Distinctions between health care delivery problems and social policy problems regarding premature births

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Today the March of Dimes released their 2009 premature birth report cards for each state. Premature births are an important issue to discuss for occupational therapists because so many of the children who require OT services have a history of prematurity. Even so-called 'late preterm births' where the children are 34 weeks gestation and older have a higher incidence of learning problems.

People will take advantage of the release of this report to politicize the findings as an indictment of the US health care system. This is only partially true because a multitude of social and cultural factors causes this problem, including:
  1. MDs practicing defensive medicine and increasingly using 'late preterm' cesarean delivery.
  2. Couples opting for fertility treatments that inevitably lead to increased incidence of twin/triple/quad pregnancies (and sometimes more).
  3. Poor prenatal care among illegal immigrants and undocumented aliens who do not have health insurance.
  4. Poor prenatal health care among groups who DO have access to Medicaid.
  5. Smoking, obesity, teenage pregnancy, and other lifestyle factors.
The best way to combat prematurity includes several approaches. There should be tort reform to limit the practice of defensive medicine and more education for physicians on best practice for late term pregnancy management. Couples who opt for fertility treatments (and the MDs who facilitate) should be held financially accountable for the costs of the prematurity that they create. Open border and sanctuary city policies need to be re-evaluated because rate of uninsured women is directly related to these factors.

The health care system CAN do more to improve access and quality of prenatal care delivery, particularly to vulnerable or at-risk populations who already have Medicaid coverage. Continued education and outreach to help control the impact of negative lifestyle factors is also critical. Still, the larger indictment is on our social policy and NOT on our health care system. Once preterm infants are born, the care they receive in the US is unparalleled in the world. The problem is in how the prematurity occurred - which is more about social policy than anything else. There seems to be a real confusion in separating out the CARE system from the SOCIAL POLICY. They are quite different from each other and each requires a very distinct approach for improvement.

Update on OT Practice Act and new regulations re: COTAs and supervision

Here is the revised language of the regulation that allegedly will not be available to the public until after it is published in the New York State Administrative Register.

This information was sent all over NY State today and was released by an Albany law firm who I assume must represent someone in the know.

I can't state definitively that these are the final versions, but the state or national associations aren't releasing anything and this came from a reputable source so I am going on the assumption that these will be the final regulations.

I encourage OT practitioners to contact the NYS Board for OT if they have questions about these (proposed??/accepted??) regulations. They presumably will be retroactive to today so OTs around the state will want to be aware of new requirements with as much advance notice as possible.

Of particular note is that the State Board for OT values public protection so little that they are removing a provision that stops people with limited permits from practicing when they have failed their certification examination.

The maximum number of COTAs that an OTR can now supervise is 5 FTE. If they are employed less than full time the total number of COTAs can not exceed 10. That means that some employers will need to hire more OTRs because there are many places around the state who are employing COTAs in excess of the current OTR to COTA ratio.

There are new requirements for supervision in general as well as documenting the supervision of COTAs, OT students, and limited permittees that will have a major impact on OTR time.

Finally, there was some deft tap dancing around the statutory language that required COTA students to be supervised by OTRs. The regulations as written seem to allow for COTA students to be supervised by a COTA fieldwork educator but the requirement for OTR supervision of the whole process remains. That places a new wrinkle in requirements for COTA student placements which previously did not always include direct OTR oversight.

Public participation regarding these regulations has been hijacked because they are being proposed as emergency regulations.

In NYS a single OT can still supervise a million OTAs, for a while at least.

According to the NYS OT Board, supervision guidance for OTAs in NYS has been placed on hold, at least until the next Board Meeting.

Of course the State Board wouldn't state why there are is no new supervision guidance - just that the previous regulations on supervision remain in effect. This is probably welcome news to many school districts who use models where a single OTR supervises many COTAs across a wide geographic area.

It is my best guess that school districts would have found themselves in the very unfortunate position of being out of compliance with the new regs, which would have impacted their ability to receive Medicaid reimbursement, which would have likely cost hundreds of thousands of dollars if not more in lost revenue.

So you see they HAD to pass these emergency regulations and bypass public comment, but I will do the State Board a favor and help them rewrite their justification (I also fixed their date errors from the letter to the Regents):

Emergency action is necessary for the preservation of the public health and general welfare to immediately conform the Commissioner's regulations to chapter 460 of the Laws of 2011, and thereby ensure that such regulations are in effect on February 14, 2012, the effective date of such law, to implement the new practice and supervision provisions consistent with statutory requirements, EXCEPT FOR WHERE IT MESSES UP OUR ABILITY TO GET MEDICAID REIMBURSEMENT, IN WHICH CASE NOTHING IS A GREATER EMERGENCY THAN OUR ABILITY TO RECEIVE THOSE FUNDS. (italics mine)


Chalk this one up to yet another entry into the category of "Ooops, we didn't stop to think about that."

Expect some changes or clarification to the supervision requirements once the school year ends and once districts have a reasonable opportunity to change their staffing patterns - or once someone instead effectively lobbies the State that the previously recommended 5:1 ratio is not a good idea if it impacts the government's ability to collect Medicaid payments from the Feds. It will be interesting to see if the previously recommended supervision ratio stands now that someone obviously noticed that there are rather large fiscal implications and it will cost more money to implement the new 5:1 model.

Meanwhile, many parents around the state will bemoan the fact this Spring that their children are rarely if ever really seen by an OTR.

The sanitized reporting of the NYSOTA website states: "Regulations regarding supervision of occupational therapy assistants and occupational therapists with limited permits have been placed on hold when last minute concerns were raised regarding the impact the regulations may have on school-based practice. The state board anticipates resolving those concerns and promulgating additional supervision regulations in March or April."

Really, what is wrong with just reporting on the issues so people can understand how this legislative sausage is actually made?

People will be better served having full information about how and why these decisions are made. For the record, I will eat my UDO forms if this didn't have anything to do with Medicaid reimbursement. :D

Updates will be posted as needed.

At the end of the day, there are still the tomatoes


What a beautiful and busy day we have a tendency to had these days.

Getting ready for vacation is often the foremost nerve-racking a part of occurring a vacation to ME. I forever feel an enormous push to catch up all the work, get all the charge out, ensure all the small items square measure well organized.

I have one pressing downside that i do not knowledge to resolve yet: what do I do with my garden once I am away?? these days I picked my 1st tomato. It happy ME, however raised the big question.

Then I remembered, there'll forever be tomatoes left on the tracheophyte. perhaps the rabbits can eat them, which would not be therefore dangerous.

More regulatory changes to impact NYS occupational therapists very soon.


This is a follow-up to my entry on 2/16/12: In NYS a single OT can still supervise a million OTAs, for a while at least.

Something will happen on June 13th...

Unless there are some unanticipated changes, new regulations regarding supervision of OTAs will go into effect in NY. Perhaps the largest issue that will impact jobs is the new restriction that reads as follows:

In no event shall the occupational therapist or licensed physician supervise more than five occupational therapy assistants, or its full time equivalent, provided that the total number of occupational therapy assistants being supervised by a single occupational therapist or licensed physician shall not exceed ten.

That means that a couple things might happen on 6/13/12:
  1. A bunch of OTAs will get their walking papers and agencies/schools will hire OTRs instead to avoid being out of compliance with the regs.
  2. A bunch of job postings will appear for OTRs so that agencies around the state will be in compliance with the new regs and OTAs will maintain their employment.
I have some OTR colleagues around the state who I know are supervising more OTAs than the proposed regs will allow. In this economic climate I will not be holding my breath to see agencies bite the bullet and just hire more OTRs.
My advice to OTAs who believe they will be out of compliance with the new regs is to start having conversations now with your supervisors. You don't want to be blindsided in June.
Other significant issues that will occur with these new regs are stricter supervision requirements that will decrease OTR productivity and have an associated impact on the cost of delivering OT services. It is impossible to predict the exact cost impact because of the varied experience of OTAs and the flexibility allowed in the new regs with regard to developing plans. Still, there will be some cost impact. Too bad that NYS is doing their time and motion studies BEFORE the regs go into effect and BEFORE there is any increase in indirect costs associated with stricter supervision requirements.
In NY State when regulations are proposed there needs to be a statement of potential costs associated with regs and a potential job impact statement. This is the best that NY State will offer:
Entities that employ occupational therapy assistants and holders of limited permits might believe that the additional cost associated with compliance will result in the loss of jobs or job opportunities.
If you are an OTA and if you lose your job, you will probably think that is the whitewash of the century. If you are an agency who contracts for OT services and you suddenly find that costs are increasing because of these requirements you also aren't likely to be very happy. Provide your comments here (presumably for 45 days from publication):

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