Elizabeth Nielsen is working with a young client at her private speech therapy clinic in rural Kane County. Her clinic, “Tiny Voice,” is on a small farm, complete with pigs, goats, and horses.
Nielsen weaves the animals into her speech-language lessons and the warm barnyard makes for a uniquely comforting space for kids with communication disorders.
“We have a couple of communication boards,” she said, helping one of her clients take the bridle off a horse. “For my kids that are non-speaking [we have] these communication devices, I have a pillow we put on the horse so they can rest their communication device on the horse and use their device.”
Nielsen often works with eight clients a day. And after eight hours of direct therapy with her kids, then there’s lesson planning, report writing, insurance billing, invoices and -- oh yeah -- the farm work.
She loves her work and sees how crucial it is, but, “We're just tired,” she said. “We're not being valued.” Speech therapists, also known as Speech-Language Pathologists or SLPs for short, are facing major challenges like stagnant pay and sky-high caseloads. It’s making many consider leaving the field.
For one, Nielsen says insurance reimbursement rates -- including Medicaid– are, as she puts it, “insultingly” low.
“I haven't seen a rate increase in insurance in years, and they actually decreased the rates for a while. When they increased, there was only a few cents more than what it was originally,” she said.
She’s an Early Intervention service provider but can’t take on many of those clients because reimbursements are so low. She says insurance companies deny communication devices for kids who need them, and some plans don’t cover developmental speech and language disorders.
Nielsen works primarily with kids at her private clinic, but “speech-language pathologist” is a broad term. There are SLPs who work in schools helping kids with speech delays, in hospitals working with patients with swallowing problems, and at-home care therapists assisting elderly patients with memory issues, among many more.
Not many people know exactly what speech therapists do and why it’s important. That’s one of the reasons Audrey Meyers thinks the profession is undervalued. She's a speech therapist who works in at-home settings with elderly patients in northern Illinois.
“A lot of our jobs are life and death," she said. "If they choke or aspirate on something, get pneumonia and pass -- I could have saved them."
But she feels like she has to compete with physical and occupational therapy to prove to insurance companies why her work is just as important.
“Communication is key. Cognition is key,” said Meyers. “They can't do PT and OT without communicating and without following directions and remembering things -- and that's what I do.”
She says SLPS are fighting other battles too with referrals, insurance authorizations, and approvals.
“Insurance is really strict on the number of times we can go, especially for speech therapy," she explained. "I'll get a new patient; it says one visit is allowed. I can do an evaluation, sure, but they're probably going to need therapy if they wanted me to come there in the first place."
Meyers has been a speech-language pathologist for over a decade and says her pay has barely budged either. With inflation, it’s a pay cut. It is especially tough considering the level of education and licensing requirements you need to be a speech therapist. You need a master’s degree, to pass a licensing test and continue professional development.
She took this at-home job after a rough experience working in nursing homes. Caseloads soared, so 45-minute sessions became 15-minute whirlwinds where she had to help lift patients out of bed and barely did any real therapy.
“It broke my soul to work there, to be honest,” she said.
Stress is a universal concern for Speech-Language pathologists. In a recent survey, 76% of respondents cited "above average stress levels" as a significant weakness of the profession. And 83% noted salary as a weakness.
The at-home gig offers more flexibility and more time with patients, but now Meyers is struggling with insurance companies to get enough referrals. She’s not sure if this work is sustainable either.
“I feel like I'm just doing this just because I'm stuck,” said Meyers. “I don't know, it's such a sad feeling.”
Conditions like this are forcing many speech therapists to leave the field, people like Bethany Rasmussen. She spent a decade as an SLP in northern Illinois hospitals. When she started, she was at a 350-bed facility with only one speech therapist.
“It was insane. I mean, it was evaluations all day, absolutely no treatment,” she said. “No patient really got any treatment unless they really couldn't swallow and we had to see them to try to get them to eat something before they left, so they didn't need a feeding tube. And there was no weekend coverage.”
She reached her breaking point two years ago after another Christmas away from her family due to staffing issues.
“I wish I would have done it a lot sooner," she said. "It makes me sad, because what I was doing before was actually directly impacting people and their ability to speak and swallow. But it made my life so much harder that I doubt I'll ever go back."
Many of the challenges are the same as when she entered the field over 10 years ago, but -- like pay rates -- things just haven’t improved. Rasmussen thinks about students who want to become speech therapists today, whether in hospitals, schools, or private practices.
“Anyone going into the field, I would tell them to run very fast to something else,” she said.
There is a national organization who advocates for better work conditions for speech language pathologists -- it’s called the American Speech-Language Hearing Association (AHSA). But many speech therapists say even though ASHA says they’re doing everything they can to help improve reimbursement & productivity rates -- they’re not seeing it and want more transparency. And, Elizabeth Nielsen says, it’s worse than that.
“We're passionate about helping these people," she said, "but we're being taken advantage of."
Nielsen says ASHA has a certification product called the Certificate of Clinical Competence (CCCs) that costs over $200 per year -- and the price recently went up. Many speech therapists, including Nielsen, Meyers and Rasmussen, say they don’t know what they’re actually paying for aside from getting to put three “Cs" next to their signature.
“In Illinois, I now know you don't actually need it to practice. But I didn't even know that!” said Rasmussen. “It's sad that there's so much misinformation and that they certainly are not going to be the ones to clear things up for us since it wouldn't financially benefit them.”
ASHA says the certification ensures a standard of quality across the country. Therapists must complete professional development hours and abide by a code of ethics. But Illinois licensure already requires the same number of professional development hours and mandates ethics training.
Nielsen says she has to pay for it in order to supervise graduate students, but another speech therapy advocacy group, Fix SLP, say that’s not true either -- and if universities say it’s required, it’s based on old information.
Therapists like Nielsen say they’ve been afraid that if they don’t renew, they’ll have to retake their license exams or even go back to school. And some employers require it, even though it’s not part of the state licensure process.
“There's still this fear of, ‘I need to have my Cs. I need to have this product!’” she said.
They say too much of ASHA’s money goes to lobbying to have their product linked with state licensure or Medicaid reimbursement. In a statement to WNIJ, an ASHA spokesperson said they don’t lobby to make their certification required, just to offer it as a pathway to licensure.
But in 2022, they wrote in support of regulations in Nevada that would require speech therapists to pay for their product to renew their standard license. And they lobby to make sure graduate students are supervised by people who hold their certification.
The group also advocates for issues SLPs say are essential like Medicare funding.
Back at the barn, Elizabeth Nielsen is using one of her horses, named Eli, for an activity with one of her clients.
“A lot of advocacy stuff with her right now," she said. "And just overall being able to express her needs and how her body feels."
The main goal of the game is to feel comfortable verbalizing your needs. She says so much of what she does is about teaching people how they can advocate for themselves.
Illinois-based therapists like Nielsen say they wish there were more people advocating for them. She and the other speech therapists want the organization to spend more time focusing on issues they’re facing on the ground -- ones that are making many speech therapists wonder if they have a future in their profession.
