Blog: If I Ran the NVHA, I Would Educate Nevada’s Healthcare Workforce on Collective Action
Matthew Brandenburg, OTD, OTR/L
If I ran the Nevada Health Authority, I would never miss an interdisciplinary healthcare conference.
Last month, the Nevada Occupational Therapy Association, Nevada Physical Therapy Association, and Nevada Speech-Language-Hearing Association hosted the Connected Care Interprofessional Conference in Las Vegas. It brought together clinicians, researchers, small business owners, students, and advocates from across our state and beyond.
And if you were there, you could hear and feel something beneath the CEUs, the networking, and the presentations.
Frustration.
The kind that comes from knowing something is wrong, feeling it in your clinic every day, fighting like hell to make it right, and not having the language to name it.
I heard it in conversations with private practice owners from all over Nevada:
Owners of interdisciplinary pediatric clinics.
Outpatient orthopedic practices.
Community-based therapy providers.
Many of them (especially in northern and rural areas of our state) are carrying waitlists.
Demand for OT, PT, and Speech therapy services is high. People need and want our care.
Despite overwhelming demand, there are not enough therapists willing or able to do this work under current conditions:
One owner shared that they are struggling to keep their doors open.
Another said they are turning away families every week.
Another said they are treating more patients and making less money than they did five years ago.
ALL of them are feeling the impact of systemic underpayment (a deliberate, structural pattern in which insurers and payers set reimbursement rates below the actual cost of delivering care).
Systemic underpayment is a healthcare system problem.
And if I ran the NVHA, I’d start teaching Nevada’s healthcare workforce to understand the system they’re working inside.
At the conference, Kalani Kauwe gave a presentation that should be mandatory viewing for every healthcare provider in this state: From Frustration to Power – How Healthcare Workers Transform Workplace Conditions Through Collective Action.
He outlined four mechanisms that many providers experience every day:
Reimbursement Rate Suppression
This is the foundation of the problem.
Reimbursement rate suppression occurs when insurers keep payment rates artificially low for years, or decades (47 years for physical therapists in NV) without adjusting meaningfully for inflation, labor costs, rent, equipment, or rising operational expenses.
In 1980, a therapy clinic would receive between $60.92 and $85.90 for an OT evaluation. Nearly 50 years later, they may receive between $68.10 and $74.91 for that same service, despite wages, rent, and supply costs quadrupling and a cumulative inflation rate of 118.52%.
That’s a pay cut for essential services that have been proven to improve the health and well-being of real people.
The result? Clinics are forced to increase patient volume just to survive.
Therapists get less time with each patient. Burnout rises. Quality drops. Small practices serving tight-knit communities close.
Patients face longer waitlists. Shorter visits. Fewer providers willing to accept their insurance.
This is how access to care erodes, year by year.
Utilization Management
This is how insurers ration care after the patient comes off the waitlist and makes it through the door.
Utilization management includes prior authorizations, visit limits, repeated re-certifications, and medical necessity reviews designed to limit how much care a patient can receive.
A child with cerebral palsy may need ongoing occupational therapy to maintain function, build independence, and prevent secondary complications. But the insurer approves six visits.
Six visits to help a child adjust to life with a chronic disease and the difficulty of their body not developing and functioning as they hoped it would.
The therapist requests more. They spend unpaid hours documenting, justifying, appealing.
The reviewer may be a nurse, DO, MD, or podiatrist in another state. Or increasingly, an algorithm.
Not someone who has met the child. Not someone who has seen their living environment. Not someone who has completed a skilled evaluation of the child’s environmental influences, physical, cognitive, emotional, and mental capacities.
Not someone who understands their goals, struggles, and triumphs.
And often, not someone with rehabilitation expertise.
The family returns to their still warm seat on the waitlist.
Progress stalls.
Function declines.
For providers, this creates unpaid administrative labor and moral injury. For patients, it creates interruptions in care that can have lifelong consequences.
Capitation and Capitated Agreements
Capitation flips healthcare incentives upside down.
Instead of paying for the care actually delivered, insurers pay providers a fixed amount per patient per month, regardless of how much care that patient needs.
For example, a clinic might receive $40 a month to manage a patient who needs weekly therapy after a stroke.
If that patient needs four visits, the clinic absorbs the cost.
If they need eight?
Same payment.
The insurer’s costs stay fixed.
The provider’s risk skyrockets.
This creates pressure to shorten visits, reduce frequency, avoid complex patients, or discharge early.
In theory, capitation rewards efficiency.
In practice, it discourages best-practice and often rewards under-treatment.
And when under-treatment becomes profitable, patient outcomes become secondary to financial survival.
Multiple Procedure Payment Reduction (MPPR)
This is one of the least understood (and most quietly damaging) mechanisms in outpatient rehab.
MPPR reduces reimbursement when a provider performs multiple billable interventions in the same session.
Let’s say a therapist spends an hour treating a patient recovering from a traumatic brain injury:
15 minutes of neuromuscular re-education
15 minutes of therapeutic activities
15 minutes of self-care training
15 minutes of cognitive retraining
Clinically? That’s comprehensive, individualized care.
Financially? Only the first billable unit of the session is reimbursed at full value.
The rest are discounted.
Same therapist.
Same time.
Same patient.
Less pay.
This punishes competency and complexity.
The more holistic your care, the less you’re compensated.
It creates an incentive to simplify treatment, not because it’s better, but because it’s more financially survivable.
That is the opposite of patient-centered care.
Unfortunately, these aren’t isolated frustrations.
They are interconnected strategies deliberately employed in our health system.
And when insurance companies stack low base rates, utilization denials, capitated risk, and payment reductions, they create a system where providers are expected to deliver more, document more, fight more, and absorb more… while being paid less.
And it is killing outpatient rehabilitation.
In Nevada, we talk a lot about provider shortages. But what if the shortage isn’t just about recruitment?
What if it’s because the math doesn’t work?
What if our best therapists, physicians, and nurses are burning out, leaving practice, or avoiding outpatient work entirely because the economics are upside down?
That’s the conversation I’d want the NVHA leading.
Because right now, most healthcare workers are clinically educated, but economically illiterate.
We know anatomy.
We know neuroplasticity.
We know trauma-informed care.
But many of us don’t know how reimbursement structures shape our working conditions, our patient access, or our ability to survive.
And that ignorance is expensive.
For centuries, powerful corporations and wealthy interests have used complexity as a shield. They make systems so opaque that the people inside them cannot organize against them.
Insurance contracts.
Fee schedules.
Denial systems.
Lobbying.
Regulatory capture.
Same playbook. Different century.
Empire of Pain by Patrick Radden Keefe (Shout out to my book club) tells the story of the Sackler family and how concentrated wealth, political influence, and strategic ignorance helped fuel one of the deadliest public health crises in American history: the opioid epidemic.
That book is not just about opioids.
It’s about what happens when healthcare systems are controlled by people whose incentives are disconnected from human outcomes.
That should concern every Nevadan.
Because when healthcare workers do not understand the economic and political systems shaping care, they cannot protect patients from them.
And if I ran the NVHA, I’d build that literacy.
I’d educate providers on reimbursement policy.
I’d teach clinicians how utilization management affects access.
I’d train practice owners and workers on collective action, legislative strategy, and payer accountability.
I’d make sure every healthcare professional in Nevada understood who profits when care is delayed, denied, or diluted.
Because the providers at that conference weren’t just complaining.
They were doing something far more important.
They were naming the problem.
They were asking better questions.
They were sharing data.
They were building alliances.
That’s where power starts.
Nevada doesn’t need more disconnected healthcare silos.
It needs organized clinicians who understand that improving patient outcomes and improving provider conditions are the same fight.
And if we don’t learn that soon, outpatient care in this state will keep shrinking until the waitlists become the system.
