Rehabilitation in Managed Care: Controlling Cost, Ensuring Quality.

Rehabilitation in Managed Care: Controlling Cost, Ensuring Quality Hagen C. Gaithersburg, MD 20878, Aspen Publications Inc, 1999, paperback, 323 pp, ISBN: 0-8342-0923-3, $48.

This book is about health care delivery and financing as it presently exists under managed care. It covers the events leading to present-day policies and what one needs to know in order to remain successful in practice. As stated in the preface, payments for rehabilitation are changing from fee-for-service to a capitated method of managed care, a payment form that every health care worker must know thoroughly in order to maintain his or her professional status at a high level.

Strengths of the book lie in the heavily laden contents of every page, where the author always provides guidelines and emphasizes the qualities necessary for successful practice. The book has 8 chapters, with each chapter heading seeming to "leap" from the page to hold your attention. To further focus the reader's attention on content, each chapter begins with a "key points" segment. Chapter 1 is entitled, "Managed Care: Where Did It Come From, What Is It, Why Should I Care?" This chapter identifies the systems that manage health care, and it contains guidelines for treatment classifications based on therapy intensity and intensity of assistance and payment based on total needs. An appendix defining the major managed care terms and organizations follows the chapter.

Chapter 2, "The Business of Rehabilitation: Where Does All the Money Go?", addresses the economics of rehabilitation. The chapter emphasizes that therapists must understand basic business concepts and that they must understand the factors critical to maintaining the fiscal health of their businesses. It explains and itemizes business management concepts with examples of fixed and variable costs; provides guidelines for establishing a budget, maintaining fiscal health, and reducing expenses and increasing profitability; and discusses shifts in revenue sources (eg, Medicare, Medicaid, indemnity plans, managed care organizations, individual private payments). The conclusion of the chapter emphasizes that rehabilitation providers, like all other businesses, must make a profit. According to the book, rehabilitation teams have always been responsible for controlling treatment effectiveness; now, they are responsible for determining the amount of resource utilization, service delivery format, duration of treatment, and appropriate level of care and for managing the risk complications (ie, what happens to the patient when he or she is discharged).

Chapter 3 discusses clinical case management and covers the expanded role of the therapist. The author points out that therapists are now case managers who must be able to treat the patient while managing and supervising resources and producing a meaningful patient outcome. As we know, this a tall order. In preparing the therapist for such a formidable task, the author discusses clinical case management tools, providing specific case studies that include establishing expected outcomes, modulating the frequency and amount of rehabilitation intervention, and developing critical pathways when specific criteria are met. These criteria are presented in table form. The chapter also devotes some space to guidelines about co-treatment, cross-training, use of rehabilitation aides, skilled versus nonskilled services, and family caregiver providers. As expected, all treatments are based on the level of care required. The author argues that cost management does not lead to decreased quality of care; effective cost management arises from sound clinical judgment and appropriate use of resources.

Chapter 4 explores client management tools and includes overviews of managed outcome rehabilitation, medical and rehabilitation models, client management plans, short-term team focus, and several other topics. The chapter contains case studies and an appendix about client-family requests for services. The chapter emphasizes the importance of establishing expected outcomes before rehabilitation begins, that these outcomes must address the patient's and family's goals, and that treatment must address real-life functional needs and those factors that will ensure continued maximal function after discharge. The chapter reiterates that the entire rehabilitation team is responsible for working together to achieve successful patient rehabilitation.

Chapter 5, "Process Management Tools," continues the discussion of how the therapist manages resources. The "key points" emphasize the need to provide consistently good rehabilitation with concurrent case management to enhance effectiveness and to use retrospective case studies, which are necessary in upgrading professional services. In his discussion of prospective case management and the client management plan, the author lists and explains the expected evaluation sequences performed by all physical therapists (ie, prior level of function, current level, risk factors, short term goals). In the conclusion of the chapter, the author restates some rather obvious matters: for instance, he states that managed care organizations will contract only with those providers who can control costs while maintaining a high level of proficiency.

Chapter 6, "Family Management Tools," emphasizes the major role the family plays in achieving and maintaining optimal outcomes in the shortest time. The "key points" state that: (1) the family is as equally "injured" as the client, (2) the team must develop a family rehabilitation plan, and (3) family education and training must be provided at the right time and in the right way. The author then discusses the needs of the family, phases of family response to disability, and development of a family rehabilitation program, with scales to evaluate understanding of disability.

Chapter 7, "Team Management Tools," provides methods for health care providers from many disciplines to move past their own professional boundaries and become members of a self-managed rehabilitation team. According to the author, efficient management of the rehabilitation process requires a self-managed team that is empowered to make timely clinical, financial, and personnel decisions. He states that the concept of a self-managed rehabilitation team is derived from the manufacturing concept of self-directed work teams. Initially, workers produced isolated parts of a product without any knowledge or responsibility for the whole product. After managers reorganized the workers into self-directed work teams, quality improved while costs decreased. The chapter discusses various methods to assist with these paradigm shifts, such as communication, documentation, meeting each team member's expectations, achieving conflict resolution, problem solving, and establishing measurable performance goals. This chapter also has an appendix that delineates areas of responsibility for team members.

Chapter 8, "Successful Documentation," covers an area that has certainly caused all health care providers some anguish in recent years. The author presents practical methods that will produce objective information to facilitate sound clinical judgment and that will result in appropriate reimbursement. The entire content of this chapter is directed toward development of guidelines for producing objective and measurable clinical information that can be used by case managers to authorize frequency and duration of treatment.

This book is outstanding; all health care providers would do well to obtain a copy. However, the author on occasion presents a rather utopian approach to patient care that is not always possible for physical therapists to implement, with the possible exception of hospital-based therapists. Hospital-based therapists may have the luxury of frequent team meetings, but they do not get any true picture of the home setting or of who the true designated caregiver will be. That leaves this process up to those professionals who see the patient at home. However, physical therapists in private practice very often must "go the extra mile" just to renew orders from the physician and then try to obtain authorization from a penurious case manager. The actual occurrence of significant total team conferences is rare.

My overall impression is that the book is excellent and timely. However, if physical therapists attempted to follow all of the guidelines presented to the letter, there would be no time to treat the patient, and that's what we're supposed to do!

Clifton S Mereday, PT, PhD, CPO
Hauppauge, NY

Dr Mereday is Professor Emeritus and former Chairman of the Physical Therapy Department at the State University of New York at Stony Brook. He maintains a limited private practice.