wall.  the music filling my home is old, from the 90’s.  hard to believe the 90’s are old which is because i too have aged without my full attention to the passing of days lost without my consent. 

my career as an SLP is the most stable it has ever been.  i work with a wonderful team in a fantastic location with an exceptional client base.  it is nearly miraculous to have happened on such a terrific opportunity this late in my career.  i am truly blessed.

mixed in with that blessing is the bittersweet realization, it is late in my career. my study of SLP began in 1981.  i entered Bridgewater State College undeclared and drifted for a semester.  my drift ended when i reviewed the course book and saw Communication Disorders did not require statistics or a foreign language.  the major i took as an escape turned out to captivate me. it has been a long love affair with the basics of human communication.  ideas to sounds to words to understanding; it still leaves me nearly breathless tracing the path from my idea to your understanding.  every sound is a miracle. 

it has been fascinating and wonderful and action packed adventure.  a career i stumbled into changed the course of my once directionless life.  more than a job.  more than work. more than a phoneme.  more than a word.  an idea.  a miracle. 



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Summer slipped away

Summer slipped away

i’m not sure how it happened. When it crept by me is a mystery. The moment my favorite season drew to a close for 2012 is lost to me.  Where i was looking while the dog days of summer cooled is quite clear; my gaze was fixed on the horizon.  Less poetically, i’ve spent the last few months looking ahead.  It’s not that i’m dissatisfied with the present.  Not at all.  It is merely the coming months are filled with opportunities.  But, i need to do a significant amount of preplanning to take advantage of all the fall and winter are offering. 

In about fifty four days, Lisa and i will be boarding a plane for Atlanta and ASHA 2012.  We are packing our CCCslp gear and heading south to spend a few days with 12,000 of our colleagues.  It should be a fun filled three days.  It certainly is chalk full of celebrities; Maya Angelou, Gabrielle Giffords, Captain Mark Kelly, John and Annie Glenn.  i haven’t seen the courses scheduled yet but i thinking i’ll save that planning for the plane ride. 

i would be more enthusiastic about the convention if the costs were not so jaw dropping.  For an ASHA member to register now, the price is $410.  This is only to attend the basics.  Short courses are $70 extra per course.  Travel, room, and po are all extra too.  The registration was $35 cheaper during August.  Still, $375 is a steep some of money. 

Personally, $410 is a significant chunk of my ‘disposable’ cash.  It represents a month of groceries for me.  It is more money than I spent on clothes and shoes combined in 2012.  That sum is what i spend on prescription medication… , four and half months of prescription medication.  i could fill my jeep six times which is a month and a half worth of driving. 

It’s a lot of money no matter how you break it down.  And, it makes me wonder how long ASHA will be affordable for SLP’s and AuD’s.…

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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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