Disability and health care reform: principles, practices, and politics.

The magnitude of change in health care policy within the United States is parallel to the evolution of computer technology during the last decade. The changes have been swift, extensive, radical, and unprecedented. The reform in health service provision has completely reshaped the landscape of medicine and the allied professions. Persons with disabilities have not been spared the effect. For example, public funded medical providers such as Medicare, Medicaid, and worker's compensation are increasingly being privatized through contractual agreements between the states and health care providers (Hagglund & Frank, 1996). Oftentimes, these agreements result in economic limits on services for recipients such as persons with disabilities.

The aforementioned change in health care policy is being fueled by the public and private sector's concern for cost control. Private industry has experienced double-digit inflation annually in the cost of employee health benefits. Kongstvedt (1989) stated that corporations have addressed the escalation in cost by reducing coverage and/or offering creative benefits packages such as managed care arrangements (e.g., health maintenance organization [HMO], preferred provider organizations [PPO], and independent practice associations [IPA]). Rising cost for local, state, and federal agencies has been more rapid than in the private sector. Treatment cost at county clinics and hospitals have encouraged both the state and federal government to consider reducing payments to physicians, increasing premiums paid by Medicare beneficiaries, allowing states greater control over Medicaid, and persuading enrollment in private sector managed care plans (Bellamy, 1995). Although passage of a comprehensive reform package failed in the 104th Congress, states such as Oregon and Tennessee have made major reforms by focusing on managed care. According to Cavaliere (1995), at least twelve states have been granted 1115(a) waivers from the Health Care Financing Administration (HCFA). The waivers enable the states to mandatorily enroll Medicaid recipients in managed care service delivery systems.

The significance of adequate health care coverage for all Americans is indisputable. However, it is particularly crucial for persons with disabilities because of special health care needs, greater risk for higher health care costs, and tougher approvals for private insurance coverage (Reno, 1994). Uninsurance and underinsurance is a prevalent and severe problem for persons with disabilities (Watson, 1993). Although the common belief is that Medicare and Medicaid cover all persons with disabilities, nearly 16 percent (2.1 million) of working-age individuals in 1984 with an activity-limiting disability had no insurance (Watson, 1993). A typical private health insurance plan covers acute care hospitalization and physician expenses, yet it rarely provides for long-term needs such as medical equipment, supplies, rehabilitation, or personal assistance services. Watson (1993) reported that in 1991 a woman with multiple sclerosis indicated in testimony to the National Council on Disability that she spent $8,000 of her $20,000 annual salary on health-related needs, even though her full-time employment provided health insurance. The perceived importance of medical coverage for recipients of Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) is so great that the risk of losing coverage is a larger rehabilitation disincentive for employment than is the loss of their cash benefits (Quinn, 1995). Thus, secure medical coverage for persons with disabilities is paramount to developing stable health care policies that facilitate entry or return to employment following rehabilitation.

Watson (1993) noted that persons with disabilities have been conspicuously absent from the debate regarding health care, yet they have much at stake. Moreover, many of the conventional proposals of reform ignore the varied and group specific needs of persons with disabilities. Although politicians and health care reformers are largely to blame for the inattention to persons with disabilities, rehabilitation professionals and disability advocacy groups bear some responsibility. For instance, disability groups such as the National Council on Disability and the Consortium for Citizens with Disabilities entered the debate late and demonstrated cursory involvement by conducting hearings and issuing position papers (Watson, 1993). Nevertheless, the adoption of HMOs, IPAs, and PPOs, even on the part of public programs for which persons with disabilities are a major constituency, proceeds at a steady pace (Tanenbaum & Hurley, 1995).

In the current political environment of health care, rehabilitation professionals must acquaint themselves with the language and strategies of the health care debate. Consequently, the purposes of this article are as follows: (1) to define managed care and examine its components; (2) to discuss the inherent contradictions between rehabilitation philosophy and health care reform; (3) to explore the components of public health care programs; and (4) to examine the merits of national health care for persons with disabilities. The article will not be inclusive about these issues but is intended to educate and facilitate further discussion.

Principles of Managed Care

A common complaint concerning health care is cost inefficiency of service rather than effectiveness or quality (Blendon, Brodie, & Benson, 1995). The high cost of health care is attributed to factors such as excessive administrative hierarchy, proliferation of skilled specialists, redundancy of exams and treatments by neighboring facilities, and overinvestigation of illness to reduce risk of malpractice suits (Landry & Cox, 1996). Managed medical care is perceived as the remedy to control spiraling cost. Hastings, Drasner, and Michaels (1990) defined managed care as any formalized approach to medical service provision that favorably affects the price of services, the site at which services are received, or their utilization. It is comprehensive and involves planning and coordinating care, educating patients and providers, overseeing quality of care, and monitoring costs (Lepler, 199:), Economic control is a central theme in managed care. Familiar practices of managed care include minimal access to specialists, limited access to hospital beds, and increased prepayment and copayment.

Landry and Cox (1996) delineated four principles used to achieve cost containment in managed care. First, participants in managed care plans are typically assigned a primary care physician (PCP). The PCP functions as a gatekeeper to services. The participant in the plan is prohibited from seeking specialist services before consulting the PCP. Thus, costly self-referral for specialty care and unnecessary procedures are replaced by more cost efficient monitoring and care by the PCP Similar to the PCP, case managers serve participants with chronic and severe medical problems requiring extended care. The case managers make quality and economic judgements concerning the appropriateness of the care a participant has received.

Second, utilization reviews are conducted in managed care plans. A team of health care administrators and professionals examine the resource usage patterns in patient care. Taylor and Taylor (1994) indicated that the purposes of a utilization review are to provide cost control, promote quality care, and guarantee participant satisfaction. Utilization reviewers are responsible for reporting unsatisfactory findings to the plan's authorities for corrective action (Landry & Cox, 1996).

A third feature of managed care plans is the establishment of medical networks and associations such as HMOs, PPAs, and IPOs. Contractual agreements between subscribers and service providers concerning payment for health care services are integral to the managed care networks. The organizational composition and ownership of the networks can vary from a single entity of financing, administration, and service delivery to a loosely defined system of numerous independent contractors (Landry & Cox, 1996). For example, rehabilitation specialists could be affiliated with a network as either an employee of a participating clinic, a self-employed professional contractor, or as an employee of the managed care network.

Lastly, managed care involves payment capitation. Defined as predetermined payment rates for service utilization, payment capitation bases reimbursement on measurements such as per diem, per enrollee, per procedure, and per admission (Landry & Cox, 1996). A set amount of reimbursement for each month is determined by the total number of participants in the plan. Payment capitation is designed to shift the financial risk of overexpenditure or waste from the managed care program to the health care provider. Thus, the health care provider (e.g., rehabilitation specialist) is encouraged to control costs because payment is fixed at a predetermined amount.

Again, a major objective of managed care is to improve profitability by controlling costs. Therefore, health care delivery will often entail outpatient treatment and utilization of less expensive medical professionals (Landry & Cox, 1996). Accountability of health care professionals will increase because of emphasis on quality assurance. Moreover, emphasis on disability prevention and health promotion will increase as a result of its influence on utilization rates. Knowledge of these concepts will increase rehabilitation specialists' competitive advantage in the managed care arena.

Philosophical Contradictions

It would stand to reason that health care reform would be a natural issue for political activism among persons with disabilities and rehabilitation professionals. However, disability advocacy regarding health care has been impaired by factors such as internal bickering, social phenomenon, and minimal congressional support (Watson, 1993). Since the disability community is diverse, members have different medical priorities, service requirements, and strategic ideas. Therefore, establishing support for one's moral or political stance and plan of action is difficult. Social occurrences such as the broad change in the public's willingness to readily support government programs (e.g., Welfare, Affirmative Action) affects the goals of disability advocacy. Thus, strategies for addressing reformation activities must be responsive to changes in social sentiment (Watson, 1993). The absence of a strong cheerleader in Washington's congressional circles is detrimental. Consequently, we do not enjoy allegiances or uncompromising support with members of key congressional committees.

Despite the aforementioned impediments to a cohesive disability advocacy movement regarding health care reform, contradictions between rehabilitation's traditional philosophical positions (e.g., societal independence, self sufficiency) and basic health care reform assumptions pose the greatest challenge. For decades, trends and developments in health care benefitted persons with disabilities. Advancements in medical technology and rehabilitation methods increased survival rates and lengthened life expectancy (Watson, 1993). Also, Watson noted that insurance plans were "community rated"; all employees, including persons with disabilities, paid no more than others. However, recent trends in health care appear to threaten the welfare of persons with disabilities. For instance, practices such as exclusion clauses for pre-existing conditions are now commonplace in the health insurance industry.

During the past twenty years, the disability community and rehabilitation professionals have worked to transform the negative image of persons with disabilities from passive patients requiring supervised medical care to informed consumers of medical and social services who make responsible choices (Watson, 1993). Interestingly, the health care community perceives persons with disabilities as individuals potentially requiring long term and major medical care, and it is attempting to determine the extent, type, and process of coverage that can be provided in today's health care environment. Watson asserted that the rehabilitation community has worked diligently to separate the issues of health and disability, but now finds itself struggling to reconcile the two. There is extreme difficulty in acknowledging the need for significant benefits in some cases without reviving the negative stereotype of people with disabilities as sick and dependent. In the past, it was considered offensive if anyone asserted that persons with disabilities can have higher than average health care costs or may need expensive accommodations and additional sick leave (Watson, 1993). Whereas in reality, there can be truth to the assertion in certain cases.

Rehabilitation professionals have taken an asset oriented approach rather than a deficit oriented approach when advocating for persons with disabilities. The abilities of persons with disabilities have been emphasized rather than inabilities. Moreover, the medical nature of disability (e.g., home health care and personal assistance) was de-emphasized and the independent living model was adopted (Watson, 1993). Under the independent living model, personal assistance services are viewed as social services dictated by individuals who are usually healthy persons. In contrast, proponents of the medical model consider personal assistance as a health service provided to fairly dependent patients by medically trained and supervised personnel. The dilemma lies in the rehabilitation community's advocacy for inclusion of personal assistance services as a health benefit in health care reform legislation and policy revisions. It is crucial that the rehabilitation community emphasize the preventive value of personal assistance (e.g., reduction in medically expensive ulcers) as a health benefit rather than contribute to stereotypes of persons with disabilities as medically fragile and dependent.

Universal Health Care

The demise of the Health Security Act during President Clinton's first term temporarily derailed a national health care package for the country. Instead, the debate on health care shifted from public support for universal coverage for all citizens to a massive federalist reform movement in which reducing "big government" became the focus (Blendon, Brodie, & Benson, 1995; Frank & VandenBos, 1994). Nonetheless, discussion of universal health care continues to appear on the agenda.

The guarantee of universal protection -- independent of work status, disability, health, or cash benefit status -- has significant implications for persons with disabilities. Underemployment and unemployment are high within the community of persons with disabilities (Bowe, 1983). Consequently, adequate health care coverage is a particularly salient issue for the population. Even in cases of employment, employer-sponsored health insurance may not provide the services needed by persons with chronic conditions. Benefits desired by persons with disabilities include coverage for prescription drugs, durable medical equipment, personal assistance care, adaptive devices, rehabilitation services for job development and searching, and counseling services for mental illness (Reno, 1994).

Passage of universal health care would revolutionize national policy regarding work, income, and public benefits for persons with disabilities (Reno, 1994). Currently, the United States offers the following four types of social assistance to citizens who are not in the labor force: (1) work-base interventions (e.g., vocational rehabilitation services) provide rehabilitation training and job development; (2) unemployment benefits allow term-limited income continuity to those who lost jobs but are actively seeking work; (3) disability benefits (e.g., SSI, SSDI, Medicare, and Medicaid) provide income and medical security to individuals with severe limitations in their work potential; and (4) poverty assistance (e.g., Welfare) provides income and other benefits based on eligibility test for the poor (Reno, 1994). According to Reno (1994), universal protection would alleviate the insecurity of Medicaid and Medicare recipients who fear losing their benefits if they find work. Similarly, it would foster the cash benefits of SSDI and SSI while subtly promoting employment for persons with disabilities who are capable of work.

It is important to note that the author is not assuming a stance on the merits of universal health care. Furthermore, the author is not suggesting that universal health care policy is the only or best approach for addressing the needs of persons with disability. A discussion of universal protection is included in the article to illuminate the observation that reliable and expansive health care for persons with disabilities can facilitate entry or reentry to paid employment.

Public Assistance versus Private Insurance

As indicated earlier, health care for a large portion of persons with disabilities is funded through public mechanisms such as Medicare and Medicaid. However, a trend is growing in which these programs are increasingly being administered through private managed care plans. Hagglund and Frank (1996) indicated that persons with disabilities are concerned that this trend will result in substandard care and poorer outcomes (e.g., medical complications, increased rehospitalization, reduced community integration, and greater handicaps). Proponents of the trend insist that managed care can remedy the fragmented and costly service delivery system of public assistance by instituting greater controls and coordinated service systems. Obviously, both approaches have strengths and weaknesses. An overview of both systems of service delivery is provided below. The discussion is neither an endorsement nor a condemnation.

For example, Medicaid provides conventional medical care as well as coverage for services such as residential facilities for persons with developmental disabilities, personal care, prescription drugs, and occupational therapy. In addition, Medicaid provides program regulation waivers for home care and environmental adaptations (Tanenbaum & Hurley, 1995). The waivers for home health and community based services helped to solidify the movement of placing previously institutionalized, technology-dependent children with their families or in foster care. Similarly, Medicaid was instrumental in the establishment of community based living arrangements for adults with mental illness, developmental disabilities, and HIV (Tanenbaum & Hurley, 1995).

Managed care has not typically shared Medicaid's disability oriented service approach. To control costs, managed care plans have implemented "selective avoidance of risk" strategies. The aim is to minimize utilization of medical services. Persons with disabilities are often calculated and perceived as high risk and can be excluded or offered restricted benefits (Kopelman, 1996). Moreover, Tanenbaum and Hurley (1995) asserted that the prominent role of primary care physicians may jeopardize the specialist/patient relationships of some Medicaid recipients. Fox, Wicks, and Newacheck (1993) reported that inadequate access to specialty providers was a major disadvantage of HMOS serving children with disabilities. Lastly, health care provisions such as psychological services for persons with substance abuse or certain types of mental illness can be viewed as extreme and identified for coverage limitations or omitted from the benefits package.

Despite the shortcomings of managed care plans for persons with disabilities, there are appealing aspects to its health service approach. Care coordination is a key advantage to managed care plans. Since the primary care physician directs and structures the individual's total treatment, there is assurance that services are logical, customized, and prompt. Thus, persons with disabilities should experience less frustration and confusion from splintered service provision systems which can be commonplace in public programs.

The multiple physician and professional composition and strong clinic network of many managed care plans present more advantages for persons with disabilities. Tanebaum and Hurley (1996) asserted that a privately managed program can mobilize its referral system of service providers to foster a treatment team method of diagnosis and delivery. For persons with disabilities who may have distinctive health needs requiring highly specialized care, the professional network/team advantage is particularly attractive. Finally, some managed care organizations provide transportation between the patient's home and one of their comprehensive facilities. Transportation and mobility limitations are ubiquitous problems for persons with disabilities. Tanenbaum and Hurley (1996) noted that access to care has been an ongoing challenge for Medicaid recipients. Service transportation provided by managed care plans is a luxury that can greatly improve accessibility of care for persons with disabilities.

Conclusion

Hagglund and Frank (1996) delineated several professional and political advocacy considerations for the practice of psychology in the health care system. Many of their suggestions are applicable to rehabilitation. First, rehabilitation professionals should assume a proactive stance in Medicaid reform discussions. Persons with disabilities are primary recipients of Medicaid and their numbers are increasing rapidly within the system. Thus, reform modifications such as privatization of Medicaid can drastically transform service provision and impact the treatment outcome of our customers. Rehabilitation professionals must mobilize their professional organizations (e.g., National Rehabilitation Association) at the state level to encourage representation at the "decision table" with state politicians and policymakers. Advocacy for the protection and growth of adequate medical services for our customers is paramount.

Second, standardization of treatment to maximize value is at the core of health care reform. Consequently, policymakers are developing practice guidelines for many major disabilities and diseases (Hagglund & Frank, 1996). Rehabilitation professionals must not contribute to a narrow and shortsighted view of practice guidelines. To help ensure flexible, responsive, and integrated practice guidelines, rehabilitation professionals should participate in defining the parameters of rehabilitation treatment/services for severe diseases and disabilities. Our expertise in the medical, psychosocial, and vocational needs of persons with disabilities makes us logical consultants for development of practice guidelines.

Lastly, rehabilitation education programs should enhance course offerings to prepare professionals for practice in the health care system of tomorrow. Despite efforts to reflect current issues, programs accredited by the Council on Rehabilitation Accreditation (CORE) continue primarily to emphasize traditional state-federal training preparation. Educators should work with CORE to develop innovative training models by creating more flexibility in accreditation guidelines. Greater instruction in content areas such as medical management, catastrophic injury, cost containment analysis, and health care policy are appropriate.

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