Vocational and medical rehabilitation: the impact of health care policy and funding on service provision.

The United States economy is experiencing an environment of diminishing resources for social and human service programs. Government expenditures for such programs, as a percentage of the Gross National Product (GNP) and as a percentage of total funds, has remained static despite the increasing demands on the system for additional resources (Heimerdinger, 1993; U.S. Bureau of the Census, 1991). With a shift toward rugged individualism, soaring health care costs, and decreased funding for human service agencies, the priority of the political agenda of 1997 is to solve the crisis in health care, education, and welfare reform. The State-federal Rehabilitation Program has evoked a challenge to policy developers in the face of health reform and dwindling financial support.

The purpose of this article is to discuss health care policy development and reform as it relates to persons with disabilities in both medical rehabilitation and vocational rehabilitation service delivery. Areas that are addressed include trends in acute rehabilitation, financial issues, implications for rehabilitation, and recommendations. In a time of scarce resources, an increasing demand for services, and an uncertain political climate, the most challenging aspect of service provision in vocational and medical rehabilitation is to manage the needs of the medically complex rehabilitation consumer (Mahoney, 1995). The combination of factors previously mentioned places rehabilitation [medical organizations in a politically vulnerable position.

Trends in Acute Rehabilitation

Medical rehabilitation has experienced enormous growth in the last decade. According to Carrillo (1993), medical rehabilitation is market driven, resulting in specialized programs (e.g. spinal cord injury, orthopedic injury, pain management) that have cost-effective outcomes. While there is consensus that cost reduction and achieving efficiency are necessary, the question is at what point in the process will quality of care be compromised (Duchene, 1995). One area in which this question is continually at the forefront is in acute care units. Mahoney (1995) indicates that "the rehabilitation patient with medical complexity adds a new dimension to traditional interdisciplinary issues in rehabilitation" because "patients are transferred quicker and sicker' to rehabilitation program " to facilitate "health care reform, prospective payment, functional related groups, capitation, and managed care" (p. 152). However, with the facilitation of cost-containment, using this paradigm, quality of care can be certainly threatened.

Another trend in acute care is that consumers are leaving acute care and transitioning to long term care settings without emphasis on outcome accountability (Duchene, 1995). This trend contradicts the call for accountability through outcome measurement (Carrillo, 1993). Additionally, Carrillo points out that amid charges of high costs, poor care, and, in some cases fraudulent practices, medical rehabilitation will continue to receive critical scrutiny by policy makers, funding sources, and accrediting and licensing agencies.

Decreased lengths of stay in most acute rehabilitation programs is a third trend. Over a three year period, the average length of stay (ALOS) for all patients in rehabilitation hospitals decreased 12% (Suplitt, 1993). Specifically, in 1988, ALOS decreased 7% over the same time period: 1988, 25 days; 1989, 25 days; and 1990, 24.2 days. Likewise, Faraci, Leiter, and Weeks (1996) report the ALOS decreased 6.3 days (18%) over four time periods (1987/88-1990/91) for all patients and each subgroup. Furthermore, "individuals with complex stroke, spinal cord injury or traumatic brain injury are treated in the rehabilitation setting for less than 30 days" (half of the ALOS of a few years ago) (Duchene, 1995, p.252). This decrease in ALOS raises several questions: Was quality sacrificed? Is this a reflection of a well coordinated program? How were outcomes defined? and What type of services were delivered?

Finally, the health maintenance organization (HMO) determines the manner in which rehabilitation professionals deliver care (Duchene, 1994). The ALOS, program components, and discharge disposition are all influenced by the HMO case manager. Carrillo (1993) states that case management approaches fail to address optional outcome; instead, it "is seen as the technology which will meet the need to control costs" (p.6). While case management approaches may satisfy funding sources because of a demonstration of cost effectiveness, they many not meet the service needs of consumers in an adequate manner. Clearly, the issue of cost effectiveness versus consumer need serves as an impetus to close re-examination of public policy when the continuing conflict exists for both consumer and the service provider (Heimerdinger, 1993).

Financial Issues

Financial support of patients is a distressing issue and this substantial economic burden placed on American Society by injury is borne by various types of payers - federal, state and local governments; private insurance; workers' compensation; and private individuals. Private sources include private health, disability, and life insurance; Workers' Compensation federally administered, but almost exclusively financed by employers); and uninsured or uncovered care. Age is an important determinant of payment source. Adults are often covered by employment-related health insurance. Public sources pay for 72 percent of care for persons aged 65 and over through Medicare, Medicaid, and other government programs. For persons aged 15-44, on the other hand, private payments cover 86 percent of injury-related medical care (U.S. CDC, 1986).

Workers' Compensation medical payments for injured persons account for one-fourth of total medical expenses for persons aged 15-64. Included in hospital care expenditures are those for initial hospitalization, rehospitalization, medical/surgical care, mental health care, inpatient rehabilitation, and inpatient prescription drugs. Of expenditures for the hospital care of injured patients, 32 percent comes from public sources and the remaining 68 percent from private sources, mainly private health insurance and Workers' Compensation (Miller, Brinkman, & Luchter, 1988). The financial issues relating to the care of traumatic brain and spinal cord injury, for example, is staggering. The National Head and Spinal Cord Injury Survey of 1980 estimated that spinal Cord related injuries cost the nation approximately $380 million in 1980 (Ravichandran & Silver, 1982). According to Webb, et. al. (1979), these patients will spend approximately 184 days of hospitalization to make an initial recovery at a cost of approximately $29,000 (Webb et. al., 1979). These patients are generally representative of the trauma population, in that many have no insurance or resources to satisfy their financial obligations. Duchene (1992) concurs that "comprehensive rehabilitation is among the most costly of health care services" (p.69). The average per diem charge for inpatient rehabilitation is $700 to $1100 (Uniform Data System for Medical Rehabilitation, 1993).

The tremendous impact of the cost of injury crosses all economic boundaries. Holders of private insurance are not insulated from the economic ravages of injury. The vast majority of these patients have inadequate and non-comprehensive coverage largely due to the fact that employers are negotiating contracts that are conducive to keeping total costs affordable per employee. This often translates into coverage that is consumed quickly and early during the hospitalization post-injury. Families are forced to discover loopholes within their contracts to prolong the coverage of the patients' expenses; however, expenses continue to mount forcing these patients and their families to look toward public sources. In one catastrophic stroke, a person/family enjoying financial security can be thrown into the downhill spiral of financial unrest and in some cases financial ruin.

Acute-care hospitals must treat all patients with the highest standard of care, regardless of social or financial circumstances. However, major obstacles arise when long-term rehabilitation is sought. Currently, there exists little state or federal aid for indigent patients with severe physical disabilities. The sparse resources available are often exhausted during the primary hospitalization. Financial aid, which may apply toward physical rehabilitation, is almost always restricted to patients who have definite rehabilitation potential, and who do not require respiratory support. An informal survey of a local rehabilitation facility, for example, revealed the average cost for retraining a patient who is quadriplegic to be approximately $32,500 per month. Their average stay in 1989 was 69 days; now, it is approximately 30 days (DeVivo, 1989). Therefore, with limited-to-no financial resources, increased costs, and decreased length of stay, the issue becomes who will pay for rehabilitation. Given the need for more resources, issues of policy development and cost containment become as important as treatment itself.

The need for financial support for rehabilitation must be addressed on a national level. Only when injured patients have an equal opportunity for rehabilitation will the trauma of physical injuries be diminished. However, health care benefits and economic status are linked by federal regulations. In order to be eligible for Medicare benefits, an individual with a disability under 65 must be receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI). To qualify for Medicaid, one must be indigent. The broader problem is clearly that American publicly-subsidized health and social service benefits are inexorably and traditionally tied to an individual's earned income (DeJong & Wenker, 1993). These facts wreak havoc on a person's desire and ability to be a part of the workforce, to contribute to society, and to gamer self-esteem in the economic marketplace; hence, the catastrophe following the injury tragically manifests itself and the strides made during the rehabilitative process are oftentimes irrevocably destroyed.

The financial circumstance for non-indigent persons with severe disabilities or catastrophic injury is no different than for their counterpart. Due to excessive medical bills, loss of wages and associated benefits, and inaccessibility of the workplace (Krause & Anson, 1996) these individuals experience a high level of economic or financial strain. These individuals become the near-poor and working poor without insurance who may qualify for coverage under Medicaid as the medically needy. This catastrophe coverage provides some measure of protection; however, consistency of regulations regarding coverage from state to state is severely lacking (Davis & Rowland, 1990).

Money is central to the well-being of the injured person and the family. The cost of serious injury goes far beyond initial medical treatment and includes housing and assistive technology, long-term rehabilitation, educational and vocational training. For most individuals, the ability to financially survive a catastrophic injury depends upon winning a large legal settlement, in addition to having good private insurance coverage. Yet, even with a legal settlement and excellent coverage, it is realistic to be continually fearful of the cost of potential medical complications, follow-up surgical procedures, and future rehabilitation, housing, education, or job-training. The needs do not stop with medical stabilization; they continue for years, or for a lifetime.

Government benefits are set up on an either/or basis: presence of a disability or employable; sick or healthy; indigent or ineligible for funds. Such inflexible criteria may not fit individual needs or unusual circumstances. Federal regulations are insensitive to the fact that many people with severe disabilities want to work, and are capable of doing so. Medicaid and SSI have complex and variable eligibility criteria, and have been redesigned to provide benefits to persons with disabilities, or below poverty level. Services for those with disabilities; however, are not consistently available (e.g., quality or quantity) across the country.

Implications for Rehabilitation

One of the reasons that issues about health-care-policy development and cost containment is so important to vocational rehabilitation practitioners is that the priority for services is given to the individuals with the most severe disabilities (i.e., paraplegia and quadriplegia). Secondary to the degree of functional limitations involved with severe physical disabilities, the amount of medical intervention and vocational rehabilitation are extensive and expensive. Costs for recovery and rehabilitation continue to rise. "Rehabilitation, although a seemingly small part of the healthcare picture, is not exempt from this early impact of health care reform" (Duchene, 1994, p. 137). According to Gibbs, Dodd, Hecimovic, and Nickoloff (1996), drastic increases in the cost of health insurance premiums are forcing employers and institutions to restructure health benefits and employ cost-cutting measures. Gibbs, et.al., also point out that a conflict may arise when services needed by consumers result in an economic discrepancy for vocational rehabilitation and the health care provider. For example, the cost for services may exceed the economic resources of the agency. While vocational rehabilitation cannot regulate medical costs, rehabilitation practitioners need to address the issue of allocating their resouces ethically. Veatch (1990) asserts that "patients will not be treated fairly if too few or too many resources are committed to them" (p. 188). hi order to assist in the decisionmaking process of the allocation of resources, Rhodes (1985) recommends that:

For reasons of equity and practicality, organizations

cannot deal with each person uniquely but must deal

with people as parts of categories. Only in this way

can bias be eliminated and only this way can services

be distributed on a mass basis. (p. 103) Since vocational rehabilitation cannot be all things to all people, it must be able to rank its needs to concentrate enough resources (both financial and human) to be beneficial. The capacity to target resources effectively and efficiently will impact service delivery, influence funding sources, and clarify the agenda for policy development and reform.

Rehabilitation practitioners, who assist people with disabilities to find employment, need to understand the impact of unemployment on health care coverage. Since individuals, for example, with spinal cord injury have a high rate of either unemployment or underemployment, rehabilitation practitioners and their consumers experience "the extensiveness of unemployment in today's economy," and call attention to "the need to refine the link between employment and health insurance coverage" (Davis & Rowland, 1990, p.46). Therefore, job placement efforts need to consider not only the type of job and salary, but the benefits associated with the job. Rehabilitation practitioners will need to work with consumers on becoming skilled negotiators (for benefits), and not simply knowing how to be good at job searches and interviews. These skills need to complement and reinforce each other.

While vocational rehabilitation is designed based on the medical model, vocational rehabilitation and medicine have different missions. Vocational rehabilitation has a humanitarian mission (e.g., to assist individuals with disabilities to obtain competitive employment and independent functioning) and the medical arena has a profit-making, research, and education mission (Ehrenreich & Ehrenreich, 1990). Since vocational rehabilitation clients are often major consumers of medical services, knowledge about medical costs and health care policy are critical for rehabilitation practitioners. Ehrenreich and Ehrenreich venture to suggest that "patient care is not the only, or even the primary, aim of the medical care system" and health care reform is aimed, largely, at "preserving and strengthening the medical system as it now operates" (p. 68). The current system is too often contrary to the needs of the consumer - especially, those who are uninsured. Rehabilitationists have the responsibility of advocating for and helping consumers advocate for themselves in the pursuit of adequate and cost-effective health care services in a system that is inherently counterproductive to the needs of many vocational rehabilitation consumers. This suggests the need for counselors to utilize and empower consumers at the grass-roots level, and lobby for legislative mandates relative to health reform.

The role of vocational rehabilitation in health care policy development and reform is to help set the agenda in order to benefit individuals with [severe] disabilities. As a segment of the poor, working poor, near poor, medically needy, and uninsured, individuals with disabilities are often the recipients of inequitable health care differentials (Davis & Rowland, 1990). Thus, rehabilitation advocates, policy developers, and insurance providers need to work collaboratively to create a pragmatic approach to healthcare coverage. One of the most important aspects to consider in the development of a pragmatic approach is the availability of regional resources. Although policy is distributed from a national forum, its impact is lessened if local or regional resources are absent or inadequate. Collaborative efforts between local agencies and policy makers may be a means by which to achieve substantive policy.

In the past two decades federal disability policy and the performance of the economy have seen major swings. According to Burkhauser, Haveman, and Wolfe (1993), in response to rapid increases in expenditures and the number of recipients on the disability roll, government "established more stringent periodic evaluation regulations and constrain benefit generosity" (p. 263). However, wage earnings of individuals [men) with disabilities did not grow accordingly with previous economic expansions. In actuality, earnings remained close to recession levels and fell relative to the earnings of their counterparts (Burkhauser, et. al., 1993). The most significant disparity is among those with low levels of education and nonwhites. The result is that individuals with disabilities who are minorities have limited education, and earn less income, compose an increasing part of the nation's poverty population (Burkhauser et. al., 1993). These factors have important implications for vocational rehabilitation. Rehabilitation will need to create an intensified training or workplace effort so that persons with disabilities will be in a position to capitalize on economic growth and workplace opportunities. Hence, increasingly, the independence of workers with disabilities will rest on the increased earnings of those with whom they live or on the availability of public income transfers (Burkhauser et. al., 1993). In light of recent welfare reform and decreasing public income support, vocational rehabilitation will need to consider using a collaborative training effort with a focus on strategies similar to that of the displaced homemaker.

The obvious question is, "what can be done?". The Committee on Trauma Research report published by the National Academy of Sciences (Committee, 1985) identifies significant research needs in the areas of injury epidemiology, prevention, biomechanics, and treatment and concludes that in light of the magnitude of the injury problem, increased efforts are warranted. The establishment and funding of a Center for Injury within the Centers for Disease Control to provide a focal point for national injury prevention activities is vital to this effort. Additional recommendations would include the provision of additional resources to existing agencies that currently pursue the prevention and control of injury resulting from motor vehicles, fires, consumer products, and occupational hazards; conducting research and controlled experiments to evaluate the effectiveness and savings of a wide range of injury control interventions and implementing programs shown to be cost effective, conducting research to evaluate the societal barriers to the application of injury prevention strategies that have been proven to be effective, conduct collaborative interdisciplinary research to identify and evaluate factors in trauma care that produce optimal results; greatly expand research for the development and evaluation of cost-effective model systems of rehabilitation and for the design and production of affordable and reliable assistive devices to serve the needs of people with disabilities, ultimately decreasing the risk of secondary disabilities. The involvement of people with disabilities in this process is of utmost importance. Lastly, the link between insurance cost, insurance coverage, rehabilitation, and employment with competitive benefits needs to be established.

Self-reliance and independence are valued attributes in this society; however, our present system of government benefits for those who have incurred injury and hence a disability does not aid in the preservation of these values. The cost of lifetime care represents a growing national dilemma that must be addressed. For example, despite the fact that spinal cord injuries are relatively rare, their aggregate costs to society exceed one-tenth the costs of cancer, one-sixth the costs of motor vehicle injuries and coronary heart disease, and one-third the costs of stroke (Devivo, 1989). If policy and the economic well being of persons with disabilities do not improve, the public sector will ultimately bear the burden of health care payments and demands on related public services (Burkhauser et. al., 1993). Medical rehabilitation also will need to consider new avenues for improvement and policy impact.

Conclusion

Medical and vocational rehabilitation agencies and programs provide services to persons with disabilities. These programs are influenced by and impacted on by public policy and funding guidelines. All sectors of the nation's economy share the burden of health care payments and demands on related public and rehabilitative services. As a result of financial issues and discrepancy of wage earnings of persons with disabilities, current accommodation policy and health care reform are likely to do the most harm to those ill-prepared to compete in the labor market, purchase services in the product market, and negotiate terms and benefits in the political market.

In an era of increasing accountability and major health care reform (Thomas & Goffey, 1996) demonstration of quality, service provision, efficient implementation of services, and effective outcome are critical to program improvement and survival in a competitive market. Rehabilitation practitioners, as well as other team members, need to have an understanding of how health care policy and costs impact the ultimate rehabilitation process for the consumer. Policy, costs, and outcome are irrevocably linked, resulting in a synergistic force of increased benefit to the consumer. Any attempt to address the impact of policy and funding on services in medical and vocational rehabilitation for persons with disabilities requires an effective mix of affordable healthcare coverage, job training, and cost containment. There is no single solution to better the lives of persons with disabilities.

As society deals with welfare reform and other political concerns, consumers with disabilities and the service providers who work with them need to be active participants in policymaking. Participation of all parties with a vested interest in how policy impacts people and services, resource allocation, and political opinion will create an environment that is conducive to the creation of more sound and equitable policy.

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