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:

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About Author

Viktoriya Friedman
Viktoriya Friedman

Viktoriya Friedman is a board certified clinical exercise expert on exercise for aging adults (CEEAA). Her primary clinical interest has been working with adult and geriatric patients living with diagnoses of idiopathic PD, atypical PD, ataxia and MS. In this capacity, Viktoriya developed the first skilled nursing facility (SNF)-based telemedicine program for Parkinson’s (PD) and other movement disorders. She started a community-based outreach program to promote exercise for patients with movement disorders: ParkFIT. As an LSVT BIG certified clinician she evaluates and provides specialized treatment for patients with idiopathic PD and PD-like disorders. Currently working at Office of Mental Health (OMH), Viktoriya is treating patients with medication/drug-induced gait and balance disorders. As a Director of Rehabilitation Services for nine years prior, she focused on value based outcome services, ethical clinical decision making, program and staff development, as well as specialized program development to improve quality of rehabilitation care provided. Viktoriya graduated from Boston University Sargent College in 2003 and is currently pursuing her DPT at Arcadia University.

1 Comment

  1. David Bragga on

    Regarding the health files ethics article.
    The way the PPS system works now it allows the doctors nurses, and therapist alike the opportunity to achieve positive outcomes for their patients Which can only be a collaborative effort between the patient and their caretakers. Not the federal or state governments. In fact that is who the patient has been paying their entire working lives to have access to their Medicare when they grow older.. This money these patients have paid to our government is a life long medical savings plan that they finally gat access at the age of 65. Moreover, only 2.5 /5 do actually end up utilizing their medicare benefits in America. . The rest the government the keeps. The government owes this debt and this opportunity to these patients to take all the time they need to recover at the discretion of the care givers and not at the discretion of the federal or state governments… In the first place the Medicare money paid in by woking Americans each week goes into a general fund where our politicians continue to squander the (Medicare money) for their own favor in most examples for social programs designed to get themselves re-elected. According to your article you are in favor of giving our government and non-medical establishment (data crunches) full reign of power to begin and end therapies based on data regardless if its accuracy. Out-come based data that will be dramatically different for each and every patient. Furthermore, this data for the most part only represents one single diagnosis irregardless of comorbidity, age or others factors such as cognition psychological or social factors the are apparently leaving out to the algorithm as seen with the so called government (bundled payment system). . First of all is supper easy to manipulate any data and /or statistics for which our government is very good at and will do in their favor.. These so call rug categories your referring to give the patient and the therapist as well as the staff of care takers time to for the patient to recover from life threatening illness and as we age that is almost always accompanied by multiple co-morbidities. Recently we have had to deal with the results of this so called data researched out come based healthcare in the way of the so called (government bundle system) that only provides for 14 days of skilled therapy after a massive stroke regardless of comorbidity or any other factors. I could go through the whole list of insane bundle payment parameters regarding skill rehab but their so ridiculous they are not worth discussing, except to say thats what you get for healthcare when government gets involved as if they are in the healthcare business. There will always be companies and governments trying to take advantage of any system they can manipulate especially one as big as the healthcare industry. But letting the government gain full power, free rein and the latitude to decide the beginning and the end of our healthcare or rehab process is a huge mistake and the wrong road to recovery from any illness as seen with the recent ridiculous parameters of the insane bundled payment system.. This is referred to as socialized medicine is a grave mistake and a fools notion of fairness and will not end up good for America.

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