Physical Therapists' Ethical Dilemmas in Treatment, Coding, and Billing for Rehabilitation Services in Skilled Nursing Facilities: A Mixed-Method Pilot Study.

OBJECTIVES: Reimbursement in skilled nursing facilities (SNFs) is driven by the number of minutes a patient receives rehabilitation. Physical therapists' (PTs) clinical decisions in evaluation and appropriate treatment of patients drive the dosing of rehabilitation services. Many times these 2 dynamics clash. The purpose of this study was to determine how PTs in SNFs viewed their ethical work environment, what primary issues drove their views, and what potential solutions were identified for the issues. DESIGN: This was a mixed-methods, cross-sectional survey study. SETTING AND PARTICIPANTS: An organizational ethics survey along with 2 open-ended questions were sent to a random sample of 1200 PTs in the state of Georgia; 340 surveys were returned, and the respondents were categorized into 9 typical PT work settings. Twenty eight participants (8.2%) reported they worked in SNFs. MEASURES: The Ethics Environment Questionnaire was the quantitative measurement tool used for the study. In addition, 2 open-ended questions were asked regarding ethical concerns and possible solutions to those concerns. RESULTS: Of the 9 workplace settings, therapists working in SNFs had the lowest perceptions of ethical work environment. They were also the only group that scored below the survey cut-off point for positive ethical work environment. Their primary concerns were overutilization issues, productivity standards, and billing and coding issues. The 2 primary themes regarding solutions were allowing PTs to be autonomous in their decision making and decreasing productivity standards. CONCLUSIONS/IMPLICATIONS: The current Medicare reimbursement system rewards quantity of rehabilitation over quality. PTs are trained to deliver quality care that is dosed appropriately, and this may conflict with organizational objectives. The primary implication in this study is that clinicians and administrators should engage more in open, honest dialogue on how to share responsibility and balance organizational goals with clinical ethics.

Ascension health's demonstration of full disclosure protocol for unexpected events during labor and delivery shows promise.

Communicating openly and honestly with patients and families about unexpected medical events-a policy known as full disclosure-improves outcomes for patients and providers. Although many certification and licensing organizations have declared full disclosure to be imperative, the adoption of and adherence to a full disclosure protocol is not common practice in most clinical settings. We conducted a case study of Ascension Health's implementation of a full disclosure protocol at five labor and delivery demonstration sites. Twenty-seven months after implementation, the rate of full disclosure had increased by 221 percent. Practitioners saw insurers' acceptance of the full disclosure protocol, consistent and ongoing leadership by local practitioners and hospitals, the establishment of a well-trained local investigation and disclosure team, and disclosure training for practitioners as key catalysts for change. Lessons learned from this multisite initiative can inform liability insurers and guide providers who are committed to ensuring that full disclosure becomes the only response to unexpected medical events.

Delicate dances: immigrant workers' experiences of injury reporting and claim filing.

INTRODUCTION: Immigrants often come to Canada for the purpose of employment and make up a large proportion of our labour force. Yet, these workers' labour market experience may not always be positive - new immigrant workers can have difficulties finding a job in their field and may end up working in 'survival jobs' that expose them to workplace hazards. Workers who are new to Canada may not be familiar with legislation designed to protect them at work or with social programs that can help after a work-related injury. METHODS: Through a series of in-depth interviews this study examined the experiences of new immigrants after they were injured on the job. RESULTS: The analysis revealed that many workers were in manual, 'survival jobs' and had not received job or occupational health and safety training. Many did not speak the English language well and knew little about their rights. While workers often felt trepidation about reporting their injury, most told a health care provider or employer that they were injured or in pain. This, however, rarely led to timely or appropriate claim filing. Workers were often discouraged from filing a claim, misinformed about their rights or offered 'time off work' in lieu of reporting the injury to worker's compensation. In instances where a claim was filed, communication problems were common and led to mistakes being made on forms and misunderstandings with the adjudicator and employer. Interpretation services were not always offered consistently or at the correct time. CONCLUSION: Efforts must be made to systematically inform new immigrants of their health and safety rights, responsibilities and entitlements as they are entering the labour market. Systems must be put in place to ensure that immigrants can access the compensation system in the event of a work-related injury and that employers and healthcare providers fulfil their reporting responsibilities.

Insurance reports.

Case histories are based on actual medical negligence claims or medicolegal referrals, however certain facts have been omitted or changed by the author to ensure the anonymity of the parties involved. General practitioners find their patients requesting that they complete documentation for a myriad of insurance purposes. Often these forms are time consuming to complete, containing seemingly irrelevant questions. This article examines the responsibilities of GPs in providing reports to insurance companies.