Last Saturday, speech-language pathologist Summer Branch went to work as usual at the two skilled nursing facilities (SNFs) she traversed. Both West Texas facilities contract with a larger rehabilitation company, and Branch was surprised to get a call from the company’s regional manager when she clocked out of work that day.
The manager told her that, as of that minute, the job she’d had for four years was terminated due to staffing changes. “I just didn’t see it coming,” Branch says.
Suddenly, she no longer had health insurance. But, if she wanted, she could opt for pro re nata (PRN) employment, in which the company would hire her to work as needed. Branch rejected that option because the company would pay her the same hourly wage without providing benefits or paid time off. (Typically PRN offers a significantly higher hourly wage to offset the lack of benefits and leave pay. Not in this case.)
Several states to the east, in Georgia, another SLP (who asked that her name not be used) experienced a similar shock. Her two-year job in a SNF contracted with a large rehabilitation company came to an abrupt end Monday. They had given her only two weeks’ notice. The company refused to pay out the entire 80 hours of leave she’d accrued and hasn’t sent her an official termination letter despite her requests. That’s made it impossible for her to claim unemployment.
These two SLPs aren’t alone in losing their SNF employment. In the past week, SLPs, occupational therapists (OTs), physical therapists (PTs), and OT and PT assistants in SNFs have experienced a seismic wave of layoffs, pay cuts, and reductions in hours as the skilled nursing industry reacts to Medicare’s shift to the Patient Driven Payment Model (PDPM) Oct. 1. These effects are noted in news reports, messages sent to ASHA, and social media postings. ASHA is working with the Centers for Medicare and Medicaid Services (CMS), rehabilitation providers, SNFs, and industry organizations to address these effects.
PDPM replaces the former Resource Utilization Group, or RUG, model of Medicare reimbursement, basing payment for services on a patient’s clinical characteristics, rather than the amount of therapy provided. The new system seeks to remove incentives to maximize reimbursement levels by providing more therapy than medically necessary.
PDPM is likely to bring about increases in group and concurrent therapy—a phenomenon that, along with the move away from therapy volume, appears to have driven the staffing and pay reductions seen at some SNFs (note that not all SNFs have responded this way). According to an ASHA statement on PDPM effects, issued last week, “Workforce reductions are not warranted since there are no significant reductions in reimbursement for delivering medically necessary care.”
Medicare implemented PDPM in a budget-neutral manner, meaning that the industry as a whole receives the same Medicare reimbursement under PDPM that it did under the RUG system. Given this, the expectation is that facilities providing appropriate levels of medically necessary care are unlikely to face significant reductions in payment. Staffing changes in SNFs thus are related to business decisions, rather than financial hardship, according to ASHA health care policy staff.
At this point, the SNF workforce reductions are difficult to quantify due to a lack of systematic reporting, but they may be as high as 6%. Branch says OT and PT assistants have been hit hardest, as part of some companies’ reaction to PDPM’s shift away from treatment volume. She notes that only a third of the rehab staff are left at one of the facilities she worked for. At another, those who lost jobs include an SLP and mother who is on unemployment because part-time jobs won’t cover her childcare costs. At the Georgia SLP’s former company, all the PRN staff had their pay cut.
SLP Julie Fechter has been monitoring SNF social media sites since PDPM took effect, and says she knows of job losses in Texas, Ohio, Nevada, Utah, Florida, and California—and there are no doubt more. The biggest job losses seem to be in Texas and Florida, she says. Based in Seattle, Fechter left SNFs for other health care sectors six months ago because of concerns about her clinical judgment being compromised.
Another effect of the business reaction to PDPM, says Branch, is a marked reduction in amounts of therapy provided to each patient, even though CMS requires that patients receive all medically necessary care. An SLP friend of Branch’s has been ordered through a SNF’s administrative mandate to limit treatment for each patient to 13 minutes, while being pushed to achieve 100-plus% treatment productivity. “That makes for an extremely stressful day,” Branch says.
Such a treatment approach is unethical, notes Tim Nanof, ASHA’s director of health care and education policy. “It violates the clinical judgment of the therapist and cannot meet the individual medically necessary needs of the patient,” he says.
The SLP left at the Georgia SLP’s former SNF is also under pressure: She’s taken on her laid-off colleague’s caseload of 15 to 16 patients, in addition to her duties as a manager. Sometimes the work is falling to OTs and PTs, “who don’t know how to be us,” the Georgia SLP says. She worries that her former patients won’t get the quality help they need with cognitive skills and swallowing.
Another West Texas SLP—who lost her SNF job on Sept. 30 and also wishes to remain anonymous—still provides services there sometimes and is concerned about the drastic reduction in treatment minutes from 45 to 15, which, she says, clearly goes against meeting patients’ needs (which did not change on Oct. 1). “I had a two-week post-trach removal patient who has speech, language, voice, cognition, and swallowing deficits and was given 15 minutes with him today,” she recounts. “He had a swallow study today. I had to get him awake, provide oral care, place dentures, do swallow exercises, provide trials, redo oral care, call the SLP at the hospital doing the MBSS to inform her of the patient’s deficits, talk to the SLP on the phone following MBSS to hear about his new diet, document and write new diet orders, and educate the staff, family, and patient. In 15 minutes. Not possible. I billed more than 15 minutes for my services and probably still did not bill enough. That’s just one case of many. This can’t happen! There has to be a better system. My patients deserve better.”
This type of situation breaches the federal Fair Labor Standards Act, notes Nanof. “SNFs and rehab agencies can’t break the law, and our members shouldn’t give away their services for free,” he says.
Adds Sarah Warren, ASHA’s director of Medicare policy: If you feel pressured to do anything that’s clinically inappropriate for a patient, immediately speak to your SNF administrator—and if that doesn’t help, report your concerns to corporate compliance, the state, or Medicare. Ultimately, she says, per ASHA’s ethical standards and standards of practice, SLPs’ clinical judgment, and not administrative mandates, should drive clinical decisions for patients.
Editor’s note: Questions about navigating changes at your SNF? Contact Monica Sampson, ASHA’s director of health care services, at email@example.com. For questions specific to PDPM and Medicare, contact Sarah Warren at firstname.lastname@example.org. Also, an upcoming episode of the ASHA Voices podcast will feature SLPs’ PDPM experiences. If you’re interested in being interviewed, email email@example.com. Or leave your story (anonymously if you wish) on the podcast voicemail at (301) 296-5804, and we may include it in the episode.
Bridget Murray Law is editor-in-chief of The ASHA Leader.