The purpose of this letter is to reveal, through my personal experience as a speech therapist in NYC, the many problems plaguing my profession, and to shine light on the dysfunctional role that Medicaid, the Department Of Education (DOE), and agencies play within this profession – a profession whose primary purpose it should be to benefit the children of our city.
New York City is divided into school districts, and each district has a Committee on Special Education (CSE). Most schools have a speech teacher on staff, hired directly by the DOE to provide therapy. In situations where the caseload cannot be accommodated by the speech teachers on staff, the CSE is responsible for directing parents in finding therapists and for processing paperwork necessary for children to receive therapy. They are also responible for mandating occupational and physical therapy, and counseling services.This is the case both for public schools and some private and parochial schools. They are supposed to update students’ mandates for services each year. This year however, one fourth of the students at my school do not have updated programs and are “out of compliance.” There are confused, frustrated parents at my school at any given time waiting to hear back about their child’s evaluation or services status.
When I finished graduate school for speech/language pathology in 1992, I knew that I wanted to work with children. Given the low teacher salaries offered at the time, I could not afford to work directly for the DOE as a Speech Teacher in New York City. I had also heard nightmarish stories about unmanageably large caseloads that greatly reduced the therapist’s ability to provide quality therapy. Instead, I took jobs at various schools throughout the city as an independent provider, many of them through SLP employment agencies who had contracts with the DOE. After moving to Washington Heights in 2006, I managed to find work at a Catholic School nearby without the assistance of an agency. Contracting directly with the DOE, I began with one student, but the fact that the school had an onsite SLP drew more parents whose children required therapy, and over the next several years, my caseload gradually grew to 30 children.
While there were financial advantages in working directly for the DOE, it did not come without frustrations, among them an antiquated paper-based attendance and reporting system, and lengthy delays in receiving payment. At the start of each school year, the SLP is required to submit a parentally-signed Related Service Authorization (RSA) to the CSE for each student receiving therapy. If an RSA is not signed by a CSE supervisor and entered into the system, the SLP will not be paid for their time with that student. It was not uncommon to work with kids for three months before finding out that their paperwork did not go through, leaving me unpaid for those hours. This happened with several children each year. I would email and call, repeatedly, only to be ignored. Usually by December, the issues were settled– four months into the school year. Despite all this, I felt lucky and proud to have built up a solid caseload in a field that I felt made a difference in children’s lives. I loved my school, the students, and their families who I had grown to know and care about. My salary was not high, but, in those pre-Obamacare days, I was still able to purchase health insurance.
Speech therapists are considered health care providers so the DOE receives funding from Medicaid for their work. Federal audits done in 2011 discovered that literally millions of dollars worth of claims the DOE filed with Medicaid were un- reimbursable because of faulty paperwork and recording. Paradoxically, numerous students went without their services during the same period. This second part has always been especially bewildering to me. I have applied numerous times at various points in my career to be a speech teacher with the DOE, and been told that the jobs are “few and far between,” and never given a second directive. Working as an independent provider was discussed on the DOE website, and after putting my name on a municipality list, I typically got five to ten calls between December and June from desperate mothers seeking therapists for their kids, usually after I had already established a solid caseload. This would suggest that the need for therapy exceeds the supply of therapists, while this simply is not true. It is a reflection of the DOE’s inefficiencies and ill-equipedness in servicing children.
For financial reasons, the City “sells” school district monopolies to competing agencies through a bidding process. The lowest bidding agency in turn dictates school assignments and therapy rates for their respective districts/therapists. In September of 2012, when I returned to work after the summer break, I was notified that an agency now had successfully bid for control of my district and that if I wanted to continue to work in my school, I had to work through the agency and not directly with the DOE – this with an additional salary reduction of more than twenty percent. Therapists working for the agency make the same fee, whether they have worked for one year or twenty. After doing a little informal research, I found that I was not alone, that there were many other SLPs who had had their caseloads taken away from them. As a byproduct of this little- publicized take-over, individual SLPs who had established deep relationships over time with schools, parents and students, were replaced by agency designated clinicians without regard to prior relationships or personal preference of the parents/child. In my case I was told that I could either work for the agency that had my school in its district, at a huge pay reduction, or look for work elsewhere.
I chose to work for the agency so that I could continue to work with the school where I had established relationships with people who had become almost like family to me. I now deal with three or four people at the agency, assigned to different tasks I used to do myself, such as billing and caseload management. From what I can gather, they barely communicate with each other. To make matters worse, a new online attendance system was put in place to address the DOEʼs incompetence in recording speech therapy attendance to Medicaid, in which SLPs have to submit their notes online, through an extraordinarily time-consuming system. The United Federation of Teachers (UFT) fought and is now receiving reimbursement for the hours its SLPs put into it. But independent providers are still expected to do this paperwork online without extra compensation. We do not get paid for note-recording, reports, meetings, calls with parents, planning time, or materials. Further, my agency was new to the DOE and its ways, and I watched, through trial and error, as they made mistake after mistake. In September of 2013 my hourly rate was reduced further to compensate for money they lost due to errors they made during their learning phase.
Going from working fairly independently to being dependent on this dysfunctional and time-consuming system was very stressful. In fact, so stressful that I incurred an ulcer and digestive problems for which I needed some medical procedures. Unfortunately, the agency had also mistakenly offered me medical benefits, at no great discount, but which I took. They stopped the insurance when they realized the mistake, but neglected to inform me they had dropped me from the policy. Two of the procedures I had done were in August, after my insurance had been dropped without my knowledge. I had to threaten a lawsuit and reporting them to the Better Business Bureau before the agency was willing to give me any compensation for medical bills I incurred as a consequence.
What SLPs, and other types of therapists, need to be aware of is that as long as we have this huge, malfunctioning system in place, the chances of having a private practice are greatly diminished. We will be at the mercy of this system unless we speak up, and changes are made. Traditionally, women- dominated fields make less than male-dominated ones. I, for one, couldnʼt find anything on the internet or in my professional journals regarding these issues. There is no union for independent providers of speech.
The DOE needs to actually hire therapists if there is a need. And be accountable. They recently opened up a new position called Medicaid Services speech provider. I tried to apply online, but found that my previous application was still on the site, and not surprisingly, could not get information regarding whether it was also good for this new position. If these agencies are to remain in place, Medicaid needs to either raise the fee– so that SLPs receive more of the money that the agencies are using to pay their staffs, or the system needs to be dramatically re-formulated. The fee per hour has been $90 for the last 25 years. So, adjusting for inflation, beginning in 1992, when I began my career, that 90 dollars is worth 56 dollars today. In other words, my salary, despite my increased knowledge and 22 years of experience working here has gone down 38 percent. I can tell you that I have often had to question my decision of going into this field. And I can also safely say, that if more young people find out about the system, and the way things are looking now, the quality and caliber of therapists will drop dramatically, and that would be a shame, because it is an absolutely wonderful field, and children and parents deserve more than they are able to get under this system.