Volume Over Value: The current direction of healthcare
To understand how healthcare professionals have been absolutely pushed to the brink in terms of productivity, we have to look at the historical shift from value… to volume. Recently, hospitals have engineered an average length of stay that has plummeted from its prior levels.
For patients in acute care specifically, the main goal was to move patients in and, more importantly, out faster than ever before. And at the same time, total hospital employment skyrocketed.
Instead of this increased workforce resulting in more comprehensive, patient-centered care, it has created a pressure cooker. And the meal being cooked has been the healthcare worker.
What happens when you put cost before care? What happens when you prioritize the bottom line over quality? The result is that therapists and nurses are increasingly viewed by administrators as a cost, instead of the driver of value we actually are.
One of the craziest parts of all this is how differently managers and therapists see the same exact situation…
What do the surveys say?
In a national survey, managers actually claimed that high productivity goals made patient care better, while the therapists doing the work said the exact opposite.
They don’t even use the same words to describe their day. For example, in a 2019 national survey, managers talk about "profit margins" and "billable units," while therapists talk about “clock-watching” and the heavy weight of “unethical standards.”
It’s like they’re together on the same field, but playing completely different games with a completely different set of rules, making it impossible to keep score and figure out what’s needed to actually win.
But who dictates the rules of this game? The therapists? The caregivers? The patients? No, no, and no. It’s the administrators and owners. Does it make sense for a team franchise owner to dictate the game plan on the field? Not usually. But this is what’s happening in healthcare, and it's having a direct effect on professional ethics and patients’ lives.
In a survey of over 3,400 physical therapists, it was discovered that as corporate productivity expectations increase, the rate of unethical behavior rises right alongside them. In fact, a staggering 90% of respondents reported observing unethical behaviors in their clinics.
That’s almost everyone. To hit these arbitrary targets and satisfy management's spreadsheets, clinicians are essentially being pressured to cheat just to survive their day.
What does this look like in practice?
Research shows it’s keeping patients on the caseload who no longer actually need skilled care, inappropriately discharging patients, billing for inappropriate treatment intensities, or counting a patient's rest time or travel time as billable treatment.
One clinician described it this way: She said the productivity pressure was a constant background noise in the room. Even when the session was going well, part of her mind was already on the next appointment, the next unit, the next deadline. It’s the invisible ghost that haunts us all day long.
Now, don’t get me wrong, I’m not saying any of you are doing these things. I’m sure you are the good ones. But it doesn’t mean you’re not pressured to do them. And pressure creates stress. And stress creates bad decisions.
I came across one clinician who mentioned that the hardest part of their job is not the workload itself, but the moral whiplash of knowing what good care looks like and not being given enough time to provide it. This has become not the exception, but instead the reality of the vast majority of clinicians working in healthcare today.
The situation is particularly noticeable in nursing facilities, where clinicians are over FOUR times more likely to witness high levels of these unethical practices compared to any other setting.
And the ultimate kicker? Over half of the clinicians surveyed reported having absolutely ZERO say in setting these productivity goals. Again, the coaching is coming from the box seats very far away from the field.
The game is rigged and winning feels impossible…
The Triple Aim Misses Its Mark
Modern healthcare has shifted toward what’s known as a Triple Aim approach where three things are addressed simultaneously:
Improving the patient's experience
Improving health outcomes
Decreasing the growth rate of costs
But one of these three rules the other two, and I’m sure you can guess which one that is. Clinicians are trained for the first two attributes of this triple aim, but are valued by #3. It’s all about the benjamins in healthcare these days.
The sad part is, we can do so much for our patients' experience, health, wellbeing, and quality of life. We can improve communication, reduce risks of decline, and improve independence and quality of life. Yet, many administrators remain completely stuck in this mindset where billable hours and healthcare costs are king.
The P&L statement has become our unofficial constitution. Instead of assessing a clinician’s worth by asking, “Did this patient's quality of life improve?” We are asked, “How many units did you bill today?” or “Did you meet your productivity levels?”
This mindset is literally hardcoded into our daily tools and technology. Think about our electronic medical record (EMR) systems, one of the biggest changes to hit healthcare in the last few decades. This could have been a breathtakingly positive technological shift in our practice.
Think about it: It could have made documentation easy, seamless, and a way to more effectively note detailed patient assessments, illustrate our clinical thought processes, or detail the management of complex cases. Instead, it’s mostly used for billing, decreasing insurance denials, and dodging expensive lawsuits. That alone should tell you which one of the triple aims the administrators are focusing on.
Our triple aim has been broken down to a single, very focused aim… Increase revenue and reduce cost.
Ok, next week we are going to get into a dangerous trend specific to nursing homes, where corporate landlords are taking over the landscape, raking in the profits, and leaving very little left over for the hardworking staff and the patients seeking help. I’ll see you there.
