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Topics in
SPINAL CORD INJURY
REHABILITATION
IMPACT OF MANAGED CARE ON
SCI TREATMENT
Gary R. Ulicny
Issue Editor
An Aspen
David F. Apple
Volume 3 Number 4
Publication
Editor
Spring 1998
Topics in Spinal Cord Injury Rehabilitation
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The appearance of advertising herein does not constitute
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Purpose of journal: Topics in Spinal Cord Injury Reha-
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bilitation (TSCIR) is a PEER-REVIEWED quarterly topical
the responsibility of every practitioner to evaluate the
journal devoted to multidisciplinary commentary on the
appropriateness of a particular opinion in the context of
management of persons with disability because of an
the actual clinical situation and with due consideration to
insult to the spinal cord. The topics presented, which must
any new developments in the field.
be current on the treatment of patients with spinal paraly-
sis, will be of interest to one or more of the treatment team
Issue: Vol. 3, No. 4 J6112
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ISSN: 1082-0744
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Publishers, Inc. All rights reserved. Aspen Publishers, Inc.
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grants permission for copies of articles in this issue to be
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made for personal or internal use, or for the personal or
Michael B. Brown, Senior Vice President and Publisher
12345
Editorial Board
Editor
Associate Editor
David F. Apple, Jr, MD
Lesley M. Hudson, MA
Medical Director
Co-Project Director
Shepherd Center, Inc.
Georgia Regional Spinal Cord Injury Care System
Atlanta, Georgia
Shepherd Center, Inc.
Atlanta, Georgia
Special Feature Editor
Gary M. Yarkony, MD, Vice President, Clinical
Program Development, Schwab Rehabilitation
Hospital, Clinical Professor, Department of
Surgery, Section of Orthopaedic Surgery and
Rehabilitation Medicine, University of
Chicago Medical Center, Chicago, Illinois
Editorial Board
Cynthia Dahlberg, MA, CCC, Director, Speech
Wayne A. Gordon, PhD, Professor and Associate
and Language Pathology, Craig Hospital,
Director, Department of Rehabilitation
Englewood, Colorado
Medicine, The Mount Sinai Medical Center,
New York, New York
Stephen F. Figoni, PhD, RKT, Associate Professor,
Department of Physical Therapy Education,
Karyl M. Hall, EdD, Director of Rehabilitation
University of Kansas Medical Center, Kansas
Research, PM&R Department, Santa Clara
City, Kansas
Valley Medical Center, San Jose, California
Cynthia Kraft Fine, RN, MSN, CRRN, Program
J. Anderson Harp, JD, Senior Partner, Taylor, Harp
Director, Spinal Cord Injury Program,
and Callier, Attorneys, Columbus, Georgia
Department of Administration, Magee
Karen A. Hart, PhD, Assistant Professor, Depart-
Rehabilitation Hospital, Philadelphia,
ment of Physical Medicine and Rehabilitation
Pennsylvania
at Baylor College of Medicine, Vice President
for Education, The Institute for Rehabilitation
Marcus J. Fuhrer, PhD, Director, National Center
and Research, Houston, Texas
for Medical Rehabilitation Research, National
Institutes of Health/National Institute of Child
Jane Mattson, PhD, OTR/L, CRC, CCM, Presi-
Health and Human Development, Bethesda,
dent, Jane Mattson Associates, Inc., Stamford,
Maryland
Connecticut
Gail Gilinsky, OTR, Director, Department of
M.J. Mulcahey, MS, OTR, Clinical Supervisor
Occupational Therapy, Craig Hospital,
Research, Research Department, Shriners
Englewood, Colorado
Hospitals, Philadelphia Unit, Philadelphia,
Pennsylvania
Tonnie Glick, BS, RN, MEd, CCRN, CRRN, Acute
Care Coordinator, Northern New Jersey Spinal
Kenneth C. Parsons, MD, Assistant Director,
Cord Injury System, Kessler Institute for
Spinal Cord Injury Program, The Institute for
Rehabilitation, West Orange, New Jersey
Rehabilitation and Research, Houston, Texas
Marilyn Pires, RN, MS, CRRN, Clinical Nurse
len H. Sie, MS, PT, Research Associate, Regional
Specialist-Spinal Injury, Department of
Spinal Cord Injury Care System of Southern
Nursing, Rancho Los Amigos Medical Center,
California, Rancho Los Amigos Medical
Downey, California
Center, Downey, California
Robert L. Waters, MD, Medical Director, Rancho
Kristjan T. Ragnarsson, MD, Professor and
Los Amigos Medical Center, Downey,
Chairman, Department of Rehabilitation
California
Medicine, The Mount Sinai Medical Center,
New York, New York
Gale G. Whiteneck, PhD, Director of Research,
Craig Hospital, Englewood, Colorado
J. Scott Richards, PhD, Professor and Director of
Cynthia Perry Zejdlik, RN, Program Develop-
Research, Department of Rehabilitation
ment Consultant, Executive Offices, BC
Medicine, University of Alabama at Birming-
Rehabilitation, Vancouver, British Columbia,
ham, Birmingham, Alabama
Canada
TSCIR 3:4, Spring 1998
Contents
Impact of Managed Care on SCI Treatment
V From the Editor
vi
Foreword
Gary R. Ulicny, PhD
1
Managed Care and Catastrophic Injury: The Case of Spinal Cord Injury
Gerben DeJong, PhD, and Janet Sutton, PhD
17 Managed Care and Its Effects on How We Deliver Services
Connie Burgess, MS, RN
28 Impact of Managed Care on Spinal Cord Injury Physicians and Their
Patients
Kenneth C. Parsons, MD
36 Rehabilitation Facility-Based Case Management in Evolution: Responding to
Managed Care
Jeanette Ray MS, CRC, CCM, LPC
44 CarePaths: A Tool for Coping with Managed Care
Donna Court, RN, MN, Donna Loupus, RN, MN, and Sarah Morrison, PT
53 Managed Care's Impact on Marketing Catastrophic Rehabilitation Services
Mitchell J. Fillhaber, MA
61 Outcomes in a Managed Care Environment
Michael L. Jones, PhD, and Randall W. Evans, PhD
74 Accreditation and Managed Care: Partnering for Success
Christine M. MacDonell
Consumer Viewpoint
80 Spinal Cord Injury and Managed Care: A Consumer Viewpoint
Lex Frieden, MA, Laura Smith, MS, Wendy Wilkinson, JD, Laurie Redd,
and Quentin Smith, MS
ASPEN PUBLISHERS, INC.
From the Editor: A Defining Moment
Everyone who is old enough remembers
ability to cope and certainly faster than
where they were and what they were doing
anatomy and physiology would allow.
the day President Kennedy was shot. The
Paraplegic patients were home before reflex
people of Atlanta remember what they were
bowel and bladder patterns developed.
doing at the time the city was announced as
Quadriplegic lungs had not become ad-
the winner for the 1996 Olympics. English
justed to altered physiology and skin had
citizens remember circumstances on the
not become adjusted to increasing toler-
day Princess Diana was killed. These are
ance. Result-increased complications.
defining moments. But no such time can be
Now we see workers' compensation carriers
attached to the time managed care hap-
asking for longer stays to prevent this. Why?
pened. It has been insidious, but has
Because they have financial responsibility
changed the way medical care is delivered
for the lifetime of the patient and see the
and is testing the tenets of good practice.
economic value in allowing "nature to take
This issue is offered as an attempt to
its course" assisted by good rehabilitation
update rehabilitation health care personnel
care. Indemnity carriers know their respon-
on the current status of managed health
sibility usually ends in two years and the
care. Many have stated it is only managed
government takes over through Medicaid or
cost with quality being paid lip service.
Medicare.
Certainly the practitioners are trying to keep
Will government get the message? It may
quality as part of the equation. I think this
if we help them by being proactive with our
can and will happen. We are already seeing
patients and our legislators.
quality remain in the equation in some
areas.
Take for instance workers' compensation.
-David F. Apple, Jr, MD
Rehabilitation care teams have been
Medical Director
pressed and have succeeded in shortening
Shepherd Center, Inc.
lengths of stays. This focus pushed patients
Atlanta, Georgia
probably faster than their psychological
Editor
V
Foreword
Perhaps the two most frightening words in
stay in the hospital for a minimum 48-hour
the history of health care are "managed
period. This lack of trust between payer and
care." The fear induced by these two words
provider is no doubt attributable to histori-
is no doubt attributable to the fear of the
cal interactions. If in fact this is the predomi-
unknown. When I was asked to be the
nant way enacted to control costs, then
special editor of this journal issue, I jumped
what we have is not managed care, but
at the chance, because as a rehabilitation
managed reimbursement.
administrator, I spend so much time trying
Another way that health care plans have
to keep up with managed care that I get very
tried to implement managed care is through
little time to think about what it truly is.
the use of a primary care gatekeeper. The
There is no doubt that health care provid-
theory was that by providing financial
ers share a large brunt of the blame for the
incentives to physicians to control what type
introduction of managed care. The health
of care their patients receive, physicians
care industry was unable to control costs,
would be encouraged to use only those
which were spiraling out of control with
procedures that were absolutely necessary.
double-digit inflation. Employers and payers
Unfortunately, many critics argue that this
sent out many messages that they couldn't
put undue pressure on physicians to limit
continue to absorb these cost increases on
care to patients, because their financial
an annual basis. Instead of heeding these
compensation was directly linked to the
messages and beginning to look at how
amount of care they prescribed. Also, initial
costs could be controlled, health care
estimates that this would be an excellent
providers basically allowed the payers to do
way to manage costs appear to be ill
it for us. The result of their actions is what
founded. It appears that critics' arguments
we now-refer to as managed care.
against undertreatment may be com-
Although managed care seems to be a
pounded by increased costs in catastrophic
confusing topic to many, the meaning of the
and chronic cases brought about by primary
term is relatively clear. Managed care is
care physicians who tend to overtreat
simply an attempt to control health care
because of their lack of knowledge of their
costs by managing care efficiently. In that
patients' condition.
definition, money is spent when there is a
In the rehabilitation of spinal cord injuries
return on that investment for the majority of
and other catastrophic injuries, the primary
the parties involved. For example, spending
methodology for controlling costs has been
money may dramatically improve the
reduced lengths of stay. Providers have
quality of life of the patient or significantly
experienced increased pressure to dramati-
reduce the costs of secondary complications
cally reduce lengths of stay, and some
for the payer. However, in the current
insurance policies have a defined inpatient
model, managed care has taken on an
limit. At the Shepherd Center in Atlanta,
entirely new definition. Most attempts at
Georgia, we are beginning to examine
controlling costs by health care plans have
preliminary data that look at the effects of
focused on limiting benefits. The perfect
shortened lengths of stays on patient
example of this is the recent issue over the
outcomes. In an attempt to analyze these
length of hospital stay for new mothers. The
effects, we conducted a small anecdotal
unfortunate result of this was involvement
study at Shepherd in which we looked at all
by the courts that resulted in legislation
the patients who were admitted in 1992 and
stipulating that mothers must be allowed to
compared them with all patients who were
vi
admitted in 1996. We did not match these
to Medicaid, which puts a tremendous
samples for obvious reasons, but admitting
burden on all taxpayers.
FIM scores for both years were virtually
There is no doubt that the first iteration of
identical. The results were somewhat
managed care was a best-guess attempt. As
surprising in that even though lengths of
managed care models have evolved in the
stays and costs were reduced by approxi-
recent years, we are beginning to see
mately 40%, the average FIM change per
movement back toward the issue of quality.
patient actually went up in 1996. At first
Some health care plans, such as Oxford,
glance this might appear that we are doing a
have begun to move toward specialty
better job now than we used to do. I would
primary care providers for patients with
agree from a strictly rehabilitative stand-
chronic and catastrophic disabilities. This is
point, and if the FIM is a true indicator of
a move to control costs by ensuring that
outcomes for people with spinal cord injury,
individuals receive the care they need to
then we are doing a better job.
prevent secondary complications, which
However, I have grave concerns regard-
can be more costly than undertreating these
ing the education of family and patients, the
individuals initially. This move away from
psychological well-being of these individu-
the gatekeeper approach is being driven by
als, and the increase in secondary complica-
a consumer marketplace. This move toward
tions seen with shortened lengths of stay.
consumers demanding quality and choice in
One of the first areas that this began to show
health care plans may have dramatic effects
up was in the incidence of pressure sores.
on what managed care looks like in the
Our staff began to note that we were seeing
future. Providers of catastrophic rehabilita-
more and more patients with pressure sores
tion services undoubtedly are not going to
at 1-year follow-up than were seen in the
see longer lengths of inpatient hospitaliza-
past. For this reason we used the model
tion. For this reason the challenges to us are
systems database to analyze the percentage
to find new and more efficient ways of
of patients with pressure sores at 1-year
monitoring people with catastrophic injuries
follow-up and to correlate that with the
on a long-term basis. Rehabilitation provid-
decline in length of stay: Figure 1 in the
ers need to move away from treating
article by Jones and Evans shows the data
rehabilitation as an episode and begin to
that were available. As can be seen, there is
look at it as a life span event. This concept
a very strong correlation between reduced
of controlling costs over the long term
lengths of stay and the percentage of
should be especially appealing to payers
patients who present with a pressure sore at
who have life-long exposure to these
their annual evaluation. In my opinion,
consumers (eg, workers' compensation,
there are probably many other variables that
Medicaid, Medicare).
providers should follow to ensure that
The purpose of this special issue was to
shortened lengths of stay do not result in
begin to look at where managed care is
secondary complications, whether psycho-
today and where it will be in the future; and
logical or medical. Unfortunately, many
how it has affected the way in which
health plans are geared toward today's costs
services are provided to patients with
rather than the long-term well-being of the
catastrophic injuries. This issue may well be
patient. An increasing number of individu-
outdated by the time it is published, as the
als, once they cannot pay their health
concept of managed care is evolving almost
insurance premium, are being switched over
on a daily basis. However, the authors have
vii
attempted to "push the envelope" in these
provide the highest quality of outcome
articles and to look at managed care in a
possible to patients.
global and futuristic way. This special issue
Sincerest thanks and appreciation got to
attempts to lay out the most salient issues of
my secretary/assistant/frien Jaycee
managed care and, more importantly, to talk
Harding. Without her hard work this issue
about how they have affected rehabilitation
would never have been possible
professionals and the rehabilitation industry.
I hope that readers of this special issue will
take the time to think not about managed
-Gary R. Ulicny, PhD
care in the past or present, but what the
President/CEO
current model might evolve into, and how
Shepherd Center
new and efficient services can be created to
Atlanta, Georgia
viii
Managed Care and Catastrophic Injury:
The Case of Spinal Cord Injury
Gerben DeJong and Janet Sutton
Catastrophic injuries such as spinal cord injury (SCI) provide a useful lens through which to evaluate the
strengths and weaknesses of managed care. The authors examine the health care utilization and expenditure
profiles of individuals with SCI and how these profiles place people with SCI at risk under managed care as
currently organized. The article also explores how managed care can be adapted to address the particular
health and long-term service needs of individuals with SCI. The authors conclude by examining seven
emerging trends in managed care and their implications for people with SCI. Key words: carve-outs,
consumer information, health care utilization, managed care, market consolidation, risk competition, spinal
cord injury
O
NE of the best ways to test the
thing to be opposed, not accepted, and cer-
strengths and weaknesses of man-
tainly not embraced. Such apprehension was,
aged health care is through the ex-
and remains, justified given the many short-
periences of people with catastrophic inju-
comings of managed care organizations in
ries. People with spinal cord injuries (SCIs)
addressing the needs of those with above-
in particular experience a fairly predictable
array of postinjury health challenges that
require vigilant health maintenance and
Gerben DeJong, PhD, is Director, Research and
timely intervention when an adverse health
Training Center on Managed Care and Disability,
event occurs. The ability of a health system,
NRH Research Center, Medlantic Research Institute,
Washington, DC, and Professor, Department of Fam-
managed or unmanaged, to address these
ily Medicine and Adjunct Professor, Georgetown Pub-
health challenges is a strong indicator of that
lic Policy Institute, Georgetown University, Washing-
system's overall ability to meet the needs of
ton, DC.
people with significant health and disabling
conditions.
Janet Sutton, PhD, is Associate Director for Health
Services Research, NRH Research Center, Medlantic
Managed care is currently the dominant
Research Institute, Washington, DC, and Adjunct
form of health care financing for individuals
Professor, Georgetown Public Policy Institute,
participating in employer- and Medicaid-
Georgetown University, Washington, DC.
sponsored health plans and soon will also be
the dominant form among Medicare-spon-
This article was supported by the Research and Train-
ing Center on Managed Care & Disability sponsored by
sored health plans. The issue is no longer
the National Institute on Disability & Rehabilitation
whether, but how, managed care should re-
Research under grant number H133B70003. The opin-
spond to the health needs of people with
ions contained in this article are those of the authors and
catastrophic injuries such as SCI.
do not necessarily reflect those of the sponsoring orga-
The initial response to managed care of
nization. The authors wish to acknowledge Marcel
Dijkers, PhD, Michael DeVivo, DrPH, Rachel Post,
both consumers with disabilities and their
Thomas Stripling, Tony Young, and Lauro Halstead,
providers was one of frustration, fear, and the
MD, for their input and review of this article.
feeling that health care was moving in the
Top Spinal Cord Inj Rehabil 1998;3(4):1-16
wrong direction. Managed care was some-
© 1998 Aspen Publishers, Inc.
1
2
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
average health care needs. This apprehen-
of traumatic brain injury, which often results
sion is increasingly shared by the non-
in a more disparate set of outcomes depend-
disabled population as well-an apprehen-
ing on the site of the lesion.
sion that is best reflected in the more than
To understand how managed care can and
1,000 bills introduced in state legislatures to
cannot respond to the needs of people with
regulate managed care organizations. State
SCI, we must begin by examining the spe-
legislatures have been willing to proscribe
cific health care needs and health care utiliza-
the behavior of managed care organizations,
tion experiences of people with SCI. Next we
even at a time when public sentiment for
must consider the overall growth of managed
government intervention of any kind is at an
care and the extent to which it is penetrating
especially low ebb.
the health plans in which people with SCI and
However, the "managed care backlash" is
those at risk for SCI most often participate,
not likely to abate the rapid enrollment of
including Medicare and Medicaid. This said,
new populations into managed care health
we want to examine the impact of managed
plans. Despite its many downsides, managed
care on people with SCI during both (1) the
care also presents opportunities for innova-
initial acute and rehabilitative phase of SCI
tion that can better meet the health care needs
care and (2) the ongoing postrehabilitation
of people with catastrophic injuries than has
phase of care. In both phases we note the
traditional fee-for-service (FFS) medicine.
threats and opportunities that are inherent in
The thesis of this article, then, is that man-
the economic incentives that drive managed
aged care has both a dark and a bright side. If
care. We will observe how some provider
managed care is to be the main form of health
organizations have already taken advantage
care financing and delivery, then it is incum-
of managed care's latent opportunities to
bent on consumer and provider advocates,
better meet the needs of people with SCI.
policy makers, health plans, and researchers
This article then reviews some of the emerg-
to proffer ideas that harness the principles of
ing trends in managed care and their likely
market-based managed care to effectively
implications for consumers with SCI and
meet the needs of people with disabilities.
providers of SCI services. Finally, we want
Catastrophic injuries comprise a diverse
to emphasize that payer-driven managed
collection of injuries with various sequelae
care is but one step in a much larger transition
and long-term outcomes. Generalizing
in American health care from yesterday's
across catastrophic injuries is difficult.
provider-driven system to tomorrow's con-
Hence, this article uses the needs of one
sumer-driven system.
group, people with SCI, as the point of depar-
Before proceeding, we must have a com-
ture for understanding some of the strengths
mon understanding of what is meant by man-
and weaknesses of managed care. To some
aged care, a concept that describes a myriad
extent, the experiences of people with SCI
of health plans and financing arrangements.
can be generalized to other populations with
catastrophic injuries, although the medical,
What is Managed Care?
social, and financial consequences of SCI are
far more predictable than, for example, those
Managed care is not a unitary concept. It is
Managed Care and Catastrophic Injury
3
used to describe a wide variety of health
ently because of the manner in which these
plans ranging from Medicaid-sponsored pri-
problems interact with SCI-related health
mary care case management (PCCM) to pre-
risks and the individual's residual functional
ferred provider organizations (PPOs) and
abilities. At the same time people with SCI
health maintenance organizations (HMOs),
are more prone to experience health prob-
of which there are several genres ranging
lems that are less common in the general
from individual practice associations (IPAs)
population. There are seven ways in which
to staff-model HMOs. Conceptually speak-
people with SCI are likely to differ from the
ing, managed care can be characterized along
general population in terms of their health
the following four dimensions:
care needs:
1. presence of physician gatekeepers
1. At the outset, people with SCI need
2. a significant degree of utilization re-
access to good trauma care, surgical
view and case management
care, medical stabilization services, and
3. provider assumption of financial risk
an array of postacute services such as
4. channeling of patients to network pro-
medical rehabilitation and other tran-
viders
sition services needed for independent
In many types of health plans, only one or
living.
two of these elements are in place. A strict
definition of managed care embraces all four
dimensions. Unless indicated otherwise, this
People with SCI need ongoing access
article uses the more strict construction of the
to an array of durable medical
concept. The most important element in this
equipment and assistive devices needed
construction is dimension 3, assumption of
for independent living.
provider risk, whether it be through capita-
tion (eg, per health plan member per month)
or some other provider risk model such as a
2. People with SCI need ongoing access
case rate for an episode of care. In either case
to an array of durable medical equip-
the provider commits to providing all the
ment and assistive devices needed. for
care that is needed for a fixed price. The
independent living.
element of provider risk creates the financial
3. People with SCI are at risk of acquiring
incentives that drive the provision of care.
a known set of SCI-related health con-
ditions (eg, upper respiratory illnesses,
Health Care Needs and Expenditures of
deep vein thrombosis, urinary tract in-
People with SCI
fections, skin breakdowns, and spas-
ticity).
There are many ways to characterize the
4. People with SCI often need access to
health care needs of people with SCI. Al-
personal assistance services to accom-
though people with SCI experience many of
modate their functional limitations.
the same health problems experienced by
5. People with SCI may experience ear-
people in the larger population, they are
lier onset of certain chronic health con-
likely to experience these problems differ-
ditions (eg, heart disease or adult-on-
4
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
set diabetes) than people in the general
published data come from a cross-sec-
population because people with SCI
tional survey of health care charges during
have, for example, fewer opportunities
one 12-month period (1989-1990) among
to participate in aerobically demand-
the 508 individuals entered into the Na-
ing activities and a greater propensity
tional SCI Database since 1973.¹ (See
for obesity.
Table 1.) These data are charge data, not
6. People with SCI who acquire a chronic
cost or expenditure data, and as such tend
health condition apart from their origi-
to overstate the actual outlays made. They
nal impairment are likely to experi-
do, however, illustrate clearly how the
ence secondary functional losses that
acquisition of an SCI results in high annual
make the management of a new chronic
outlays and how these outlays vary with
health condition more demanding.
the level and completeness of injury.
7. People with SCI may require more
The two largest outlays are for hospital
complicated and prolonged treatment
care and attendant services, where mean
for a given health condition than people
annual charges averaged $5,255 and
in the general population because their
$11,448, respectively, in 1992. The num-
functional limitations may limit their
ber of hospitalizations in the 1-year study
participation in various therapies (eg,
period varied with the number of years
using a treadmill or exercise bicycle
since onset of injury (Table 2). Among
after an acute myocardial infarction).
those who sustained their injury within the
Although the list is long and potentially
previous 5 years, there were 55 hospital-
intimidating to a health plan, it can also
izations per 100 individuals, with some
misrepresent the state of well-being that
having more than one hospitalization. The
many people with SCI currently experience.
average length of stay for each hospitaliza-
The onset of an SCI should not be construed
tion for this group was 17.5 days. Among
as a cascading set of complications resulting
those who sustained an injury 16 to 18
in ever-diminishing states of health and ever-
years earlier, there were 32 hospitaliza-
increasing expenditures for medical care.
tions per 100 individuals. The average
More importantly, the list speaks to the need
length of stay for each hospitalization for
for effective health maintenance and medical
this group was 17.9 days. The experience
management that can help avert many of the
of people with SCI can be contrasted with
otherwise predictable complications of spi-
the experiences of a somewhat compa-
nal injury. The list underscores the need for a
rable group of working-age people in the
health care system that values prevention,
general population who do not have limi-
health maintenance, and a capacity to inter-
tations in activities of daily living (ADLs).
vene quickly when a new health need
Using data from the 1987 National Medi-
emerges to avert downstream complications.
cal Expenditure Survey, the NRH Re-
The health needs profile of people with
search Center estimates that among work-
SCI is borne out in higher-than-average
ing-age people in the general population
health care expenditures. The most recently
without ADL limitations, there are only
Managed Care and Catastrophic Injury
5
Table 1. Annual charges for health care, attendant services, and environmental modification by SCI
Frankel grade* (1992 dollars)
Frankel grade A, B, or C
Group 4
Group 1
Group 2
Group 3
Frankel
(C1-C4)
(C5-C8)
(T1-S5)
Grade D
Mean
Health care
Hospitalization
$14,296
$5,064
$4,828
$2,082
$5,255
Nursing home care
1,666
578
1,064
0
748
Outpatient services
2,027
1,168
904
640
1,032
Outpatient physician fees
368
401
332
200
322
Durable medical equipment
3,421
1,660
1,132
486
1,361
Medication
1,467
1,393
887
581
1,007
Supplies
1,556
1,508
1,309
547
1,204
Total mean
24,801
11,772
10,461
4,536
10,929
Total median
10,578
5,767
3,749
1,233
4,067
Attendant services
Mean
47,563
16,527
3,106
3,390
11,448
Median
21,758
8,191
0
0
942
Environmental modifications
Mean
616
1,048
1,115
587
90
Median
0
0
0
0
0
* Incurred annually after the first year of injury. Items and services provided free of charge were priced at usual and customary
charges; unmet needs were not included. Only charges directly related to SCI were included; charges for concomitant conditions
such as cancer and diabetes were not included (De Vivo M, personal communication, August 13, 1997).
Source: Modified and reprinted with premission from De Vivo MJ, Whiteneck GG, Charles ED Jr. The economic impact of spinal
cord injury. In: Stover SL, DeLisa JA, Whiteneck GG, eds. Spinal Cord Injury: Clinical Outcomes From the Model Systems,
Gaithersburg, Md: Aspen Publishers; 1995.
about 8 hospitalizations per 100 individu-
Growth of Managed Care
als in any single year. The average length of
stay for each hospitalization is 5.1 days.
Various forms of managed health care
Using more recent data from the National
have been around for many years, starting
Database, Ivie and De Vivo² reported about
perhaps with the staff model HMOs spon-
the same rate of rehospitalization but with
sored by Kaiser for its shipyard workers on
shorter lengths of stay for each hospitalization
the West Coast during World War II. In 1973
(11.6), reflecting what DeVivo (personal com-
Congress passed legislation setting forth the
munication, August 13, 1997) believes may be
requirements for becoming a qualified
the increasing impact of managed care.
HMO. Not until the 1980s, when large corpo-
6
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Table 2 Hospitalization data by postinjury year for all persons enrolled in the national SCI Database
since 1973
Average days
Average
hospitalized per
hospitalizations
Average days per
Postinjury year
year
per year
hospitalization
1-5*
9.60
0.55
17.5
6-10
6.97
0.44
15.8
11-15
7.31
0.39
18.7
16-18
5.74
0.32
17.9
*Apart from initial hospitalization in year 1.
Source: Modified and reprinted with premission from De Vivo MJ, Whiteneck GG, Charles ED Jr. The economic impact of spinal
cord injury. In: Stover SL, DeLisa JA, Whiteneck GG, eds. Spinal Cord Injury: Clinical Outcomes From the Model Systems,
Gaithersburg, Md: Aspen Publishers; 1995.
rations turned to managed care to arrest the
has enrolled 98.8% of its Medicaid population
rapid rise of their health care costs, did man-
in managed care plans. Some states have en-
aged care begin to grow rapidly. As a result,
rolled their Medicaid populations into PCCM
managed care has matured most quickly
forms of managed care, which use case man-
among private sector employers. From 1992
agement but do not use capitation.
to 1996 alone, the proportion of private sec-
By comparison, the Medicare program
tor employees participating in managed care
lags in managed care enrollment but is rap-
health plans increased from 49% to 77%.³
idly catching up. Currently only 17% of
Among public sector payment sponsors,
Medicare beneficiaries are enrolled in a man-
Medicaid has seen the most rapid growth in
aged care plan. Despite this relatively modest
managed care as individual states have sought
participation rate, enrollment in Medicare-
to reign in their rapidly growing Medicaid
sponsored managed care is increasing at a
expenditures. For most states Medicaid has
rate of 33% per year. The highest rate of
been either the fastest growing or second
participation is in California, where 36% of
fastest growing (next to criminal justice and
Medicare beneficiaries participate in a Medi-
corrections) area of state expenditures. Most
care-sponsored managed health plan.⁵
states have been able to convert their Medic-
Among workers' compensation pro-
aid programs to managed care with the benefit
grams, only 9% of expenditures for medical
of federal government waivers under §1115
benefits were made under managed care ar-
and §1915 of the Social Security Act. The
rangements in 1996. Workers' compensa-
number of Medicaid recipients participating
tion is also poised for rapid growth in man-
in managed care rose 31.3% from 1994 to
aged care.
1995.4 Ten states have enrolled 50% or more
Managed care concepts have also come to
of their Medicaid population in managed care.
the Department of Veterans' Affairs (VA),
Tennessee, a bellwether state in this respect,
an important source of health care services
Managed Care and Catastrophic Injury
7
for certain groups of people with SCI. The
systems of care that create an integrated array
VA has reorganized itself into 22 Veterans
of interventions, from trauma care through
Integrated Service Networks (VISNs). The
initial inpatient and outpatient rehabilitation
VA sponsors 23 SCI centers that provide a
and on to community reintegration. The
range of services related to both the initial
theory behind system integration is that it
injury and ongoing care. The SCI centers
minimizes disruptions, averts complica-
serve 375 people with new injuries each year,
tions, hastens the individual's return to the
and overall the VA serves more than 13,000
community, and saves money. This model of
people with previous injuries. Starting in
care has been championed by the federal
fiscal year (FY) 1998, under its new Veterans
government in its support of the model re-
Equitable Resource Allocation (VERA) sys-
gional SCI systems funded through the Na-
tem, the VA will capitate basic care at $2,596
tional Institute on Disability and Rehabilita-
per year and special care at $35,707 per year.
tion Research (NIDRR). The success of this
The special care rate applies to persons with
model has led to the funding of similar model
new SCI injuries and those with existing
systems for traumatic brain injury and burn
injuries (Stripling T, personal communica-
care.
tion, July 21, 1997).⁶
As long as FFS medicine prevailed, it was
The rapid growth of managed care among
possible to channel the newly injured indi-
all sponsors means that managed care will
vidual with SCI to a tertiary medical center
become a reality for most people with SCI. In
that subscribed to an expert systems ap-
the future there will be few safe havens for
proach and had the requisite equipment, spe-
individuals seeking shelter from the de-
cialized services, and expert staff. With the
mands of managed care.
advent of managed care, however, in which
health plans are linked to specific networks
of providers, a person with a new SCI may
Impact of Managed Care by Phase of
not have access to the provider system best
SCI Care
equipped to manage a new SCI. Representa-
The impact of managed care is likely to
tives from the model SCI systems program
vary with the phase of SCI care. For purposes
report, for example, that nonexpert provider
of this discussion it is important to distin-
networks often fail to refer people with new
guish between (1) the acute phase and initial
injuries to model expert systems and that
rehabilitative phase, and (2) the ongoing
many currently in such systems face shorter
postrehabilitative phase of care. Some man-
lengths of stay (Dijkers M, personal commu-
aged care issues are common to both phases
nication, August 8, 1997).
of care while others may be specific to one or
Given the low frequency of new SCIs (40
the other phase of care.
cases per 1 million population per year),⁷ it
simply is not possible to have more than one
Acute and initial rehabilitative phase
fully developed SCI system in any one region
or health care market and still have a critical
One important advance in the manage-
mass of SCI patients, expertise, and experi-
ment of SCI has been the development of
ence in any one location. Fortunately, man-
8
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
aged health plans are beginning to open up
In short, providers who are willing to as-
their provider panels in an effort to compete
sume risk will also enjoy a great deal more
for subscribers and market share. This open-
flexibility in how they manage individual
ing also provides an opportunity for orga-
cases and will search out nonhospital venues
nized SCI systems to market themselves to
in which people with SCI can test out their
health plans as centers of excellence. Typi-
newly acquired skills that are more akin to
cally, managed care health plans do not carve
those needed for successful community liv-
out low-incidence events such as SCI for
ing. Such flexibility will help to unleash
center-of-excellence care. The high cost of
innovations that will be in the interests of all
initial SCI care, however, could make such a
concerned-persons with SCI, providers, and
carve-out an attractive option.
payers.
To attract more health plan participation,
model systems and others may have to be
Ongoing postrehabilitation health care
willing to go at risk for both costs and out-
The downside
comes by developing case rates for an epi-
sode of care. Although some providers may
Once beyond the initial episode of care,
have difficulty determining their actual
the person with SCI is faced with a new,
costs, most have information systems and
but not altogether different, set of issues.
other data sources that will enable them to
Before the injury, he or she was simply a
develop case rates that integrate both acute
member of the general population. After
and postacute care with a defined end point or
the injury, from the perspective of a com-
outcome.
petitive health plan, he or she is a member
In the absence of assuming risk, acute and
of a high-risk group of patients who are
postacute providers are at the mercy of health
likely to incur health care expenditures
plan micromanagement in which each day of
that exceed the per-member health plan
care and expenditure is subject to review. In
premium. The health plan's assessment
many instances providers find themselves
reflects this article's earlier description of
having to justify to health plan case manag-
the health care needs and charges among
ers, many of whom have little or no knowl-
people with SCI. True, many people with
edge of SCI, decisions that simply reflect the
SCI do not incur any significant health
prevailing standard of care. A contentious
care expenditures in any one year, but
issue, to use an example, is in the prescription
from the standpoint of the health plan,
of durable medical equipment and assistive
persons with SCI are still at risk of incur-
technology, in which health plans are prone
ring high expenditures in any single en-
to be skimpy. Because a wheelchair is
rollment period.
cheaper, a health plan may insist on a wheel-
Private health plans have always com-
chair rather than long-leg braces for a person
peted on risk: They want to avoid enrolling
with a thoracic-level SCI who could, and
high-cost subscribers to remain price com-
would prefer to, ambulate and thus also ac-
petitive, increase market share, and maintain
quire the secondary health benefits of
financial margins. Prior to capitated man-
ambulation.
aged care, however, risk competition at the
Managed Care and Catastrophic Injury
9
In pointing out the limitations of primary
Price and risk competition create
care under managed care, one should not
enormous pressures to underserve
forget that even under FFS health care, indi-
people from higher risk groups such as
viduals with SCI have great difficulty obtain-
those with SCI or other catastrophic
ing access to primary care providers who are
injuries.
knowledgeable about their particular health
condition. In a study on access to primary
care in the Washington, DC area, Batavia et
al⁸ found that approximately 25% of persons
health plan level was moderated at the pro-
with SCI reported difficulty in locating a
vider level, since providers were paid by the
primary care physician who was knowledge-
health plan on an FFS basis and their overall
able about their health care needs. Many
expenditures were not seriously questioned.
primary care physicians are unwilling to take
Under managed care, risk competition at the
on too many people with disabilities who
health plan level is extended to the provider
may require more time and slow down a busy
level, since providers are paid a fixed rate and
office practice where income depends on the
compete on costs. In short, capitation financ-
number of visits billed.
ing hardens the impact of risk competition at
the health plan level and extends risk compe-
The upside
tition down to the provider level as well.
Risk competition pervades our health care
Price and risk competition create enor-
system and is made worse under managed
mous pressures to underserve people from
care arrangements in which providers as-
higher risk groups such as those with SCI or
sume most of the financial risk. There are
other catastrophic injuries. Moreover, man-
essentially two ways to address the risk com-
aged care plans restrict access to specialty
petition problem. The first is to "risk adjust"
care through the use of physician gate-
health plan premiums so that health plans
keepers who share in the financial risks re-
that serve higher risk groups receive addi-
sulting from downstream utilization of
tional compensation for their more costly
health services. Theoretically, managed care
case mix. The science of risk adjustment,
organizations use primary care physician
however, remains problematic, since most
gatekeepers as a way to coordinate patient
risk adjustment models developed to date
care and minimize the use of unneeded or
account for only a fraction of the variation in
ineffective care and thus reduce wasteful
expenditures between individual subscribers
health care utilization and costs. Moreover,
and health plans. Rarely are health plan risk
primary care gatekeepers are given financial
adjusters developed for a single diagnosis or
incentives to avoid making unneeded refer-
impairment group such as those with SCI.
rals to specialty and tertiary care. Managed
In the face of this problem, the second
care seeks to minimize the practice of
solution is to carve out select populations
"churning" in FFS systems, in which provid-
such as groups with disabilities and thus
ers maximize billings by passing the patient
creating what is essentially a customized
from one provider to another.
health plan for the group in question. Carve-
10
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
outs are replete with opportunities to better
the Medicaid FFS rate for actuarially similar
manage the health care of people with cata-
populations. In addition to its physician
strophic injuries such as SCI through innova-
team, CMA counts on its nurse practitioner
tive arrangements that can address their par-
staff to make home visits and to serve as the
ticular constellation of health needs.
front line for its preventive health strategy.
Carve-outs are not without their detrac-
Nurse practitioners are available 24 hours
tors, however. Critics argue that carve-outs
per day, 7 days a week, and respond within 30
merely segregate populations and further
minutes if the presenting condition is urgent.
fragment the health care system. They argue
CMA has been able to reduce significantly
that carve-outs are inherently incompatible
the incidence of preventable high-cost events
with the principles of integration and
such as pressure sores and other events lead-
mainstreaming. These are valid observa-
ing to a hospitalization episode.
tions, but they do not address the risk compe-
Another health plan of this genre is the
tition problem, nor do they face up to the
Shepherd Care Network (SCN) of Atlanta,
highly specialized nature of medical knowl-
which is gearing up to meet the ongoing
edge and medical practice.
health care needs of Georgia Medicaid par-
Just as there are many kinds of managed
ticipants with SCI, traumatic brain injury,
care, there are many varieties of carve-outs.
multiple sclerosis, and Guillian-Barré syn-
One variant is to carve out selected groups of
drome who reside in the 20-county Atlanta
people with disabilities within a health plan and
area. It, too, relies on the nurse practitioner as
assign a separate and more liberal capitation
the front-line worker. Like the CMA plan, it
rate that recognizes their higher rate of health
aims to limit costs by substituting services
care utilization. Under this arrangement, the
when one service is more cost-effective than
health plan or provider network assumes the
another. Unlike the CMA plan, which was
financial risk for managing all the health care
developed by concerned internists, the SCN
needed by the target population. With aggres-
was spawned by the Shepherd Rehabilitation
sive case management and preventive health
Center of Atlanta.
strategies, the health plan is able to help avert
medical complications that result in unduly
Emerging Trends in Managed Care and
high health care utilization and thereby also
Their Implications for People with SCI
make a financial profit for itself.
Perhaps the best known plan of this type is
Within-market provider consolidation and
the Community Medical Alliance (CMA) of
opening of provider panels
Boston, an HMO that contracts with Massa-
Population carve-outs aimed at people
chusetts Medicaid to provide health services
with catastrophic injuries and high-cost
to a carve-out of approximately 200 people,
chronic health conditions are but one ex-
including many with SCI, whose level of
ample of how managed care will evolve in
disability requires hands-on personal assis-
the future. Initially managed care attempted
tance. The capitation rate in 1994 was set at
to capitate entire groups on a PMPM basis for
$2,238 per member per month (PMPM) or
all of a member's health care needs. Provid-
$26,856 per year, a rate that is set at 95% of
ers responded by organizing themselves into
Managed Care and Catastrophic Injury
11
risk-bearing provider networks that could
majority of people are not high users of
provide the full array of health care services
health services, and when they do become
and limit the use of out-of-network provid-
high users, it is often for a specific episode of
ers. In short, if a provider system was to limit
care. A relatively small percentage of the
its financial exposure, it had to be able to
population are continuous high users be-
control the utilization and costs of all ser-
cause of a chronic health condition that is
vices rendered to an enrolled population. As
prone to exacerbation and recurring compli-
managed care penetration increased within
cations. Thus, attention is shifting toward the
markets, individual providers could no
management of infrequent but high-cost epi-
longer afford to be outside a provider net-
sodes of care and the health care manage-
work and not have managed care contracts.
ment of selected populations whose health
One result is that in more "mature" managed
requires unremitting vigilance and mainte-
care markets such as Minneapolis-St. Paul
nance. In short, with the general population
and St: Louis, providers have organized
demanding greater access to a broader net-
themselves into three or four provider net-
work of providers, managed health plans
works or systems that serve about 90% of the
have come to realize that the real cost savings
markets.
9,10
payoff is no longer in micromanaging health
In recent years another trend has emerged.
care utilization among large groups of gener-
As managed care penetration increased, indi-
ally healthy people but in (1) managing epi-
vidual managed health plans, in an effort to
sodes of care and (2) managing the health of
increase enrollment and retain market share,
selected high-user populations. This realiza-
have opened up their provider panels. Pro-
tion has led, for example, to the rapid growth
vider networks are not as selective as they
of disease management systems targeted to
once were, mainly because hard-sought pro-
people with specific health conditions.
spective enrollees were reluctant to give up
These recent trends, if exploited adroitly,
their principal care provider and demanded
provide enormous opportunities for provid-
greater access to an array of health special-
ers who serve individuals with catastrophic
ists. The public equated quality with access
injuries such as SCI. The first year after an
to providers, and health plans have re-
SCI constitutes a fairly well defined episode
sponded by broadening their provider net-
of care that lends itself to the development of
works so that most providers now participate
case rates as suggested earlier in this article.
in multiple managed health plans. The open-
The model SCI systems in particular, we
ing of panels has reduced somewhat the pres-
noted, have the experience base with which
sure for providers to consolidate into risk-
to develop competitive and cost-effective
bearing provider networks.
case rates. The development of case rates will
also provide important economic incentives
Managing episodes of care
for an even greater integration of acute and
The emerging frontier in managed care is
postacute services during the first year of
not the large vertically integrated health sys-
injury. In short, emerging developments in
tem that provides the full array of health
managed care may force a bundling of acute
services to the general population. The vast
and postacute payment, which heretofore has
12
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
At present, among the working-age popula-
An individual's need for personal
tion, Medicaid offers the best venue for ad-
assistance is not as difficult to measure
dressing this enduring social policy issue,
as some presume, despite the many
mainly because, unlike most other payment
different estimation methods used by
sources, it funds both acute and long-term
individual states and programs.
services, including personal assistance ser-
vices needed by people with catastrophic
injuries such as SCI. Private health insurance
rarely pays for personal assistance, and when
been anathema to rehabilitation providers.
it does, such payment is usually part of a
After the first postinjury year, the ongoing
structured settlement. An individual's need
health care needs of people with SCI lend
for personal assistance is not as difficult to
themselves to a population carve-out model
measure as some présume, despite the many
such the CMA and SCN programs noted
different estimation methods used by indi-
above.
vidual states and programs. 11 The predict-
Aiding the development of case rates and
ability of personal assistance needs lends
population carve-outs for SCI will be SCI
itself to case-rate development in long-term
practice guidelines such as those being de-
services and, when combined with other
veloped by the SCI Medicine Consortium
case-rate strategies, may well open up the
sponsored by the Paralyzed Veterans of
door to greater acute and long-term service
America. Practice guidelines for acute,
integration.
postacute, and ongoing care will provide an
important benchmark by which individual
Academic health centers
provider systems will be able to evaluate
their own practices and help price their prod-
Many SCI centers such as the model SCI
ucts accordingly.
systems are anchored in university-based hos-
pital systems. Under managed care, many of
Integrating acute and long-term services
the nation's premier academic health centers
A long-standing issue in American health
are struggling financially and face an uncer-
and social policy is how to integrate acute
tain financial future. Under FFS health care,
health and long-term services, especially for
there was considerable cross-subsidization
high-risk populations, and how to manage
from paying patients to nonpaying patients
either acute or long-term services in such a
and to research and education activities. Price
way as to reduce the need for the other.
competition under managed care has elimi-
Limited and highly targeted integrated pro-
nated much of this cross-subsidization. More-
grams have been in existence for some time
over, as violence replaces motor vehicle acci-
in the form of social HMOs (S/HMOs).
dents as the principal cause of SCI in urban
Some of the leading examples include the On
markets, the proportion of people without
Lok program in San Francisco and the Pro-
health care coverage or on Medicaid in-
gram of All-inclusive Care for the Elderly
creases, but at a time when there are fewer
(PACE) network aimed at older populations.
opportunities to make up the difference
Managed Care and Catastrophic Injury
13
through cross-subsidization. Now and in the
presence in all 300 markets with a population
future, SCI systems located at academic
of 100,000 or more.
health centers can no longer depend on the
There are many factors fueling cross-mar-
overall financial well-being of their parent
ket hospital consolidation; these include the
organizations to meet shortfalls. In the current
behavior of capital markets; the financial
managed care environment, this requires that
needs of struggling local hospitals; and the
academically based SCI systems directly mar-
personalities of individual CEOs, who bring
ket themselves to payers by offering a "prod-
their own vision about the future of health
uct" consisting of bundled services with de-
care. Another reason for cross-market con-
fined outcomes for a fixed price. This is the
solidation has been the role of large self-
kind of predictability that payers seek.
insured, multistate employers who would
Cross-market provider consolidation
prefer not to have to negotiate separate con-
tracts for each market in which their employ-
Historically, health care markets have
ees are located and sometimes prefer master
been regional markets and, to a large degree,
contracts. Still, rehabilitation makes up only
they remain so. When the Federal Trade
3% of the health care dollar and is usually an
Commission (FTC) and the Department of
afterthought for most employers, who prefer
Justice Anti-Trust Division evaluate a poten-
to leave it to their respective health plans to
tial hospital merger or acquisition, for ex-
locate a worthy rehabilitation provider.
ample, they usually evaluate the degree of
Managed care has had an important, but
market concentration in a given region, most
secondary, role to play in this development
often defined as a reasonable driving dis-
by creating greater cost consciousness and
tance (eg, 30 or 60 miles). The size of a given
price competition in the health care market-
market is often a contentious issue in hospital
place. Larger provider systems can often
antitrust litigation. There is little consensus
obtain volume discounts from suppliers and
as to what constitutes a market radius for
can presumably achieve economies of scale
specialty health services. The radius may
by concentrating overhead services (eg, hu-
also differ depending on whether the provid-
man resources, financial management, and
ers in question are in an urban or rural area.
information systems) at the home office.
In recent years, however, the nation has
The impact of cross-market consolidation
witnessed the rapid growth of for-profit,
on the management of catastrophic injury
cross-market hospital chains. The best
such as SCI is not entirely clear. As the major
known in the acute hospital industry have
consolidator in the rehabilitation industry,
been Columbia/HCA (342 hospitals), based
HealthSouth offers an important case study.
in Nashville, Tenn, and Tenet, based in Santa
HealthSouth's sheer size has provided an
Barbara, Calif. The best known in the reha-
important experience base on which to de-
bilitation hospital industry is HealthSouth
velop inpatient critical pathways including
(104 rehabilitation hospitals), based in Bir-
pathways for SCI. Moreover, it has demon-
mingham, Ala, which now owns 54% of the
strated a commitment to tracking patient out-
194 free-standing rehabilitation hospitals in
comes.
the nation. HealthSouth seeks to have a major
The centerpiece of HealthSouth's corpo-
14
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
rate and service delivery strategy is its well -
(CALPERS), sponsored by California's state
advertised four-part market model that con-
and local governments representing 900,000
sists of (1) the outpatient diagnostic center,
California employees, and the Buyers Health
(2) the outpatient surgery center, (3) the
Action Group, sponsored by private and pub-
outpatient rehabilitation center, and (4) the
lic employers in the Minneapolis-St. Paul
rehabilitation hospital. HealthSouth aims to
area representing 250,000 employees. Large
have this model in all 300 markets with a
employers and purchasing groups often re-
population of 100,000 or more. This model is
quire that health plans meet certain require-
oriented more toward individuals with ortho-
ments before they are offered to their employ-
pedic conditions, occupational health related
ees. Purchasers may require that health plans
conditions (e.g., low-back pain), and athletic
be accredited by the National Committee on
injuries and less toward individuals with
Quality Assurance (NCQA) and that they
catastrophic central nervous system trauma
disclose information regarding access, pre-
where the payer mix (e.g., self-pay, Medic-
vention, outcomes, and consumer satisfaction
aid) is also less reliable. Persons with cata-
based on standardized performance indicators
strophic injuries enter post-acute rehabilita-
known as the Healthplan Employer Data and
tion, not via outpatient diagnostic centers nor
Information Set (HEDIS), developed under
outpatient surgery centers, but via trauma
the auspices of NCQA's Committee on Per-
centers and acute-care hospitals, neither of
formance Measurement. This information is
which is integral to HealthSouth's four-part
used to help consumers make more informed
model. The four-part model suggests that
cross-plan comparisons.
individuals with catastrophic injuries are not
The Health Care Financing Administra-
a major target market for a cross-market
tion (HCFA) is also beginning to act as a
consolidator such as HealthSouth. Cata-
purchasing alliance and is making similar
strophic injuries will, for the foreseeable
performance measurement requirements for
future, remain mainly the province of tertiary
people participating in Medicare-sponsored
nonprofit provider systems.
managed care plans.
Concurrent with these developments is the
Consolidating the demand side of the market
emergence of consumer-oriented publica-
tions such as Health Pages, which is pub-
While the supply side of the market is
lished in several markets and provides con-
consolidating, both within and across mar-
sumers with a range of information about
kets, the demand or consumer side of the
health plans and providers in a given market.
market has not been standing still. The
In some instances, local purchasing groups
lynchpin in organizing the demand side of the
and business coalitions have teamed up with
market is the large employer and employer
Health Pages and NCQA in helping their
purchasing coalitions that have come together
members make more informed choices. In
to make price and quality demands of health
the future consumers will be able to go to the
plans and their provider networks. Currently
Internet, where they can obtain more detailed
there are about 125 purchasing coalitions.
provider information relative to their specific
Some of the better known include the Califor-
health care needs.
nia Public Employees Retirement System
The emerging demand or consumer side
Managed Care and Catastrophic Injury
15
of the market presents several challenges
Physicians, hospitals, and other providers
both for providers and for consumers with
are already beginning to form physician-
SCI. Providers who address the immediate
hospital organizations (PHOs). The rise of
acute and postacute needs of people with
such organizations is the direct result of man-
SCI will have to make sure that their ser-
aged care. The challenge for SCI consumers
vices are represented in health plan report
and their providers is to make sure that PHOs
cards, even though most consumers may
include the types of providers and services
consider their SCI risk to be very small.
that can help meet their needs.
Providers who render services during the
ongoing postrehabilitation phase of care
Toward a Consumer-Driven Health
will have to find ways to provide quality
Care System
information for what are really niche-mar-
ket services. By the same token, consumers
These emerging trends speak to larger
with SCI will have to be able to articulate
shifts in American health care. Managed care
the kinds of information they need in order
represents a shift from a provider-driven sys-
to make informed choices.
tem to a payer-driven system of health care.
The payer-driven system of the present will
The diminishing need for health plans
eventually give way to a more consumer-
driven system as the consumer side of the
Heretofore, both the supply and demand
market becomes more organized and more
sides of health care markets were relatively
informed. Although the rise of a payer-
unorganized. Providers were at best orga-
driven system is our immediate concern, one
nized into professional and trade associa-
should not overlook the larger transition to a
tions; consumers were not organized at all.
more consumer-driven system. In many
The role of third-party payers was to broker
ways the emergence of a consumer-driven
the two unorganized sides of the market by
system is also the provider's best hope, since
signing service contracts with providers on
the competition will shift from one of price
the supply side and insurance contracts with
and risk under managed care to one of price
blocs of consumers (represented by em-
and quality in consumer-driven markets. In
ployers) on the demand side. Third-party
short, price and quality competition is where
payers also helped to remove much of the
the interests of both consumers and providers
financial uncertainty for both sides of the
converge.
market by becoming the risk-bearing entity.
The needs of those with catastrophic inju-
As the supply and demand sides of the
ries such as SCI may seem small within the
market become more organized and risk is
scope of the nation's trillion-dollar health
transferred to providers and provider net-
care economy. However, this could be said
works, the need for third-party payers will
of patients with many other health condi-
begin to diminish. In the future we can
tions. The challenge for both consumers and
expect to see large purchasing groups begin
providers is how to collaborate to make sure
to contract directly with risk-bearing pro-
that the needs of people with SCI are effec-
vider networks and bypass the traditional
tively recognized in the ever-changing health
third-party payer.
care system.
16
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
REFERENCES
1. DeVivo MJ, Whiteneck GG, Charles ED Jr. The
8. Batavia Al, DeJong G, Burns TJ, Smith QW,
economic impact of spinal cord injury. In:
Melus S, Butler D. A Managed Care Program
Stover SL, DeLisa JA, Whiteneck GG, eds.
for Working-Age Persons with Physical Dis-
Spinal Cord Injury: Clinical Outcomes from
abilities: A Feasibility Study. Final report sub-
the Model Systems. Gaithersburg, Md: Aspen
mitted to the Robert Wood Johnson Founda-
Publishers; 1995.
tion by the National Rehabilitation Hospital
2. Ivie CS, DeVivo MJ. Predicting unplanned
Research Center. Washington, DC: National
hospitalizations in persons with spinal cord
Rehabilitation Hospital, Research Center;
injury. Arch Phys Med Rehabil. 1994;75:
January 31, 1989.
1,182-1,1 188.
9. Wheatley B, Delong G, Sutton JP. Managed
3. Hilzenrath DS. What's left to squeeze? Man-
care and the transformation of the medical
aged-care firms find health care costs rising-
rehabilitation industry. Health Care Manage
and cuts harder to come by. Washington Post.
Rev. 1997;22(3):25-39.
1997;(July 6):H1, H9.
10. Lerner WM, ed. Anatomy of a Merger. Chi-
4. Hoechst Marion Roussel, Inc. Medicare/Med-
cago, III: Health Administration Press; 1997.
icaid, special ed, Managed Care Digest Series.
11. O'Keeffe J. Determining the Need for Long-
Kansas City, Mo: Most data compiled by SMG
Term Care Services: Analysis of Health and
Marketing Group, Inc of Chicago; 1996.
Functional Eligibility Criteria in Medicaid
5. Levine R. Medicare risk contracting. Presented
Home and Community-Based Waiver Pro-
at a special preconference program on man-
grams. Public Policy Institute Publication
aged care held in conjunction with the annual
9617. Washington, DC: American Associa-
meeting of the American Society on Aging;
tion of Retired Persons, Public Policy Institute;
March 21, 1997; Nashville, Tenn.
December 1996.
6. Department of Veterans Affairs. Veterans Equi-
12. Scrushy RM. Presentation and response to
table Resource Allocation System: Initial Brief-
questions at a meeting of investment firms,
ing Booklet. Washington, DC: Department of
investment analysts, and venture capitalists
Veterans Affairs; January 1997.
sponsored by Robertson Stevens & Co; De-
7. Lasfargues JE, Curtis E, Morrone F, Carswell J,
cember 2, 1996; New York, NY.
Nguyen T. A model for estimating spinal cord
injury in the United States. Paraplegia.
1995;33:62-68.
Managed Care and Its Effects On How
We Deliver Services
Connie Burgess
The demands of managed care continue to grow, with no indication of letting up. The challenge faced by
providers of rehabilitation services is to redefine rehabilitation in terms that demonstrate value to the system
as a whole and to offer long-term cost savings strategies and programs. Early prediction of long-term care
planning and resource allocation assists all stakeholders in achieving their desired clinical and economic
outcomes. Key words: capitation, case rate, managed health care, National Chronic Care Consortium,
percentage discount, per diem, population-based risk identification, salient factor, team
M
UCH has already been said and
sponsiveness. They strive to provide a com-
written about the effects of man-
plete complement of services covering a
aged care on clinical practice.
large geographic area, creating convenience
The testimonials and the horror stories have
and access close to the patient's home. Cost
been advanced, and opinions have been
is highly competitive. As health care systems
formed. Often many who have yet to experi-
expand, rehabilitation programs are experi-
ence managed care hear that Medicare is not
encing an erosion of their adult client base
saving the dollars it had hoped to save and
and movement of patients to alternative care
read such information as a sign that the pro-
settings that may not be under their control.
cess is failing. It is important for them to take
Large acute care systems do not necessarily
a step back and look at the entire picture.
see subacute, home health, or outpatient care
Although faced with many challenges, man-
as part of rehabilitation services. Many chief
aged care continues to grow and demonstrate
executive officers (CEOs) and other top-
that it is a dynamic entity; it is not going
level decision makers do not perceive reha-
away. More importantly, the longer the
health care and rehabilitation sectors wait to
acknowledge it, the further behind they get in
Connie Burgess, MS, RN, is President, Connie Bur-
strategic planning and creating new relation-
gess & Associates, Lakewood, California.
ships with an expanded customer.
The author acknowledges Thomas P. Dixon, PhD, for
his work in the development of the Salient Factors
Rehabilitation in the Big Picture
Model and Gretchen H. Swanson, MPH, PT, for her
work with the Predict and Manage methodology re-
Currently large health care systems are
lated to ICIDH.
looking at their opportunities and reposition-
Top Spinal Cord Inj Rehabil 1998;3(4):17-27
ing themselves to increase their market re-
© 1998 Aspen Publishers, Inc.
17
18
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
bilitation as different from, or needing to be
contribution. The fact still remains that in
different from, any other service line in their
order for something to remain viable, it must
setting. Free-standing rehabilitation
bring value to the whole, including the pa-
continuums of care share the same dilemma.
tient and the larger provider and payer sys-
Admission patterns have been altered be-
tems.
cause of the expansion of clinical programs
within the medical center, the main referral
Moving Beyond the Team
source of rehabilitation patients. Services
have become so comprehensive in large inte-
Rehabilitationists made their mark for
grated health care systems that it may not
years as the premiere multi-inter-trans-
occur to attending physicians or internal and
disciplinary practitioners in health care. Few
external case managers to send a patient out
other professionals knew the "team" concept
to a new provider. Insurance companies have
as well as those in rehabilitation. Now, how-
clearly expressed their desire to manage pa-
ever, the recognition of rehabilitation as the
tient care within a single, comprehensive
"shepherd" of interdisciplinary practice is
continuum of care.
fading. Acute care counterparts speak of the
concept as a fresh idea, as something of
Impacts on The Team
value, as their own-which is not all bad, for
now they understand the power of the team
These trends are distressing to the reha-
and the effects it can have on the patient.
bilitation community. The practice of reha-
It is easy to become distracted debating all
bilitation is undergoing significant transfor-
the different aspects of health maintenance
mation and redefinition. Rehabilitation staff
organizations (HMOs), preferred provider
members run a myriad of emotions that range
organizations (PPOs), and capitation. Al-
from confusion to anger, enlightenment, and
though HMOs in the East may not function
enthusiasm. Regardless of discipline, age, or
quite like HMOs in the West, the differences
time spent in the specialty, managed care
will most likely be in operational aspects, not
with its new fiscal imperative has affected
in the basic premise. For those able to get
the experienced and novice practitioner
beyond this idea and understand how reha-
alike. On the one hand the loss of the "good
bilitation practice and technology can save
old days" for the veteran team member is
dollars by keeping the general population
often a significant barrier to change. The
healthy and still maintain the ability to care
notion of changing clinical approaches from
for themselves or direct others in their care,
practices of the past is too big a step for a few
there can be a great future in the field.
seasoned professionals, and they are choos-
Evolving managed health care systems
ing to do something different with their lives.
require long-range cost-effective health
Others are willing to try something new,
management strategies. Opportunities exist
work with it, and make it their own. For
for new, innovative contributions by reha-
younger professionals, these are the "good
bilitation professionals, although such op-
old days," and many are ready for new chal-
portunities may be available for only a brief
lenges and the opportunity to make their
period of time. Although many rehabili-
Managed Care and Delivery Services
19
include patients experiencing disabilities.
For specialists in the rehabilitation
Transfers of patients back to acute units or
field, the need to know more than just
medical centers for anything but the most
rehabilitation, regardless of discipline,
critical medical problem is simply a thing of
is apparent.
the past. Physicians and nurses, particularly
those practicing in inpatient rehabilitation
settings, must have acute care competencies
as well as specialty skills. Everyone working
tationists have yet to get heavily involved in
within rehabilitation must move their long-
managed care and are currently working with
range care planning expertise to the front of
predominantly fee-for-service payment
the care process. This must include more than
mechanisms, future strategies must focus on
just the rehabilitation physician making
provider-based long-term fiscal and clinical
trauma rounds. It may mean creating a team
risk. The two central questions to be an-
of experts who can move within a continuum
swered when discussing risk include (1) the
to evaluate patients in the intensive care unit
scope or extent of the risk in managing a
(ICU) and project a plan of care and the
group of patients, and (2) how long the pro-
associated costs over the entire course of
vider carries the risk and commensurate
treatment. It also may mean entirely revamp-
clinical accountability. Like many profes-
ing the approach to case management, mak-
sionals in health care today, rehabilitationists
ing it an integrated part of care (ie, a process)
must look at overhauling old practices and
instead of only a person-driven role that
building a new system of care based on
evaluates, admits, and follows patients
market-driven issues.
through parts of the rehabilitation program
and then turns them over to someone else.
Expanding the Scope of Practice
Although there are many combinations of
case managers and variations on the themes
For specialists in the rehabilitation field,
of how to case manage, very few rehabilita-
the need to know more than just rehabilita-
tion systems have begun to think about inte-
tion, regardless of discipline, is apparent. In
grating all the components that go into pa-
his 1996 presidential address to the Ameri-
tients' management of their health and
can Congress of Rehabilitation Medicine,
disability over a long period of time.
Dr. Thomas Dixon called for the field to
reevaluate its definitions of rehabilitation
A Different Picture of Case
and to explore a broader base of patients who
Management
could benefit from the specialty. Skills re-
lated to long-term chronic care and long-
One recent approach developed by the
term comprehensive health management,
National Chronic Care Consortium (NCCC)
over a broad spectrum of diagnoses, are a
is population-based risk identification (risk
good place to start. Like many colleagues
ID). "Risk ID is an ongoing process aimed at
from other specialties, rehabilitation special-
enabling health care providers to identify and
ists must expand their scope of practice to
manage the health risk of consumers and
20
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
prevent disability or delay further deteriora-
health care system at financial risk for the
tion. Risk identification can be comprehen-
long-term health care and management
sive, spanning issues of health promotion
needs of disabled patients is the provision of
and wellness, as well as chronic disease,
expert care for an often difficult-to-manage
illness and disability. Risk identification can
group of patients over an extended period of
also be specific, identifying a person at risk
time. Although space does not allow an
of using high-cost acute and long-term care
extensive discussion about risk identifica-
services. It supports the management of
tion, the work of the NCCC is worth review-
resource allocation over time and allows for
ing when considering the long-term viabil-
the prediction of care and costs over a period
ity of rehabilitation. Time and experience
of years rather than months. It is particularly
have demonstrated in an evolving health
well suited for those with disabilities. Three
care market that there is no universal tem-
levels of care are identified in the strategy:
plate to advance the practice of rehabilita-
primary care, which is the prevention of
tion. There are many tools and strategies
disease and includes lifestyle choices such as
available, but adoption of acute care meth-
smoking, diet, riding motorcycles, or cliff
odologies without regard for the forces
diving; secondary care, defined as early de-
driving the market could be the ultimate
tection measures (eg, mammograms, carotid
undoing of rehabilitation's future. It is the
artery angiograms, and diabetic screenings);
experience of the past and the vision of the
and tertiary care, which is the acute manage-
future wrapped up in a well-thought-out
ment of an episode.
plan that will make the difference.
Unless the positive effects of educational
measures, such as the "Feet First" program
Removing the Barriers
designed to prevent spinal cord injury,
reach a larger segment of the population,
introduction to rehabilitation services will
As a consultant criss-crossing the coun-
for the most part continue to occur at the
try visiting managed care markets that range
tertiary level. However, once the initial re-
from very mature to "still waiting," I can
habilitation program is complete, these pa-
make several observations. Two or three
tients require a new course of prevention,
specific issues stand out as common to
symptom management, and early detection
most, if not all, providers located outside
and intervention for conditions and diseases
highly managed care states such as Califor-
directly associated with their newly ac-
nia, Oregon, Arizona, Minnesota, and
quired disability. Long-term comprehen-
Florida. The first is that many rehabilitation
sive health management for the disabled
staff members tend to believe that the qual-
population could belong to rehabilitation
ity they provide is exceptional and that this
specialists, particularly physiatrists, when
quality alone will carry them to a secure
such specialists are appropriately posi-
position in their health care community.
tioned among a diverse group of other phy-
The second issue relates to the fear of reduc-
sician specialists. The value of rehabilita-
ing revenue streams by prematurely chang-
tion services to the medical group and/or
ing clinical practice to cost-sensitive mod-
Managed Care and Delivery Services
21
els. The third prevalent issue is frequently
rehabilitation, the merits of each of the
the belief that expanding existing systems
above issues can be debated. Regardless of
into broader-based rehabilitation contin-
the specific strategies under consideration
uums of care, without partnering in some
by any rehabilitation provider, there are a
way with a comprehensive health care sys-
few basic concepts to be considered when
tem, will be enough to position the organi-
planning and working through these transi-
zation for success.
tional phases. These are shown in the box
Although no one knows for certain what
entitled, "Suggestions for Making the Tran-
the end result will be for health care and
sition to Managed Care."
Suggestions for Making the Transition to Managed Care
Interdisciplinary team practice, which has been the hallmark for rehabilitation, is now
common to all clinical programs throughout the continuum and no longer belongs
solely to rehabilitation. Other unique, identifiable signets must be created.
There are many similarities between rehabilitation and acute care operations that, when
managed in a large integrated system, can reduce the cost of health care to all
stakeholders.
At the same time, the unique and specific contribution rehabilitation makes to patients
and to long-term cost savings must be identified and separated out from the contribu-
tions made by acute care so that the important difference can be recognized.
Acute care leaders directing risk programs, who are in a decision-making position on
how funds are allocated across the continuum, must be shown that rehabilitation can
save money when handled as a distinct program driven by imperatives that are
completely different from those of acute care.
Clinical staff must function at the high end of their practice and let go of the task-oriented
activities that have guided the evolution of rehabilitation.
Staff do not have to be taught rehabilitation skills, but they must relearn how to manage
within their practice. They must be informed of new rules, limits, and parameters and
then allowed and assisted to develop solutions within the new guidelines.
Priorities must be reestablished to make internal communication of supreme impor-
tance.
Industrial type solutions, including widespread down-sizing and redesign, rarely tap
into the human factor that really drives the change process. This human factor must be
emphasized.
Managed care, and therefore the business of health care, will not be successful if those
delivering the care are not fully involved.
Rehabilitation professionals need to advance their thinking, expand their scope, and
redefine rehabilitation to meet the needs of a broad base of consumers.
Fresh ideas regarding ways in which rehabilitation fits into the new health care "world"
must come from within and demonstrate value to the patient and the system.
22
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Preparing for a New Way of Thinking
The next payment mechanism is the per
diem system, which means the provider re-
Trying to envision the future when en-
ceives a set dollar amount each day that
meshed in the fast pace of the present is often
typically includes all care, room and board,
overwhelming. A recent study conducted by
tests, and therapies in a single rate. Per diem
Pitney Bowes found that technology such as
is also a fee-for-service mechanism, and
electronic mail, voice mail, faxes, DOS
therefore the incentive to the provider is to
notes, and the like consume so much time in
keep the patient a few days longer. This is
any executive's day that the only time for
particularly true for complex cases. Costs for
reflection and "quality think time" is at night
care on any given patient are typically the
and on weekends.³ One could speculate on
highest in the first few days of hospitalization
just how much enthusiasm there is for even
or outpatient care, as this is the period for the
more work that must be done at home. One
highest intensity evaluation and the greatest
strategy used to assist the planning process is
number of tests and early interventions.
to learn about the forces demanding the
When an organization has contracted a per
change. The first place to start is managed
diem rate that is too low, there may be a
care.
tendency to keep patients a few days longer
Understanding the differences between
than medically necessary in order to recoup
HMO and PPO plan types and the various
any losses.
reimbursement methods and incentives is im-
The third payment mechanism is cost
perative in order for all team members to be
based, and the incentive to the provider is
functional in their clinical setting. A detailed
now to conserve services so as not to use up
discussion of managed care can be found
all financial reserves. Hence the concept of
elsewhere in this issue. For the purpose of this
risk. Case rate and capitation are the two
discussion, a brief review of the practical
most common methods of payment used
differences between fee-for-service and cost-
with this methodology and are based on pre-
based care may be helpful for readers to under-
determined agreements for a group of pa-
stand how to develop specific strategies.
tients over a period of time. This is the point
The first predominant MHC reimburse-
at which the clinical team becomes particu-
ment mechanism is a system of percentage
larly stressed and distressed. Without previ-
discounts. For example, if the daily rate for
ous experience with, or planning for, case
inpatient rehabilitation is $1000 per day and
the discount applied is 25%, then the charges
applied are $750 per day. However, because
this is a fee-for-service payment system, ev-
Treating all patients the same is in
ery therapy or test ordered is billed separately
itself a form of discrimination and
but paid for at the discounted rate. The incen-
often utilizes precious resources for
tive is based on longer lengths of stay and a
activities that are irrelevant to the
high volume of clinical tests and interven-
individual.
tions.
Managed Care and Delivery Services
23
rate or capitated patients, care planning goes
Making the Transition to Managed Care
on without regard for the cost of the plan of
care or the resources available to a particular
To prepare for and successfully make the
client. In addition, the demands presented by
transition into managed care, organizations
multiple payers with different levels of ben-
must have a well-thought-out plan. Every-
efits for patients with the same diagnosis
one, including clinical staff, must understand
cause major conflict for the team.
the managed care conversion process. There
This conflict surrounds the belief that ev-
are no overnight conversions. It is a planned
eryone is treated the same, and the team cannot
event, and there are always signs that it is
discriminate against patients on the grounds of
coming. Preparation for managed care is a
economic disparity. This position suggests
time to redesign for future needs and not past
that the industry has always treated all patients
practices, not a time to downsize first and
the same. More importantly, treating all pa-
then decide what is needed. Cheaper is not
tients the same is in itself a form of discrimi-
always better. Organizations need mentors,
nation and often utilizes precious resources
and elimination of the most costly personnel,
for activities that are irrelevant to the indi-
who typically are also the most experienced,
vidual. Using the same strategies at the same
may well prove to be short sighted and fatal
costs for all patients with the same diagnosis
to the organization. Clinical staff made up
does not take into account the individual needs
primarily of new graduates, who have little
of the patient and frequently does not focus
life experience or clinical experience, fre-
care or resources on the most important activi-
quently have difficulty performing in an en-
ties or functions for that specific patient. Staff
vironment that demands creativity and im-
must understand that they will live in two
provisation rather than routinized and
worlds for several years: stakeholder incen-
prescriptive strategies. Cost containment is
tives will be different, gatekeepers and case
often implemented as a short-term "staff ef-
managers will press them for outcomes, and
ficiency" model, with little or no thought
one approach or tool for care planning will not
given to the long-term costs or needs of the
meet the needs of all patients. Two patients in
patient.
the same room may have the same diagnosis,
Before success can be achieved, staff must
but each will have a different benefit package,
understand every aspect of operations and
and one of these plans will likely include more
managed care within their organization. This
covered services than the other. Offering both
does not mean they must know how to per-
patients identical plans of care regardless of
form every step of the process, but it does
available benefits is fiscally unacceptable and
mean that staff must develop an understand-
clinically unnecessary if each patient is to be
ing of managed care contracting, reimburse-
provided with appropriate and excellent care.
ment mechanisms, managed care incentives,
This change, however, will not happen with-
how case management works, and how care
out a major shift in organizational priorities
is authorized. They must also understand
and a large investment in education and train-
each patient's benefit package and know
ing of all team members and institutional staff.
which services and equipment are covered
24
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
and which are not. It is important that staff
model focuses on all aspects of the patient's
know whether day treatment or home health
life and pushes the rehabilitation process
care are covered SO that their care planning
from the traditional impairment/disability
process includes less costly levels of care as
approach to the next higher level, with an eye
early as possible in the treatment plan. In
on reducing the disadvantage to the patient
addition, multiple populations require mul-
and increasing patients' societal participa-
tiple strategies and varying resources.
tion. The WHO has differentiated models of
care into two categories: the medical model,
One Specific Strategy
the acute care standard that is based on the
diagnosis and cure of an illness and/or injury,
The Salient Factors approach to patient
and the consequence model, the rehabilita-
care planning is one specific strategy that
tion alternative that is based on the patient's
acts as both a framework and an approach.
responses to or the impact of the injury or
When viewed as a framework, the Salient
illness on their life and function. Represented
Factors strategy offers a way of thinking,
as the International Codes for Impairment,
organizing, and selecting the most appropri-
Disability and Handicap (ICIDH), the WHO
ate clinical course for each patient. Salient
definitions for rehabilitation include the fol-
simply means "key," which in this case refers
lowing:
to the most important issues for the specific
Impairment: The loss of body function
patient. As a patient-driven approach, it ad-
resulting from the illness or injury (eg,
dresses patients' long-term needs and goals
nerve or muscle damage).
at the very beginning of the process in order
Disability: The consequence of im-
to establish a treatment strategy that effec-
pairment; disturbance at the level of the
tively utilizes and manages available re-
person; the loss of ability to perform
sources. It is a prioritized, individualized
tasks or activities in light of the impair-
approach to care and is an umbrella for all
ment.
strategies. The Salient Factors strategy has
Handicap: Social disadvantage to the
the following characteristics:
individual that results from impairment
It is a single model of care throughout
and disability. Handicaps reflect inter-
the entire health care continuum.
action with and adaptation to the
It focuses on the key issues for each
individual's surroundings.4
specific patient.
Rehabilitation does not cure its clients;
It assists in the prediction and manage-
instead, it trains most to compensate for and/
ment of cost and outcomes during an
or adapt to their loss of function. For those
episode of care.
who do return to their preinjury/illness state,
It manages each patient's resources.
resolution of their disability rarely occurs
It identifies barriers to discharge.
during the early stages of rehabilitation. Full
It identifies clinical, cost, and manage-
recovery may take months or years. In the
ment data for decision making.
new health care world, the prioritized reha-
Couched in the World Health Organization
bilitation approach is based on the need for
(WHO) definitions for rehabilitation, this
functional patient outcomes and the related
Managed Care and Delivery Services
25
allocation of resources. In this method of
stances. Every team member is trained to
treatment planning, it is the prediction of the
reinforce all aspects of the patient's plan of
elimination or reduction of consequences
care, which results in a 24-hour learning
that defines the need for care. For example,
environment and accountability for out-
look at the following focus of mobility for a
comes by all staff members, regardless of
paraplegic patient:
discipline. In the reimbursed managed care
Can the impairment be reduced or
environment, the location of care delivery
eliminated (eg, can the paralyzed legs
has shifted from inpatient to postacute and
be restored to a functional level during
community venues. Patients who do not re-
the patient's stay)?
quire 24-hour nursing care can be treated in
Can the disability be reduced or elimi-
a less costly setting. This approach requires a
nated (eg, can the person learn to trans-
continuous system of care that allows for the
port himself from his room to the gym)?
provision of therapies traditionally carried
Can the social disadvantage be reduced
out in an inpatient setting to be implemented
or eliminated (eg, can the person be
in an alternative setting. Provider partici-
independent in mobility at home)?4
pants within the continuum do not have to
If the answer to any of the above questions
begin the patient's program again at each
is no, then little or no resources would be
new step in the process but instead can build
allocated on therapy in that area. When the
on a previously established clinical plan of
answer to the question is yes, then the deci-
care.
sion is to determine how much therapy-
Once the various disciplines work out
and, therefore, resources-should be ex-
their disagreements surrounding change, one
pended, and in what setting those outcomes
of the greatest challenges is learning to think
can be achieved. If independence in mobility
and plan care over the long term. Great care
is not a prerequisite for going home, the
must be taken ensure that funds are available
decision might be made to focus on that
throughout the continuum and that the timing
specific goal in a less costly setting and to
of resource utilization is appropriate to the
first concentrate on those activities that are
patient's need. This does not always occur, as
barriers to discharge. This does not mean the
recently reported by a community-based pro-
patient will not learn wheelchair mobility,
gram providing group home living and inde-
but the training may not occur in an inpatient
pendent training for ventilator-dependent
setting. By determining what five or six func-
quadriplegics. The owner/CEO noted that all
tions the patient must be able to do to go
too often the decision for the purchase of a
home, to a board and care, or to a less costly
permanent wheelchair is made while the cli-
level of care, the team is able to refocus away
ent is still in the acute rehabilitation phase.
from the traditional establishment of disci-
Many of their clients have been out of a halo
pline goals and onto a single list of patient
for only a few weeks and are not yet ready for
goals.
a final fitting. Many patients, once they are
The new list of patient goals reflects that
completely trained on maneuvering in the
which the patient needs, in the order of im-
community, would have improved function
portance to the patient and his or her circum-
in a better fitting wheelchair. However, they
26
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
are almost always unable to get a proper chair,
source allocation, and the appropriate exper-
because the wheelchair benefit has already
tise are available at the beginning of the case
been spent.⁵ The acute care staff, on the other
to make important decisions.
hand, reported that they felt that if they did not
As providers of rehabilitation services
order the chair early, the client might never get
evaluate their future, many ideas will be
it and therefore would not reach his or her
explored and strategies set forth. Concepts to
highest functional level for mobility. At the
consider as the planning progresses include
same time, the payer was concerned that too
the following:
much .or unnecessary equipment would be
Professionals must review the long-
purchased and, lacking the expertise neces-
term stakeholders for the patients
sary to address the subleties, authorized one
served by rehabilitation. Medicaid is
chair as requested by the acute inpatient reha-
rapidly becoming a managed care prod-
bilitation team and considered its obligations
uct throughout the country. Every
met. The possibility of loaner wheelchairs was
HMO, including Medicaid, will be
never considered.
looking for long-term preventive mea-
Hence the dilemma. Each person involved
sures and cost savings strategies. Reha-
in the process has a different set of beliefs,
bilitation specialists must initiate the
needs, and expectations. However, through a
dialogue, establish a relationship with
collaborative effort during the acute phase of
these organizations, and have a plan.
the patient's hospital stay, all parties can
Rehabilitation specialists must take a
establish a long-range plan of care that looks
closer look at who rehabilitation's cus-
beyond the immediate picture and weighs the
tomers really are. If the practice setting
patient's needs, projects his or her course of
is located in a comprehensive health
care throughout the continuum, and aligns
care system in a cost-based capitated
available resources for use at the most appro-
environment, then the purchaser of ser-
priate time. The end must be envisioned in
vices will shift from the third-party
the beginning. The front-end investment of
payer or the MHC plan administrators
time and energy, however, is not like any-
to the medical group and/or the health
thing the team has ever experienced. The
system. The purchaser may decide
same might be said for the level of clinical
where and when all care is delivered.
reasoning required to plan beyond the
The quality of a program is fundamen-
patient's immediate care setting.
tally based on accreditations. If a pro-
gram is certified by the Commission on
Looking Down the Road
Accreditation of Rehabilitation Facili-
ties (CARF) or the Joint Commission
While some payers and providers are "at
on Accreditation of Healthcare Organi-
risk" for only 1 year, the patient's clinical
zations, then quality is not a concern,
needs do not go away, and ultimately some-
and the only remaining issue is cost.
one will be responsible for care. Potentially
Large comprehensive health care sys-
thousands of dollars can be saved in the
tems responsible for large groups of
health care system when care planning, re-
patients and all the services necessary to
Managed Care and Delivery Services
27
provide care and long-term health man-
If participants in the field do not step forth
agement will not consider rehabilitation
with well-thought-out plans and innovative
specialists. Rehabilitation profession-
approaches, then decisions about what is of
als must become proactive to prevent
value and what is not will be made without
this from happening.
the benefit of their expertise. Giving up the
The focus is on the patient, and the
past is a tough thing to do, but once liberated
guiding principle is: "Where will the
from old processes, the management of spe-
utilization of resources result in the best
cial patient populations can belong to those
outcome for the patient?"
who know how to make it work.
REFERENCES
1. Dixon TP. Rehabilitation across the con-
versity. Study of Executive Staff of Fortune
tinuum: Managing the challenges, Arch Phys
1000 Companies. Pitney Bowes News Re-
Med Rehabil. 1997;78:115-119.
lease. 1996. www.pitneybowew.com/pbi/
2. Paone D, Iverson LH. Risk Identification: Ex-
whatsneew/releases/communication
ploring a Conceptual Framework and Identify-
_options.htm
ing Implementation Issues. Bloomington,
4. International Classification of Impairments,
Minn: National Chronic Care Consortium;
Disabilities and Handicaps. A Manual of Clas-
1995.
sification Relating to the Consequence of Dis-
3. Pitney Bowes/IFTF/Gallup/San Jose State Uni-
ease. Albany, NY: WHO Publications; 19_.
Impact of Managed Care on Spinal Cord
Injury Physicians and Their Patients
Kenneth C. Parsons
A brief review of the impact of managed care on the rehabilitation of patients with spinal cord injury reveals
growing frustration, with threats to both the quality of care and the outcomes that can be achieved. Health
care professionals are being forced to develop new models of care that extend beyond the discharge to home.
Case management and disease management models, with target outcomes achieved through a continuum
of care, offer alternatives to extend the process of rehabilitation and achieve optimal outcomes in the
presence of shrinking resources. Key words: case management, clinical practice guidelines, continuum of
care, disease management, follow-up of SCI, managed care, rehabilitation, rehabilitation outcomes, spinal
cord injury
HE PURPOSE of this article is to
acute care stay before they could proceed
T
briefly review the impact of man-
with rehabilitation. Providers set "long-term
aged care on providers and patients.
goals" that were also "discharge goals."
Then some practical responses will be pro-
There was little need for outpatient therapy
posed that may help rehabilitation profes-
services after discharge, because patients re-
sionals be better prepared to meet the future.
mained in rehabilitation bed until they
reached their optimal level of function. Re-
The Past
habilitation length of stay was in excess of 60
days for paraplegics and 120 days for
For rehabilitation professionals caring for
tetraplegics. "Single-physician manage-
spinal cord injury (SCI) patients in the 1970s,
ment" meant that the rehabilitation physician
indemnity (fee-for-service) health insurance
could control the process throughout the
was the norm for group health. Medicaid and
patient's inpatient and outpatient program.
Medicare were well funded. In some states, no-
Technology was the limiting factor for the
fault auto insurance covered everything. Pro-
outcomes of the patients; limited wheelchair
viders were well reimbursed, and decisions
and cushion options, rudimentary environ-
about length of stay and equipment purchase
mental control units, and unsophisticated
went largely unchallenged by payers.
driving adaptations were great frustrations.
The profile of hospitalization of a typical
SCI patient in that era was also very different
from that in the 1990s. SCI patients had long
Kenneth C. Parsons, MD, is Director, Spinal Cord
lengths of stay in acute care beds before
Injury Program, The Institute of Rehabilitation and
transfer to rehabilitation. When they finally
Research, Houston, Texas.
arrived in rehabilitation, they had to over-
Top Spinal Cord Inj Rehabil 1998;3(4):28-35
come the problems acquired during the long
© 1998 Aspen Publishers, Inc.
28
Impact of Managed Care on Physicians and Patients
29
Later the casualty insurance industry de-
veloped a case management model. Provid-
Changes in Health Care Affecting
ers learned to accept case managers in work-
Patients, Physicians, and
ers' compensation cases, because good case
Rehabilitation Professionals
management focused on the needs of the
Shortened length of stay
individual patient to achieve an optimal out-
Multi-tiered medical care system:
come. Utilization review of services to other
"the haves" versus "the have-nots"
patients was still largely the responsibility of
Loss of control of the process to the
the provider. There was little pressure to
payer
control costs.
Increased requirements for docu-
Health care professionals who came of age
mentation
in the 1960s were often committed to the
Evolution of case management into
ethical principle that patients who entered
claims management
the rehabilitation hospital should be treated
Adequate versus optimal outcome as
the criterion for discharge to home
the same, regardless of their funding source.
Incomplete follow-up
Discrimination because of payer source was
Limited access to new technology
considered unethical.
The Present
sponsibility for care at home before they feel
Twenty years later there have been many
fully prepared. The rehabilitation professional
changes that affect patients, physicians, and
who remembers the "good old days" of long
other rehabilitation professionals on a daily
stays and gradual discharge planning laments
basis. These are summarized in the box,
the current short inpatient stay and tries to
"Changes in Health Care Affecting Patients,
force the old model into the new envelope.
Physicians, and Rehabilitation Professionals."
The term "payer mix" refers to a multi-
Shorter length of stay is a familiar com-
tiered medical care system that spans a spec-
plaint in the rehabilitation setting. For pa-
trum from the injured worker with virtually
tients, clinical pathways and shorter stays in
unlimited resources to the person on Medic-
the acute setting have resulted in decreased
aid with as little as 2 weeks of funded inpa-
complications. Because of the shortened acute
tient rehabilitation. In the middle is the per-
care phase, professionals may be seeing less
son who has a rigid health maintenance
depression and learned passivity, but the pa-
organization (HMO) contract with severe
tient arrives in the rehabilitation bed with the
restrictions on services and an inadequate
same sense of shock and loss and the same
allowance for durable medical equipment.
expectation of cure. Patients do not come to
Rehabilitation professionals must be compe-
the rehabilitation setting with an accurate
tent not only in their professional fields, but
sense of their likely eventual outcome, given
also in their ability to solve resource defi-
their level of injury. Meanwhile, shorter
ciencies. While forcing shorter inpatient
lengths of stay in rehabilitation force the pa-
stays, managed care payers often place se-
tient and the family to accept hands-on re-
vere limitations on support services in the
30
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
home and on outpatient therapy services.
Optimal outcome for the patient was the goal
Decreasing disability and increasing com-
because the compensation carriers and re-
munity reintegration are not recognized
insurers knew that an optimal outcome was
goals covered by the contract between the
also likely to be a durable outcome with the
managed care organization and the purchaser
lowest lifetime cost for the claim for which
of the plan.
they had statutory responsibility. Case man-
Historically, control of the rehabilitation
agers were charged with finding the best
process rested with the rehabilitation team.
services available to obtain the best out-
Now the payers control the process by the
comes. Cost, in the short term, was less
power of their decisions. Unfortunately, the
important than quality, because high-quality
decision makers are not usually familiar with
care and training decreased the risk of expen-
the problems of the person with SCI, and
sive complications. When the concept of
efforts to educate them are often met with
case management was adapted to the man-
resistance. Rehabilitation professionals have
aged care arena, the emphasis shifted. Insur-
been forced into circumstances in which ne-
ance carriers hired review companies to con-
gotiation skills are required, and in most
trol costs as the highest priority and called it
cases they are not trained negotiators.
"case management." Face-to-face contact
Documentation of the patient's needs (and
among the case manager and the patient, the
the ability of rehabilitation to meet them) is
family, and the rehabilitation team became
no longer enough. Now rehabilitation pro-
telephone contact with a single team member
fessionals must provide progress on a weekly
who is currently called the "internal case
or even a daily basis to extend the stay.
manager." The language of the contract (ie,
Entirely new methods of documentation
between the insurance carrier and the em-
have been developed at our institutions to
ployer) determined what would be done,
streamline our own records and communi-
with little regard for the needs of the patient.
cate more effectively with the decision mak-
Under managed care a good outcome be-
ers we must satisfy. Time spent documenting
came a quick discharge to a lower (usually
is time lost from direct patient care, and
less expensive) level of care. Because man-
therefore efficiency is hampered just when it
aged care patients did not yet enjoy the statu-
is most needed. However, if we fail to docu-
tory protection provided to injured workers,
ment, we will not get the days we need to
the managed care plan was not accountable
accomplish the patient's program.
for the lifetime needs of the patient. A du-
Case management has evolved into claims
rable outcome had to last only until the em-
management. Case management came of age
ployer changed to a new health care plan or
because of the need for effective and efficient
the disabled individual lost coverage or be-
management of the care of catastrophically
came covered by Medicare. Case manage-
injured workers. Knowledgeable health care
ment under managed care means cost control
professionals, employed by insurance com-
rather than quality outcomes.
panies, visited the patients, supported the
In the past rehabilitation professionals
family members, met with the rehabilitation
sought optimal outcomes, but now they must
team, and collaborated in achieving results.
settle for adequate outcomes. They once dis-
Impact of Managed Care on Physicians and Patients
31
available to get the paralyzed patient un-
Case management under managed care
dressed for a full physical examination. SCI
means cost control rather than quality
specialists have not educated PCPs to the
outcomes.
risks faced by their SCI patients. The long-
term medical management of the patient with
SCI has not yet blended the expertise of the
charged patients when patients had reached
SCI specialist with the cost controls of the
"maximal hospital benefit" and there were
primary care model.
no more goals to achieve. Now specialists
Managed care decisions limit access to
scramble to teach adequate (ie, survival)
new technology. Rehabilitation profession-
skills of skin, bowel, and bladder care, along
als already see frequent denial of basic du-
with basic transfers and activities of daily
rable medical equipment and medical spe-
living. Discharge goals aim not for optimal
cialty care. Newly available technology in
outcomes, but rather "overcoming the ob-
wheelchairs, environmental control systems,
stacles to discharge." Now rehabilitation
functional electrical stimulation, and driving
professionals find themselves developing a
aids are usually not funded at all. How much
deferred goal list that they hope the patient
more frustrating will it be if a cure for SCI is
can achieve while living at home. This has
ever discovered? Imagine the clamor of
forced them to strengthen outpatient services
200,000 or more paralyzed patients for the
and tie them more closely to inpatient pro-
new treatment and the subsequent medical,
cesses. The long-term outcomes of patients
physical, and occupational therapy services
may suffer despite the best efforts of rehabili-
that will be necessary to recondition previ-
tation specialists. The impact of managed
ously paralyzed muscles. If the present pat-
care on SCI patients needs to be documented,
tern of decisions continues, few patients will
as was recently done for stroke patients.¹
be able to benefit from treatment aimed at
When the managed care plan contracts
curing paralysis. Managed care plans, along
with the rehabilitation hospital, long-term
with Medicare and Medicaid, will face huge
medical follow-up may still be in the hands of
expenses in providing new treatments and
the plan's primary care physician (PCP), and
therapies or will face class action lawsuits
most PCPs know little about the unique
because of denials.
needs of patients with SCI. Their reluctance
to use specialists may mean, for example,
Opportunities for the Future
that urologic care is denied, and autonomic
dysreflexia may not be recognized and
Lurking in the chaotic circumstances of
treated. Treatment of pressure sores may be
the managed care revolution are some op-
delayed. Patients coming into SCI specialty
tions that rehabilitation professionals are
clinics are already demonstrating the inad-
uniquely well prepared to develop. SCI pro-
equacy of care by PCPs. In the defense of
fessionals have long known the value of
PCPs, how can a PCP provide good care if he
starting rehabilitation early and moving the
or she is expected to see four or more patients
patient quickly to the rehabilitation bed.
per hour, and time and resources are not
They have proven that by decreasing pres-
32
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
sure sores and urinary tract infections, they
blood glucose levels prevents hospital-
can also decrease costs. What is needed is a
ization for diabetic complications.
tightly organized model of care with rapid
Tertiary prevention: Avoidance of pa-
transition from the intensive care unit (ICU)
tient decline or a worsening of a serious
to rehabilitation to home. To do this, rehabili-
patient condition, as when a patient un-
tation services must be carefully orchestrated
dergoes rehabilitation to counteract the
in each venue. Rehabilitation professionals
effects of a crisis such as a stroke.
need a way to develop and manage a custom-
Typical diagnostic categories currently
ized treatment plan for each patient, keyed to
addressed include cancer, heart disease,
each stage in the process. Then this model
musculoskeletal conditions, hypertension,
must be sold to managed care entities at a
depression, asthma and emphysema, diabe-
negotiated price.
tes, trauma, and autoimmune disease. They
Early efforts at the development of SCI
share the common criteria of chronic dura-
Centers of Excellence focused on these fac-
tion after onset, need for coordinated treat-
tors.² However, managed care entities wrote
ment across a continuum of treatment set-
contracts with many rehabilitation providers in
tings, high cost per episode of care, and a high
the same geographic area, SO the volume of
level of technology or special expertise re-
patients referred to a given Center of Excel-
quired for treatment.³ SCI, once it occurs,
lence was diluted, and the deeply discounted
satisfies these criteria. LaPensee also com-
price was not balanced by a corresponding
pared the familiar case management model
increase in volume of referrals. In addition,
with the disease management model (Table
managed care plans still wanted the PCP to be
1) and discussed the difficult but crucial issue
the gatekeeper and decision maker, and in this
of calculation of costs and capitation rate,
way the tight follow-up component of the Cen-
using oncology as an example.³
ter of Excellence model was compromised.
Disease management methodology has
A recent development has been the rise of
been implemented by Paradigm Health Cor-
disease management programs or "carve-
poration (Concord, CA).⁴ After initial evalu-
outs" for chronic disease states, with the
ation of patients with SCI, traumatic brain
potential risks of expensive hospital admis-
injury, burns, or complex musculoskeletal
sions and deterioration of function. Crisis
trauma, a contract is written with the insurer
and disability prevention for these diag-
that covers all acute and rehabilitation ser-
noses, as described by LaPensee,³ will seem
vices and equipment necessary to reach de-
familiar to SCI rehabilitation professionals:
fined outcomes. Subsequent management
Primary prevention: Avoidance of in-
may extend for several years into the future.
creased disease risk through the im-
Once agreement on the price is achieved,
provement of habits, such as the preven-
Paradigm Health Corporation and the pro-
tion of high blood pressure through
viders proceed with a course of care de-
weight control.
signed to achieve optimal outcomes for the
Secondary prevention: Avoidance of
patient. Initially developed for injured
the occurrence of the acute phase of a
workers, this approach is now being used
disease once a person has been diag-
for catastrophically injured persons who are
nosed with it, as when the control of
funded by health insurance. Predicting
Impact of Managed Care on Physicians and Patients
33
Table 1. Disease management versus traditional case management
Program feature
Case management
Disease management
Strategy
Reactive: initiated in response to a
Preventive: initiated before a crisis
grave crisis
can occur
Initiating event
Hospital stay for certain condition,
Diagnosis of certain condition
or occurrence of a large insur-
ance claim
Oversight and coordination of
Case management nurse'
Primary care or specialist physician
patient care
and managed care organization
staff
Financial basis
Discounted fee-for-service
Risk sharing, carve-out, or
subcapitation
Level of preventive care
Tertiary only (prevention of patient
Secondary (prevention of recur-
decline and worsening of
rence of illness) and tertiary
condition)
Type of illness addressed
Acute illness, or the acute phase of
All phases of a chronic illness
a chronic illness
Health care quality improve-
Ad hoc, for the individual patient
Systematic, for all patients with
ment emphasis
being managed
targeted conditions
Source: Reprinted with permission from LaPensee KT. Pricing specialty carve-outs and disease management program under
managed care. Managed Care Q. 1997;5(2):12. Copyright 1997 Aspen Publishers Inc.
costs and outcome under this model re-
larly by shrinking resources. In an effort to
quires a large database of similar cases'and
accomplish all the goals that used to be
a commitment by providers to efficient
achieved in the long hospital stays of "the
achievement of target outcomes. Because
good old days," professionals attempt to
the price has been fixed, Paradigm and the
compress 60 days of rehabilitation content
providers share the risk of failure to achieve
into a 30-day package. Consequently, the
the target outcomes within the resources
patient and family are overwhelmed with the
allotted. The benefit to patients is that opti-
pace and volume of content that they must
mal outcomes are targeted. The advantage
master. The team and the physician grumble
to providers is that efficiency is rewarded
about the decisions of the managed care
and follow-up is funded. With this type of
claims manager and recognize that we do not
model, the experienced SCI team can do its
negotiate well. Patient, family, and team mo-
best work.
rale suffer because rehabilitation specialists
have failed to adapt their conceptual model to
What We Can Do Now: The Continuum
current realities. A better approach is to con-
Of Care
ceptualize the inpatient phase as a part of the
continuum of care. The goal is to overcome
All professionals who provide inpatient
the obstacles that would otherwise prevent
rehabilitation services are confronted regu-
the patient from progressing to the "next
34
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
venue of care." It was this shift of thinking
of services that achieve the desired outcomes
that prompted the latest generation of Com-
that are appropriate for our patients.
mission on the Accreditation of Rehabilita-
If rehabilitation professionals are to adopt
tion Facilities (CARF) standards for the SCI
models of care delivery or funding, rehabilita-
System of Care.⁵ Long-term goals can be
tion physicians must become more knowl-
established for 6 to 12 months after the in-
edgeable about the costs of the services that
jury, and the entire continuum of services can
are prescribed and the management of the
be used to achieve those goals in a cost-
processes that are supervised by rehabilitation
effective manner.
specialists. When outcome measures are
To manage the continuum of care, profes-
valid, processes can be redesigned to be more
sionals need new ways of communicating
efficient while achieving the same goals. This
among the venues.⁷ The achievement of
will require that rehabilitation specialists col-
long-term goals requires that all goals be
laborate with all venues within the continuum.
addressed. Outpatient therapies typically fo-
Industry-wide standards for functional
cus on measurable activities such as
outcomes based on the level and severity of
ambulation. Issues of home and community
injury have not yet been established. To this
reintegration may get less attention, because
end, an interdisciplinary team is currently
achièvement is more difficult and outpatient
developing evidence-based clinical practice
case management may not be funded. Outpa-
guidelines for "expected outcomes" by level
tient team conferences, if they occur, often
of injury under the auspices of the Consor-
do not include the patient and family mem-
tium of Spinal Cord Medicine.⁶ If standard-
bers. Therefore, progress toward goals re-
ized outcomes can be established, rehabilita-
quires a documentation system that is ac-
tion professionals will strengthen their
cessed by all members of the team and
ability to negotiate the medical necessity of
updated as often as necessary. Since not all
the services and equipment that they recom-
patients will receive their therapy at one of
mend for a given patient.
the continuum facilities, the quality of docu-
Another opportunity arises because pa-
mentation may be variable, and physician
tients may not be allowed to return for fol-
contact with the treating therapist may be
low-up care in a specialized SCI clinic. PCPs
reduced to signing monthly renewals.
must learn to recognize the importance of
Reconfiguring services toward the disease
such things as episodic headaches in a
management model and designing of new
tetraplegic patient or ascending sensory level
communication methods can proceed after
in a paraplegic. Who will teach them to look
comparing outcomes that are achieved in
after the urinary tract in such patients? Will
"continuum cases," with outcomes in cases
PCPs recognize that community reintegra-
managed in the old familiar single-therapy
tion is a health care issue? Have rehabilita-
model. The experience gained may support
tion professionals adequately prepared pa-
the development of a case rate pricing model
tients to be their own advocates within their
that may allow rehabilitation institutions to
health plan? Spinal cord rehabilitation spe-
provide a complete, cost-effective package
cialists must educate patients, their family
Impact of Managed Care on Physicians and Patients
35
members, and their PCPs about good basic
ganizations that will make such adversarial
follow-up care and when it is appropriate to
interactions unnecessary as they collaborate
send the patient back to the specialty clinic. If
with primary care providers to manage the
rehabilitation specialists fail to prepare pa-
long-term health of patients with SCI.
tients and educate their PCPs, they may be
sued, along with the PCP, for the pressure
sores and renal stones that will undoubtedly
Instead of concentrating on the frustrating
occur. A standardized follow-up plan, based
aspects of the current health care environ-
on good scientific evidence, would
ment, rehabilitation professionals must be-
strengthen the processes of education and
come proactive providers in a new environ-
persuasion. Such a follow-up plan is cur-
ment. The needs of patients have not
rently under development by another team
changed; patients still experience impair-
under the auspices of the Consortium for
ment, disability and handicap as the result of
Spinal Cord Medicine.
SCI. Therefore, commitment by rehabilita-
As health care professionals, rehabilita-
tion specialists to the best possible outcomes
tion specialists must come to grips with
for their patients should not change. Never
change in the health care environment while
has the advocacy role of rehabilitation pro-
continuing to meet their responsibilities as
fessionals been more important.
advocates for their patients. They must de-
New models of delivery and funding of
velop negotiation skills so that they can be
rehabilitation services are being explored.
more successful in appealing denials of ser-
The strengths of rehabilitation specialists lie
vice and equipment. They may have to par-
in their professional experience, their ethical
ticipate in legal proceedings against a man-
commitment to optimal outcomes, their flex-
aged care organization when a patient has
ibility in methods to achieve those outcomes,
been damaged by the manager's decisions.
and their willingness to be advocates for their
Hopefully, they will find opportunities to
patients. Their success will be demonstrated
develop partnerships with managed care or-
in their patients' outcomes.
REFERENCES
1. Retchin SM, Brown RS. Outcomes of stroke
5. Commission on Accreditation of Rehabilita-
patients in Medicare fee for service and man-
tion Facilities. CARF Standards Manual for
aged care. JAMA. 1997;278:199-124.
Medical Rehabilitation Programs. Tucson,
2. Dragalin D, Goldstein PD. The centers of
Ariz: CARF; 1997.
excellence phenomena. In: Nash DB, ed. The
6. The Consortium for Spinal Cord Medicine,
Physician's Guide to Managed Care.
Paralyzed Veterans of America, 801 18th
Gaithersburg, Md: Aspen Publishers; 1994.
Street, NW. Washington, DC 20006.
3. LaPensee KT. Pricing specialty carve-outs and
7. Currie GA. Integrated postacute care net-
disease management programs under managed
works. Rehabil Manage. 1997; December/
care. Managed Care Q. 1997;5(2):10-19.
January:43-46.
4. Paradigm Health Corporation, 1001 Galaxy
Way, Suite 300, Concord, California, 94520.
Rehabilitation Facility-Based Case
Management in Evolution: Responding
to Managed Care
Jeanette Ray
Case management of the patient in the rehabilitation setting has existed since the beginning of the
rehabilitation movement. However, over time the role has expanded dramatically due to the demands of
managed care to provide quality care and projected outcomes in a cost-efficient manner. The development
of case management into a well-defined unique role with specific responsibilities is explored. Current
philosophies and trends are discussed, as well as ways to ensure success with obtaining rehabilitation
services for our patients in the future. Key words: burnout in the case manager, case management, case
manager, case manager roles, continuum of care, evolution, future of case management, health manage-
ment, pricing, stress in the case manager, tools, venues of care
C
ASE management in health care fa-
tation counselor, or the nurse discharge plan-
cilities has become the "en vogue"
ner in rehabilitation facilities 10 to 15 years
trend. Any facility trying to contend
ago and the case manager today, it is that the
in today's very competitive health care arena
role of case management has undergone a
has either implemented or is in the process of
tremendous development. Not only are
implementing a case management model.
workers' compensation cases being case
What is this concept really all about?
managed, currently almost all cases are un-
der case management. The goal for any case
Case Management
management is to obtain the most successful
outcomes, using the least amount of re-
Brief history
sources, in the shortest period of time. Unlike
Case management is really not new at all.
most acute care settings where assessment
For years, rehabilitation facilities serving the
determines which patients require case man-
needs of the catastrophically injured, par-
agement, rehabilitation facilities work under
ticularly in the workers' compensation sec-
the assumption that all patients require case
tor, have used a case management model to
management because of the high costs in-
meet the needs of the patient and the family,
volved with the catastrophic case.
as well as the insurer. What is different,
Definition
however, is that the staff member function-
ing in this capacity was not called a "case
manager" but had case management as one of
Case management is defined as a collabo-
his or her duties listed under a more familiar
rative process that assesses, plans, imple-
role. Case management duties were often
performed by a social worker, a rehabilita-
Jeanette Ray, MS, CRC, CCM, LPC, is Director of
tion counselor, a nurse discharge planner, or
Case Management, Shepherd Center, Atlanta, Georgia.
a combination thereof. If there is any differ-
Top Spinal Cord Inj Rehabil 1998;3(4):36-43
ence between the social worker, the rehabili-
© 1998 Aspen Publishers, Inc.
36
Case Management in Evolution
37
ments, coordinates, monitors, and evaluates
manager may not provide services to address
the options and services required to meet an
these specific areas, he or she does facilitate
individual's health needs, using communica-
the coordination of these services.
tion and available resources to promote high-
quality, cost-effective outcomes.¹ At the
The Case Manager
foundation of case management is the con-
sideration of available resources so as to
A varied role
manage the resources of a patient in a cost-
The case manager has a varied role. In
efficient manner. To accomplish this, the
addition to the role of managing levels of care,
case manager has to be knowledgeable in
the case manager in the acute and rehabilita-
rehabilitation diagnoses, secondary compli-
tion settings serves as educator, advocate, and
cations associated with the diagnoses, com-
supportive counselor to the patient. It is im-
munity and financial resources, and con-
portant that the patient not view the case
tinuum of care options/venues of care² so as
manager as someone working only for the
to facilitate the moving of a patient from the
insurance company. The case manager ex-
most costly setting to the most cost efficient.³
plains his or her role as collaborator with all
The skills and knowledge employed by the
involved in the patient's care, from the provid-
case manager are essential, because timing of
ers to the payers. On the other hand, the case
service delivery and determination of level
manager serves as educator, coordinator, and
of care are crucial to successful case manage-
facilitator to the treatment/rehabilitation
ment. Murer has discussed the use of "trigger
team. The success of any facility that has
points"2 to describe those points in a patient's
implemented case management requires that
progress that should be used as discharge
ongoing education be provided to all treating
criteria by the facility-based case manager.
team members on topics associated with care
In essence, the trigger points/discharge crite-
delivery in a managed care world. Delibera-
ria in one level of care serve as admission
tion concerning utilization of resources occurs
criteria for the next lower level of care.² The
with the entire team. A broad-based under-
patient is able to move through the venues
standing of when a particular intervention,
when ready to do so without compromising
procedure, or modality is implemented, and
accomplished gains. Ultimately, the case
doing so when it is most useful and beneficial,
manager works with the patient to return him
is necessary at the team level. The facility-
or her to the highest level of functioning
based case manager depends on program
commensurate with the level of injury. Con-
managers and therapy supervisors to be savvy
sideration is given not only to physical status,
to tendencies to revert to "do as we do."
but " also to productivity status as it pertains to
Therapists need to look at why they do what
a person's ability to return to vocation, fam-
they do and determine what portions of care
ily function, and leisure status. A patient who
are indispensable.⁴ Gone are the days when a
continues with residual physical, cognitive,
patient was admitted to arehabilitation facility
and psychosocial difficulties is assisted in
and received "the comprehensive rehabilita-
compensatory techniques to accommodate
tion program," regardless of level of con-
the changes in status so as to continue in life
sciousness, level of function, and his or her
with dignity and quality. Although the case
readiness to benefit from such.
38
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
External versus internal
vocational specialist, job coach, or rehabili-
tation engineer, when indicated.
To the insurer/external case manager rep-
Pitfalls to avoid
resenting the insurance company, the facil-
ity-based case manager supports the con-
Case managers schooled in caregiving
cerns of the insurance company, ensuring
will find that they have to discriminate when
that the patient's financial resources will be
"to do" and when "not to do." In accordance
spent in the most efficient means possible,
with the rehabilitation philosophy, it is not
considering the patient's medical status and
"poor customer service" to insist that pa-
level of function. It is not unusual for the
tients and families be involved in every as-
facility-based case manager, being knowl-
pect of rehabilitation, from treatment plan-
edgeable in insurance benefits and skilled in
ning and therapy sessions to completing
negotiating, to negotiate with an external
forms required in applying for financial as-
case manager, proposing that a patient's re-
sistance or transportation services. It is only
sources be redistributed in such a way as to
after being involved with these activities that
give him or her maximum access to benefits
the patient and family will benefit from all
when they are most needed. The patient and/
the information case managers are able to
or family, when necessary, should be inti-
provide. Long after patients are discharged,
mately involved in this process. The edu-
there will be forms, letters, and applications.
cated patient and family will learn how to
What better way to provide patients and
advocate for themselves and, by so doing,
families with practice than to support and
will be able to serve as self-advocates for the
assist them in this activity? Life is not the
rest of their lives. Patients and families who
same after a catastrophic injury. Case man-
act as case managers deliver a message of
agers do families an injustice in not involving
capability for assuming responsibility to
them in some of the new activities of their
make decisions and manage their lives long
lives. The case manager's role has expanded
after they have left the rehabilitation setting.
so greatly that there is little time to spend
doing for the patient. With evolution, the
Role as educator
case manager has had to work with the pa-
The role of the case manager as educator
tient and family to help them do for them-
and advocate expands well beyond the reha-
selves. Through such education, indepen-
bilitation facility. Employers who assist in
dence is achieved and the rehabilitation
returning the patient to the work force after
philosophy practiced across all disciplines.
rehabilitation may require education on ac-
commodation and/or stigma issues as they
Stress and burnout
pertain to people with disabilities and their
peers. A case manager can explain the role of
Wood has discussed the responsibility
the vocational specialist and smooth out any
case managers have to "manage their own
misconceptions that may present with an
job stress. "5(p67) Case managers are not im-
outsider consulting in the work site. The case
mune from employee turnover and burnout,
manager can facilitate the involvement of the
an attribute of the human service field in
Case Management in Evolution
39
general. Wood commented on the fact that
many case managers do enter and exit the
profession, and this turnover is endemic to
the field. Case managers are more inclined to
Nursing
P.T.
endure if they are aware of potential hot
spots, such as role ambiguity, role overload,
and role conflict; recognize the impact these
hot spots have on job-related stress; and work
with peers and supervisors for clearer defini-
tion.⁵ Once this has been achieved, it is then
up to the individual case manager to work
Social
Rehabilitation
within the defined role and set boundaries
Worker
Counselor
where necessary.
Redefinition
So who is this case manager? At Shepherd
Fig 1. Shepherd Center case managers, as a
Center, a specialty hospital in Atlanta serving
result of their backgrounds, bring a
patients with spinal cord injury, acquired
multidisciplinary approach to the position of
brain injury, multiple sclerosis, and other neu-
case management. This diagram demon-
rologic disorders, case managers are rehabili-
strates a distinct position strengthened by the
tation professionals with varied backgrounds.
discipline in which the case manager is
Nursing, rehabilitation counseling, social
schooled. The boundaries around the position
work, and physical therapy are all represented.
are clear, yet they allow for the occasional
Most important are knowledge and working
need for the case manager to "cross the line"
experience with people having the defined
and perform a task in his or her respective
rehabilitation diagnoses. Next is the ability to
background discipline when doing so would
envision a person's ultimate outcome and
increase efficiency. This, however, is the ex-
ception and not the norm.
maintain skills to facilitate the timely move-
ment of the patient through the various levels
in the continuum of care. The case manager is
(Fig 1). The social worker as case manager
proactive in anticipating the course a patient
knows that the patient and family counselor
will take and therefore is able to justify where
role he or she once played is now another's
the patient is, where the patient needs to go,
role. What is important for the social worker as
when the patient will go, and how much it will
case manager to know is that the experience as
cost to get him or her there.
counselor enables him or her to know when or
Necessary background
when not to use the counseling resource avail-
able to his or her patient. In the times of cost
Case managers with various backgrounds
monitoring, patient services are consulted
have learned that their identity as a case man-
when appropriate. The rehabilitation counse-
ager requires boundaries be drawn with the
lor with a vocational rehabilitation back-
professional background they bring to the role
ground who functions as case manager also
40
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
knows how to use the counseling resource
external case manager to ensure that services
available to the patient and the role the voca-
were provided that addressed all problem
tional specialist plays in successfully return-
areas. There was little discussion surround-
ing the patient to productivity. The vocational
ing costs and charges. The assumption was
specialist is used as a resource in a proactive
that all justifiable charges were reimbursed.
yet timely manner. The nurse as case manager
Currently pricing strategies are evolving.
may suggest a particular test be ordered by a
The skilled case manager must know what
physician and request that the charge nurse
the costs are to care for a particular patient
call the physician to consider initiating an
type so as to negotiate and/or manage a per
order SO that the results can be ready when the
diem, case rate, or capitated rate, all while
physician makes rounds the next day, as op-
first considering the care required by a par-
posed to waiting for him or her to order the test
ticular patient along any point in the con-
during rounds. Time saved is money saved.
tinuum.
The physical therapist as case manager, at the
Per diem versus case rate
same time, may be aware of the physical
limitations a patient is experiencing and be
First-generation per diems included reha-
thinking ahead as to what resources need to
bilitation services, with certain exclusions
be lined up in the patient's home so as to
for physician fees and ancillaries. In this
have the home accessible prior to a patient's
methodology, insurers made their first at-
discharge. Community mobility, as it per-
tempts to control lengths of stay. Providers,
tains to safety, may also be considered very
being forced into accepting higher acuity
early in the continuum when it is apparent
patients, responded by unbundling charges.
that community reintegration will be an
The payers then began moving to case rate
outcome.
and capitation reimbursement models. The
original case rate model was based on a
Case Managers and Pricing Strategies
negotiated rate for a particular level of care.
Currently it is common to see case rates in
A brief overview of current payment strat-
which the negotiated case rate includes the
egies for rehabilitation patients and the im-
full continuum of rehabilitation services.⁶
plications they have for the practicing reha-
Here the facility-based case manager's skill
bilitation facility-based case manager will
is crucial in knowing when to facilitate mov-
be explored in this section. Actual charges
ing the patient through the continuum of care.
paid when social workers, rehabilitation
Capitation
counselors, and nurse discharge planners
were providing case management made for a
Capitation, the newest generation of reim-
relatively easy, predictable system. The pa-
bursement, is a method whereby the provider
tient was admitted with workers' compensa-
has negotiated a fixed amount of payment per
tion benefits and the facility-based case man-
member per month. Here the provider carries
ager served to provide supportive counseling
the risk, but is given a broad range on utiliza-
to a patient and family, discuss and prepare
tion of resources. In the capitation model,
for discharge, and serve as a liaison with the
case managers are managing the agreed upon
Case Management in Evolution
41
capitated rate while considering the care re-
facilitates movement of such patients to the
quired. The case manager's skill is to use the
more appropriate level of care. The care path
continuum to get the patient to the desired
moves with the patient to the day program;
outcome within the capitated rate.
outcome goals are reassessed weekly. Con-
versely, the case manager utilizing a care path
Tools For Success
for the patient who develops unforeseen com-
plications documents the variances and deter-
Clinical pathways
mines through team input the interventions
Clinical care paths are one tool used by the
needed to get the patient back on track. Here
Shepherd Center case manager to achieve a
the patient's course in rehabilitation may be
predictable outcome. They allow for indi-
extended, ultimately affecting the outcome as
vidualized plans of care while maintaining
it pertains to projected length of stay.
uniformity across each diagnosis, regardless
Variances
of funding source. Documentation by excep-
tion, in the form of variances, allows for
Shepherd Center case managers can moni-
efficient use of time by the case manager,
tor costs with the care paths. Any variance
physician, and the entire team. Outcome
can be quantified and compared to projected
goals are predicted by the rehabilitation team
costs of a care path phase. A payer can
within the first 72 hours of admission and are
calculate total costs expected based on the
updated weekly. These may or may not be
length of stay built into the care paths'
affected by variances that surface during the
phases. It would not be out of the question to
course of a patient's rehabilitation along the
see payers wanting to purchase phases of a
care path. Outcome goals that change at any
care path and determine additional phase
time during a patient's stay can immediately
purchase depending on the ability of the
be identified and conveyed to the funding
provider to get the patient to the outcome
source, so that it, too, is able to adjust its
expected at the end of any given phase.⁷
expectations for the patient's discharge.
Variance analysis is a two-phase process.
First the case manager analyzes variances to
Outcome goals
identify trends affecting outcomes. This
It is important to note that a patient's
same information is then used so that proac-
outcome goals may be upgraded or down-
tive measures can be taken to avoid these
graded during the course of rehabilitation. A
same variances/problems in future patients.⁸
patient who progresses through phases of the
Over time, outcomes improve.
care path more quickly than expected may
achieve the same outcome as was projected
Medicaid: Capitation and case management
but in a shorter period of time. Variances
In February 1997 Shepherd Center insti-
explain how the level of progress exceeded
tuted a unique Medicaid pilot program to
the normal rate. Patients in this category may
improve disability case management for
find that they are ready for transition to a day
the injured long after they have left the
program sooner than anticipated. The case
safety and structure of a formalized reha-
manager knowledgeable about venues of care
bilitation program. Tommy King, RN, MS,
42
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
CETN, manager of ShepherdCare, ex-
viduals who would otherwise do without.
plained, "Medicaid can be defined as the
Outcome data, not yet available due to the
safety net for those whose benefits have been
newness of the program, will soon provide the
exhausted, as well as for residents of Georgia
documented information needed to evaluate
who meet the criteria for medical and finan-
the results of ShepherdCare. Patient outcomes
cial assistance from the state. To control the
will consider patient satisfaction, overall
medical costs of people with catastrophic
health, productivity status, and cost analysis in
injuries, Shepherd Center needed to cover
this preventive health management model.
not only the initial hospitalization but the
The implications for facility-based long term
course of care over a lifetime. "9(pp95-96)
disability case management outside the Med-
ShepherdCare was the result. King contin-
icaid population are evident. Careful monitor-
ues, "ShepherdCare follows a model in
ing of outcomes in the near future will provide
which the patient and the primary care pro-
the information necessary to analyze data and
vider collaborate on care. The model fosters
determine viability for such a model for all
independence by making the patient an inte-
funding sources.
gral participant in care that is comprehen-
sive, coordinated, and personal. A goal of
Facility-Based Case Management: A
ShepherdCare is to facilitate prompt and
Concluding Note
easy access to medical care, thereby prevent-
ing, or at least reducing, the number of ad-
Managed care has affected health care at
verse outcomes and ultimately enhancing
every level. The benefits are there. Re-
every patient's quality of life. "9(p95)
engineering has made health care profession-
als look at how they are operating and forced
Case management and health management
them to ask, "Why are we doing it this way?"
In the ShepherdCare model, rehabilitation
Through this process everyone has learned a
nurses serve as case managers. Since long-
lot. All health care professionals have had to
term high costs are often associated with re-
think, be creative, take risks, evaluate the
hospitalization, ShepherdCare case managers
results, and try something different. A lot has
are able to stay on top of patient care issues to
been gained. Case management as a profes-
prevent secondary complications, which are
sion in its own right is one result.
common in catastrophically injured patients,
However, are facility-based case manag-
from occurring or, at the very least, from
ers managing care or managing reimburse-
getting worse. Patients can come to
ment? Health maintenance organizations
ShepherdCare offices for meetings, or the
(HMOs) are often criticized for not giving
case managers can visit them in their homes.
patients what they need. What obligation
Resources are used efficiently in a preventive,
does the HMO have to pay for services that
proactive manner. This program is unique
were not included in a contract? None. Case
because most long-term disability case man-
managers, on the other hand, can advocate
agers stay involved as long as there is a con-
for services needed by a patient that may be
tract to do so with the insurer. ShepherdCare
deemed "out-of-contract" if the skills of the
allows for the case management of those indi-
case manager are such that he or she can
Case Management in Evolution
43
negotiate and the data available support pay-
come of rehabilitation. Case managers
ing now to save later. There is no getting
know all the potential benefits to rehabilita-
around the fact that catastrophic injuries are
tion, and they can educate the payers to
expensive to rehabilitate. However, what is
such. With new pricing strategies, the payer
to be said for the exorbitant costs involved in
can feel sure that accountability for out-
paying for the rehospitalized catastrophi-
comes lies with the facility and the facility-
cally injured? Rehabilitation provides
designated case manager. Payers are less
people with the opportunity to regain some
concerned with how rehabilitation profes-
degree of quality of life. Quality of life may
sionals get patients to their outcomes and
be considered family function, leisure activ-
more concerned with the end product, the
ity, or-what is considered to be the greatest
outcomes themselves, regardless of how
monitor of success in rehabilitation by most
they are achieved.
insurance standards-return to work. Case
The case manager knows what benefits
managers who know the benefits can educate
can be accomplished with rehabilitation.
payers to the same goal. On the other hand,
Case managers must take an active role in
for patients whose injuries are such that re-
designing programs that will meet consumer/
turn to work is not an option, rehabilitation
patient needs. Improving access to rehabili-
that teaches a family to feel confident in safe
tation and quality of service while maintain-
assistance to the injured returning home
ing cost efficiency is the key in responding to
may itself be the most cost-effective out-
managed care.¹⁰
REFERENCES
1. Case Management Society of America, Com-
5. Wood C. Managing yourself. Case Manager.
mission on Case Management Certification,
1997;8(1):66-69.
Foundation for Rehabilitation Education and
6. Hutchins B. Straight talk. Managing cost and
Research. Case management: Who's who and
quality. Rehab Manage. 1996;9(3):25-26.
what's what. CMSA CCMC FRER Newslett.
7. Freda M, Rao P. Rehab's sea change. Rehab
1997;1:3.
Manage. 1995;8(4):135-137, 164.
2. Murer CG. Creating common knowledge. Re-
8. Rosenstein AH, Propotnik T. Case manage-
hab Manage. 1996;9(4):62-66.
ment. / Healthcare Resource Manage. 1997;
3. Murer CG. Operational restructuring:
15(2):11-16.
Rehabilitation's response to reform. Pre-
9. King T. ShepherdCare: Improving disability
sented at the American Rehabilitation Asso-
case management. Case Manager. 1997;
ciation 1995 Seminar Series; January 1995;
8(3):95-96.
Orlando, Fla.
10. Wolfe GS. Managed care and case managers.
4. Wigington T. Coping with change. Rehab
/ Care Manage. 1997;3(2):10.
Manage. 1996;9(1):95-96.
CarePaths: A Tool for Coping with
Managed Care
Donna Court, Donna Loupus, and Sarah Morrison
The standardization of care and projection of clinical outcomes has become a necessity for ensuring an
organization's viability in a managed care environment. CareMaps®, or CarePaths© as we have chosen to
call our tools, can be a valuable adjunct to interdisciplinary rehabilitation care. CarePaths are a criteria-based
guide for a patient's progression through the program. Variances that occur during a patient's stay assist the
staff in targeting key indicators that may predict better resource utilization. The use of CarePaths also
increases staff efficiency in time spent in documentation. Key words: CareMaps®, CarePaths©, criteria-
based progression, critical path method, process improvement, rehabilitation pathways, variance
ANAGED CARE has forced reha-
M
were born. Use of the pathway process for
bilitation professionals to look at
acute care became commonplace, and soon
a project and evaluate how a case
there were pathways for the many
management model and a clinical pathway
subspecialties of acute care. Now, of course,
model can be efficiently meshed. Clinical
pathways have been utilized in all areas of the
pathways and their derivative CareMaps®
continuum of care, including home health
(registered trademark of The Center for Case
and community management. In fact, in
Management, South Natick, MA) are but one
1995 a survey of hospitals in the United
tool to assist patients and their treatment
States showed that 81% were using clinical
team in achieving a positive, predictable out-
paths in one form or another.²
come.
The second generation of pathways, called
To manage outcomes effectively in a man-
the CareMap (or CarePath© [Shepherd Cen-
aged care environment, the team must use a
ter, Inc, Atlanta, Georgia]), becomes the ac-
standardized, planned approach to patient
care. The critical path method (CPM) is one
way that standardizes care. During the
Donna Court, RN, MN, is Interdisciplinary Pathway
1950s, CPM was developed to be a tool for
Nurse, Shepherd Center, Inc, Atlanta, Georgia.
industrial engineering applications such as
oil refineries, electrical generating plants,
Donna Loupus, RN, MN, is Clinical Nurse Specialist,
and managerial sciences project planning.
Shepherd Center, Inc, Atlanta, Georgia.
Karen Zander at the New England Medical
Sarah Morrison, PT, is Therapy Liason for Documen-
Center in Boston, Massachusetts, first used
tation Improvement and Therapy Supervisor, Day Pro-
CPM in health care as a strategy to review
gram, Shepherd Center, Inc, Atlanta, Georgia.
patient care delivery.¹ It was from these ef-
Top Spinal Cord Inj Rehabil 1998;3(4):44-52
forts that the first patient critical pathways
© 1998 Aspen Publishers, Inc.
44
Carepaths
45
tual documentation with the timeline, plans,
2. Staff members chart on the pathways
management, and evaluation pieces all built
using a charting-by-exception (CBE)
into the pathway. By using a pathway or
model incorporating à minimal amount
CarePath system, we have a framework for
of subjective narrative.
moving the patient toward positive, measur-
3. The CarePath is the interdisciplinary
able outcomes. Instead of reviewing patient
plan of care for the patient, and has
care retrospectively as a clinical pathway
replaced separate discipline-specific
does, the CarePath allows clinicians to plan
goal sheets.
for care by providing the general framework
4. The CarePath serves as the team con-
and preplanned goals against which to grade
ference report, and has increased effi-
themselves.
ciency and cost savings.
5. Patients are encouraged to participate
Differences Between a Clinical Pathway
in their rehabilitation care and goal
and a CareMap or CarePath
setting by use of patient-version" path-
ways.
The clinical pathway is the overview or
Why Initiate a Pathway Project?
general plan of care for a particular patient
group. Clinical pathways emphasize tasks
Because rehabilitation medicine has tradi-
rather than outcomes; they do not replace any
tionally expressed its goals for patients in
specific documents in the medical record.
terms of measurable functional outcomes, it
Although they do represent a multidisciplin-
is logical that it would be compatible with the
ary action plan, they have no built-in action
pathway approach. The teams are accus-
plan to evaluate results.
tomed to thinking in terms of goals and
The CarePath is the plan of care plus the
standards, so defining intermediate steps is
actual documentation for the medical record:
not problematic for them. What is a chal-
A large portion of the CarePath is devoted to
lenge, however, is facilitating the treatment
examining outcomes, and there is an evalua-
teams to begin thinking in an interdiscipli-
tion process for analyzing variances.
nary fashion as opposed to their usual
By making the CarePaths the core of the
multidisciplinary manner. The difference is
medical record, we have produced the fol-
this: An interdisciplinary approach implies
lowing five benefits:
that disciplines interact and treat the patient
1. The CarePath has become the center
in concert, while a multidisciplinary ap-
of all documentation and serves as the
proach simply means that a patient receives
standard against which staff chart the
services from more than one discipline. It is
patient's progress. Staff are now able
also one thing to call onesèlf interdiscipli-
to focus their energies on creating
nary and quite another to really function as a
new solutions for problems that re-
cohesive interdisciplinary unit. By using an
quire individualization, while ensur-
integrated documentation tool for a patient, a
ing that the core plan of treatment is
"back-door" approach can be used in leading
not forgotten.
the teams toward collaborative behavior.
46
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Organization of the CarePath
Advancement on the CarePath is
Prior to developing CarePaths, determine
criteria based, using measurable
the case type for which pathways would be
standards for each phase.
most helpful. Examine your diagnostic
groups and start with a client base of whom
you see a large number. It is useful to group
care into an area where patients differ in
diagnoses as they relate to care and/or func-
the frequency, duration, and intensity of
tional level. For example, C1, C2, and C3
treatment.
function similarly, and thus they are grouped
The organization of the CarePath clinical
together. All levels of paraplegia function
interventions is as follows:
similarly, and thus there is only one rehabili-
Health status: to include medical con-
tation paraplegia pathway.
sultations, laboratory results, and radi-
The organization of the CarePaths by
ology studies, as well as nutritional sta-
functional levels (as we have chosen to do) is
tus and skin condition
as follows:
Mobility: to include sitting tolerance,
C1-3 has four phases of rehabilitation,
bed mobility, transfer skills, and wheel-
during which the family is trained.
chair mobility (Fig 1)
C4-5 has 4-6 phases of rehabilitation,
Activities of daily living (ADLs): to in-
four phases for the C-4, and longer
clude eating, dressing, and grooming
depending on whether the patient is a
skills, as well as bowel and bladder skills
weak C5 or a strong C5.
Psychosocial: to include adaptation and
C6 has eight phases of rehabilitation.
behavior response to treatment
C7-8 has eight phases of rehabilitation.
Education: to include patient learning,
Paraplegia has four phases of rehabili-
as well as family training
tation.
Community reintegration: to include
The organization of the CarePath by time
therapeutic recreation activities, as well
frame is as follows:
as vocational counseling input
Admission to 72 hours: evaluation stage.
Discharge planning: to include contin-
Acute phase (criteria-based): medically
ued care planning needs, such as home
unstable, not having endurance and/or
health or attendant needs, and home
sitting tolerance suitable for rehabilita-
modification recommendations
tion. (Ventilator-dependent patients
Progression Through the CarePath
may remain in this phase while they are
weaning from the ventilator.)
Advancement on the CarePath is criteria-
Rehabilitation "phases" (based on the
based, using measurable standards for each
traditional time increment of a week,
phase. A team decision is also involved when
are criteria-based): related to the patient
the team must resolve whether the patient
achieving key intermediate goals.
should advance if some, but not all, of the
Day program: extends the continuum of
intermediate goals have been met (Fig 1).
Carepaths
47
Care Path Section: Rehabilitation
Date:
Intermediate goals (if not met, write variance):
1. Initial Rx's for equipment submitted to DME
Met
Not met
(if not already done).
2. IVP/renal scan completed.
Met
Not met
3. Sitting tolerance T 85° X 7 hours.
Met
Not met
4. Drive power wheelchair on level surface.
Met
Not met
5. Decide IC vs. reflex bladder with Urology (if male).
Met
Not met
MOBILITY:
See variance
Standard (FIM):
Sitting angle
Sitting tolerance at 85° for 7 hr
Sitting tolerance
hours
Bed mobility:
Dependent (includes rolling side/side, proning,
FIM:
coming to sit, scooting) (1)
Bed mobility:
Turn schedule: T 30 min q week if skin intact
Rolling side to side
Transfer skills:
Supine to prone
Dependent (includes mat, bed, car, toilet, tub,
Coming to sit
floor) (1)
Scooting left/right
Power wheelchair mobility:
Scooting forward/backward
Propel on smooth surfaces with modified
independence (6)
Wheelchair management:
Propel on/off elevator/through doors with
Safety strap
supervision (5)
Brakes
Skin:
Arm rests
Power recline weight shift with modified
Leg rests
independence every 30 min. (6)
Anti-tip levers
Shoe tolerance increased 1 hr/day if skin remains
Positions self
intact (maximum of 8-12 hr)
Adjust cushion
Initiate verbalizing skin checks (1)
Wheelchair maintenance
Circle appropriate choice:
Transfer skills (type):
Weight Shift
Weight Shift Schedule
Mat
Power recline
q 15 min
Bed
Manual recline
q 30 min
Car
Side-to-side
q 45 min
Toilet
Forward lean
q 60-min
Tub
Depression
Other
Floor
Cushion type:
Other
(continued)
48
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Fig 1. continued
Wheelchair type:
Wheelchair mobility:
Manual (_ NA)
Spoke Guard Standard:
Smooth surfaces
Yellow = requires 1:1 supervision while mobilizing
II ramps
and while off unit
I curbs
Red 11 requires 1:1 supervision while mobilizing
Rough terrain
and while off unit.
stairs
Do not interrupt therapy.
On/off elevators
Opening/closing door
Power
Smooth surfaces
ramps
curb
Rough terrain
On/off elevators
Opening/closing door
Skin
Weight shift
Padding/positioning
Skin check
Shoe tolerance
Prone tolerance
hrs/min.
Spoke guards:
Y
N
Color
Fig 1. Section of C-6 tetraplegia CarePath, week 2, rehabilitation. DME = durable medical
equipment; IVP = intravenous pyelogram; IC = Intermittent catheterization; FIM = functional
independence measure. Reprinted with permission from the Shepherd Center, Inc, Atlanta, GA.
The team may also decide that a patient may
meaning, these are maintained separately.
be able to skip a phase if he or she is excelling
Examples of these supplemental documents
or revert to an acute phase based on medical
include the interdisciplinary evaluation tool,
necessity such as deep vein thrombosis.
consultative reports, graphics flow sheets,
and CarePath overlays. An overlay is an
Additional Design Considerations
enhancement to the CarePath that addresses
some routinely seen differences in patient
CarePaths are the treatment plan and the
presentation. For example, patients with in-
medical record. However, when there are
complete spinal cord injury would have a gait
required but cumbersome documents that, if
overlay, or a patient younger than eighteen
inserted into the CarePath, would dilute its
years old would have an adolescent overlay.
Carepaths
49
Process Improvement
solve imminent issues. Variance legiti-
mizes documentation by exception because
After the CarePath was developed, we
all exceptions are important and must be
wanted to discern if it was worth our efforts.
examined. It enables performance improve-
The medical/surgical CarePath system
ment by providing staff a yardstick against
implemented in September 1996 provided
which to measure typical performance. Vari-
valuable information to use in the spinal cord
ance management as part of performance im-
injury CarePath project. We established a
provement is an essential component in pro-
process improvement plan to evaluate our
viding outcome-based rehabilitation.
project and gathered baseline data related to
Schmidt has stated that outcome-based
length of stay and cost. We completed a staff
rehabilitation requires a shift in the way reha-
survey that included length of, time spent in
bilitation is conceptualized, organized, and
team conference, time spent completing
delivered. It requires clinicians to become
documentation (Figs 2 and 3), and satisfac-
'managers' of outcome in addition to being
tion with the current documentation system
'caregivers. ""3(p147) When clinicians concen-
(Figs 4 and 5). We established a monitoring
trate on providing outcomes, they are engaged
process whereby managers and supervisors
in patient-focused care. As clinicians seek to
perform chart reviews on individual clini-
rearrange processes and change practice pat-
cians and then give them feedback regarding
terns for patients' best interests, true institu-
their documentation. We held informal
tional improvements can be actualized.
meetings with staff to answer their questions
At Shepherd Center, we have realized
and participated in patient rounds and team
some concrete improvements with our new
conferences to assist staff in progressing
CarePath system in the 6 months that we have
from a reactive model to a proactive model.
been using it. The first immediate change that
occurred was a dramatic drop in the average
What is a Variance?
time spent in patient-team conferences.
Conference times decreased from average
For purposes of discussion with
times of 1 hour to 1½ hours down to 20 to 45
CarePaths, a variance is defined as any
minutes (Figs 2 and 3). Therapy and nursing
deviation from the pathway plan of care.
staff are reporting that their charting times
Why is variance important? Variance indi-
have been decreased by as much as two
vidualizes care concurrently. Regulating
thirds. Anecdotally, we have also observed
agencies such as the Joint Commission for
that physicians are redistributing their
the Accreditation of Healthcare Organiza-
"freed-up time" resulting from shortened
tions (Joint Commission) and the Commis-
patient-team conferences to spend in either
sion on Accreditation of Rehabilitation Fa-
patient rounds or in patient/family confer-
cilities (CARF) require that patient care
ences. The improved efficiency in patient-
show evidence of individualization, and
team conferences has proved to be a valuable
CarePath variances are a concrete method to
physician satisfier that is directly attributable
demonstrate individualization through ex-
to our CarePath system. Prior to CarePath
ception-based charting. Variance requires
implementation, the practice was for each
judgment and collaborative planning to re-
team member to individually meet with the
50
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
SCI Time Commitments: Therapy Group
Pre and Post CarePath Implementation
3.5
-
3
2.5
n=76%
n*80%
DPre CarePaths
.
2
3/97
n=80%
Post CarePaths -
Hours
n=48%
7/97
1.5
1
n=83%
=50%
0.5
0
Time Spent Documenting
Patient Progress
Time Spent in Team
Conference
Time Spent in Patient
Conference
Time Spent in Treatment
Planning
Distribution of Team
Reports
% participation
case management only
Fig 2. Spinal cord injury time commitments: therapy group. Pre- and post-CarePath implemen-
tation. Reprinted with permission from the Shepherd Center, Inc, Atlanta, GA.
SCI Time Commitments: Nurses
Pre and Post CarePath Implementation
3.5
3
2.5
Pre CarePaths
3/97
2
29%
n-52%
Post CarePaths
Hours
7/97
1.5
1
n=19%
n=71%
0.5
n=57%
n=57%
0
Time Spent Documenting
Patient Progress
Time Spent in Shift
Report
Time Spent in Team
Conference
Time Spent in Patient
Conference
Time Spentin Treatment
Planning
n % participation
Fig 3. Spinal cord injury time commitments: nurses. Pre- and post-CarePath implementation.
Reprinted with permission from the Shepherd Center, Inc, Atlanta, GA
Carepaths
51
SCI Documentation System Satisfaction: Therapy Group
Pre and Post CarePath Implementation
80%
70%
Pre CarePaths
3/97
Post CarePaths
60%
7/97
50%
40%
30%
20%
10%
0%
not satisfied
somewhat satisfied
satisfied
very satisfied
Fig 4. Spinal cord injury documentation system satisfaction: therapy group. Pre- and post-CarePath
implementation. Reprinted with permission from the Shepherd Center, Inc, Atlanta, GA.
patient and process only those components
start-up project such as CarePath can be
of the rehabilitation program germane to his
daunting to even the most experienced and
or her discipline. Because of the CarePath
progressive people in hospital administration.
document, all team members are informed of
A visionary leader is required who under-
a particular patient's goals and predicted
stands that the time commitments for a
level of functionality. The new format for
CarePath project are not only intense, but also
patient goal setting meetings has increased
progressive and longitudinal in nature and will
our proficiency, because one therapy repre-
have pervasive and profound institutional
sentative explains the entire program, indi-
impact. After committing to the time invest-
vidual objectives, and expected outcomes to
ment, the visionary leader must also provide
the patient in a one-to-one setting.
the financial resources necessary to ensure
that a major case management initiative such
as CarePaths will flourish. Once the new
A CarePath system such as we have devel-
documentation system is perfected on paper,
oped at Shepherd can be a valuable compo-
the project team and authorship teams that
nent of a case management system for reha-
produce CarePaths will have only scratched
bilitative medicine and catastrophic injury.
the surface, for there still looms the challenge
However, none of this can be realized without
of translating the paper system into an elec-
absolute commitment and unflagging support
tronic charting system. Translating the paper
from hospital administration and medical
product into an electronic system may require
staff. The time investments alone in doing a
18 to 24 months to be accomplished.4
52
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
SCI, Documentation System Satisfaction: Nurses
Pre and Post CarePath Implementation
80%
70%
Pre CarePaths
3/97
Post CarePaths
60%
7/97
50%
40%
30%
20%
10%
0%
not satisfied
somewhat satisfied
satisfied
very satisfied
Fig 5. Spinal cord injury documentation system satisfaction: nurses. Pre- and post-CarePath
implementation. Reprinted with permission from the Shepherd Center, Inc, Atlanta, GA.
Our ultimate goal for the integration of the
performance improvement plan. The col-
CarePaths will be achieved as the data gener-
laborative practice groups' focus will be to
ated by CarePaths is distributed to
promote optimal patient outcomes and op-
multidisciplinary collaborative practice
timal patient outcomes is what rehabilitation
groups as part of the hospital's continuous
services are all about.
REFERENCES
1. Shekim L. Critical pathways. Amer Speech
Oriented Rehabilitation: Principles, Strate-
Language Hearing Assn Quality Improvement
gies, and Tools for Effective Program Manage-
Dig. 1994;Fall:1-10.
ment. Gaithersburg, Md: Aspen Publishers;
2. The prognosis is for pathways: A study of
1995.
clinical path trends in health care. Healthcare
4. Zander K. Managing Outcomes through Col-
Sys Rev. 1996;29:48-54.
laborative Care. The Application of Care-
3. Schmidt ND. Preparing rehabilitation teams
Mapping and Case Management. Chicago, III:
for outcome-based rehabilitation. In: Landrum
American Hospital Publishing; 1995.
PK, Schmidt ND, McLean A, eds. Outcome-
Managed Care's Impact on Marketing
Catastrophic Rehabilitation Services
Mitchell J. Fillhaber
The purpose of this article is to provide an overview of the complex contracting environment that
rehabilitation providers are subject to across a variety of payer sources and to describe reimbursement
strategies, market evolution models, and the process for identifying and managing contractual accounts. Key
words: contracting, integrated delivery systems, managed care, market typology, Medicaid/Medicare,
proposals
A
LTHOUGH it is common for people
Over the last several years, there has been
to talk about managed care as if it
a dramatic shift toward the development of
had a single point of reference simi-
integrated delivery systems by acquisition or
lar to health care plans; in reality, however,
merger. In many cases these new hospital
managed care has become a complex series
alliances and their corporate structures have
of payer and provider adaptations designed
created a number of opportunities and threats
to achieve greater efficiency and negotiating
for rehabilitation providers and self-con-
leverage. What makes this transformation
tained units. If a multihospital system is large
truly interesting and challenging is the extent
enough, rehabilitation providers have had
to which it has affected all the referral chan-
the opportunity to become the rehabilitation
nels that rehabilitation programs have his-
asset for that system. Others have faced po-
torically relied on for patients.
tential exclusion, depending on the rehabili-
What's changed? General rehabilitation
tation capacity that member hospitals bring
hospitals and specialized facilities such as
to an alliance or merger. Of course, as mem-
Shepherd Center in Atlanta, Ga, have relied
ber hospitals reach the clinical consolidation
on referral relationships that have developed
phase of their system evolution, it becomes
over time with community hospitals. These
more difficult to rationalize the need for as
arrangements were primarily developed with
many outside providers.
social work or discharge planning staffs.
Rehabilitation hospitals adjacent or in close
Mitchell J. Fillhaber, MA, is Vice President, Market-
proximity to their feeder hospitals would
ing & Managed Care, Shepherd Center, Atlanta, Geor-
send members of their medical staffs and/or
gia.
clinical evaluators to assess appropriate pa-
Top Spinal Cord Inj Rehabil 1998;3(4):53-60
tients for admission.
© 1998 Aspen Publishers, Inc.
53
54
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Another fundamental change in the pro-
rehabilitation providers are generated by re-
vider community is the growing number of
lated efforts by states to create home- and
health systems and community hospitals that
community-based waivered services for brain
are pursuing health maintenance organiza-
injury patients and those with other cata-
tion (HMO) licensure; new provider-spon-
strophic diagnoses who are at risk for nursing
sored certifications that are now options in
home placement.
many states, including Georgia; or joint ven-
Through a variety of new bills aimed at
turing with managed care organizations. On
reforming Medicare, providers are also vy-
average, provider-sponsored health plans
ing for the opportunity to form provider-
have achieved more significant reductions in
sponsored organizations that will be allowed
utilization than their insurance company-
to compete directly with Medicare risk plans
based managed care counterparts and tend to
for Medicare enrollees. Under existing reim-
be somewhat more restrictive in network
bursement, Medicare risk plans are paid 95%
development unless the market (ie, employ-
of the adjusted average per capita cost
ers) demands more choice and flexibility.
(AAPCC) on a county-by-county basis, al-
Many of the new insurance vehicles created
though this is targeted for reform since
for providers have been designed to take
widely divergent rates have left some regions
advantage of state Medicaid managed care
of the country underpenetrated, while others
initiatives that are sweeping the country and
are rewarded for having high medical costs.
a variety of Medicare risk demonstration
Both Medicaid and Medicare managed care
sites created by the Health Care Financing
efforts have the potential to reduce provider
Administration (HCFA) to provide more
reimbursement by replacing fee-for-service
managed care options for seniors. Because
(cost-reimbursed) patients with those reim-
Medicaid continues to consume the largest
bursed at managed care fee schedules. Other
percentage of a state's budget, states are
payment reforms establish prospective pay-
counting on managed care initiatives to re-
ment systems for home health agencies,
duce costs and expand coverage to more
skilled nursing facilities, and rehabilitation
working poor and uninsured children.
programs through bundled payments or new
Although a small percentage of Medicaid
patient classification systems, such as func-
recipients are persons with disabilities, they
tional related groups (FRGs). Finally, from
may create as much as 40% to 50% of all
an insurer's perspective, provider integra-
Medicaid costs. States such as Massachusetts
tion has created more complexity in negotia-
have "carved out" persons with catastrophic
tions and greater concern over potential com-
disabilities from their general Medicaid man-
petition from provider systems.
aged care program and placed them in a highly
In addition to the structural changes that
specialized provider network called the Bos-
have altered relationships between rehabili-
ton Community Medical Group (BCMG) un-
tation providers and referring hospitals,
der significantly higher capitation rates than a
similar changes are occurring in workers'
commercial HMO would receive for its Aid to
compensation and the case management in-
Families with Dependent Children (AFDC)
dustry. Whether through legislatively man-
enrollees. Other opportunities for catastrophic
dated managed care programs (ie, in Geor-
Marketing Catastrophic Rehabilitation Services
55
gia, Ohio, and Florida) or through its own
leased or developed preferred provider net-
The National Business Coalition on
works, workers' compensation carriers and
Health estimates that there are more
other occupational health programs are mar-
than 100 employer coalitions across the
keting "managed care" approaches to self-
country currently purchasing health
insured employers, third-party administra-
care in behalf of their members.
tors, and industry buying groups. Networks
attempt to channel employees to providers
that are cost-effective and sensitive to return-
to-work concerns. States may provide pre-
mium credits as incentives to those employ-
account in developing contracting priorities.
ers who adopt workers' compensation
The National Business Coalition on Health
managed care programs in anticipation of
estimates that there are more than 100 em-
improved risk management practices and
ployer coalitions across the country currently
fewer lost-time claims. Administrative fees
purchasing health care in behalf of their
are generally taken as a percentage of savings
members. Organizational structures range
or through network access fees. Workers'
from simple group purchasing programs for
compensation managed care organizations
pharmaceutical or dental benefits to
(MCOs) have also affected the roles of many
voucher-type systems in which employees
independent case managers, a traditionally
can choose from a broad array of providers,
strong source of catastrophic referrals to re-
with premiums indexed to maximum em-
habilitation facilities, by incorporating case
ployer contributions, and, in smaller cities, to
management functions within their own
coalitions that may choose only one hospital
managed care programs. The field of case
provider based on a "best price" philosophy.
management itself has undergone significant
These employer coalitions and self-insured
consolidation, with national firms increasing
employers may also present enough critical
contractual ties to multistate employers and
mass for direct contracting, particularly in a
large workers' compensation carriers, and
24-hour coverage environment, when all
even purchasing their own network. We have
group health, workers' compensation, and
also seen the emergence of catastrophic
disability claims are merged into one man-
carve-outs, in which risk-taking middlemen
agement structure.
use contracted providers to meet outcome
The rehabilitation industry has also seen
predictions and other cost-effectiveness in-
physicians make strategic adjustments over
dicators guaranteed to workers' compensa-
the past decade. These developments include
tion payers.
the formation of contracting vehicles such as
As employers have attempted to gain con-
physician-hospital organizations (PHOs),
trol over health care costs and accentuate the
single specialty networks, and the vast in-
importance of outcomes in assessing hospital
crease in the acquisition or management of
and health plan performance, they, too, have
physician practices by hospital-owned medi-
developed new contracting structures that
cal service organizations and for-profit prac-
rehabilitation providers also need to take into
tice management companies.
56
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
In view of these changes, the next section
regional service area is to review publica-
of this article will be devoted to describing
tions from InterStudy, a managed care re-
how rehabilitation providers can develop a
search organization headquartered in St.
keener understanding of their managed care
Paul, Minnesota. In a 1996 monograph en-
marketplace and become more managed
titled, "The InterStudy Competitive Edge,"
care-friendly in their respective markets.
641 HMOs were surveyed to develop re-
gional market structure profiles for the nine
Develop an Understanding of Your
US Census-dependent geographic regions
Managed Care Marketplace
and metropolitan statistical areas (MSAs)
with a population greater than 50,000.2 In-
Assessment models
cluded in the market profiles are the numbers
Various models have been developed to
of HMOs in the MSAs, index of competition,
help assess the stage of managed care market
dominant rival ratio (rate of the number of
development. One of the most popular tools
dominant HMOs [≥33% of the market] to
first appeared in Hospitals & Health Net-
rival HMOs [≥10% but <33% of the market])
works in March 1995 and was developed by
and estimated enrollment and growth rates.
American Practice Management, Inc, a New
York firm, and the University Hospital Con-
Strategic planning
sortium, located in Oakbrook, III.¹ The model
uses a series of variables to classify markets
Beyond market typologies and access to
into four categories, referred to as stage 1
market research, rehabilitation providers
(unstructured), stage 2 (loose framework),
who are developing strategies for managed
stage 3 (consolidation), and stage 4
care contracting should be able to entertain
(hypercompetitive). Variables include HMO
alternative views of the future of health care
penetration, HMOs with fewer than 100,000
in their regional service areas through the
enrollees, hospital occupancy, commercial
strategic planning process and/or scenario-
HMO premiums, and the percentage of
based planning. The latter technique was
Medicare and Medicaid population in
developed by a number of management con-
HMOs. It is important to note that the transi-
sulting organizations for clients in industries
tion from one stage to another does not al-
undergoing turbulent changes. The specific
ways proceed in an orderly fashion or over a
technique called Future Mapping®, devel-
predictable period of time. Market dynamics
oped by Northeast Consulting Resources,
associated with each stage require different
Boston, Massachusetts, allows participants
pricing strategies and expectations with re-
to develop parallel views of the future ("end
gard to providers' abilities to manage risk
states") and develop contingency plans to
and achieve integration of all programs and
either reduce the chance of a particular end
services.
state occurring or formulate action steps to
take advantage of a particular end state. For
Publications review
example, rehabilitation providers with cata-
Another opportunity for rehabilitation
strophic capabilities may forecast that man-
providers to get a handle on their local and/or
aged care organizations in their service area
Marketing Catastrophic Rehabilitation Services
57
may (1) concentrate all business with one or
tion hospitals and self-contained units that
more integrated delivery systems, (2) carve
are a part of an integrated delivery system
out all catastrophic business to a center of
may also receive global capitation or per-
excellence, (3) use outcomes to drive all
cent-of-premium payments that add substan-
referrals, or (4) give exclusivity to for-profit
tial risk to the contractual relationship. De-
hospitals under a national contract. The fa-
spite all the interest in capitation and its
cilities planning team would then undergo a
growing popularity as a form of reimburse-
series of exercises to produce a list of events
ment with medical groups, fewer than 10% of
that led to each end state and rank the prob-
all hospitals report capitation as their pri-
ability of occurrence and the strategic actions
mary form of reimbursement.
the provider should take in response to these
After conducting some general research
end states.
to benchmark the quality attributes of reha-
To continue to make meaningful prepara-
bilitation programs most important to
tions for contracting efforts and further re-
health plans, providers can complete a
fine the fit between strategies and the envi-
"competitiveness" matrix during the inter-
ronment, it is important to ask payers directly
view process. Asking critical referral
about their contracting priorities, This means
sources to evaluate the relative importance
taking the opportunity to interview staff in
of the admissions process, outcomes, fam-
case management, network development,
ily mastery of caregiver skills, case man-
provider relations, marketing and sales, and
agement communication, transition back
finance to discuss what drives those particu-
home, and medical staff leadership will en-
lar functions and what quality attributes con-
able providers to enhance performance in
tribute most to making referrals to rehabilita-
areas that truly make a difference from a
tion programs. As a general rule, managed
contracting perspective and, at the same
care plans want to create networks that will
time, enable an evaluation of how competi-
have credibility with employers and the bro-
tors perform along the same dimensions. In
ker community and fulfill access and pricing
addition to collecting this information, hos-
requirements. The majority of health plans
pitals have created computerized plan pro-
are still contracting with hospitals on a per
files for all the managed care entities they
diem basis, with defined rates for medical,
contract with. This profile serves the inter-
surgical, critical care, behavioral health, and
ests of several departments, including fi-
rehabilitation, but there are any number of
nance, marketing, and case management.
reimbursement arrangements that providers
The sample profile, "Managed Care Con-
can consider. These alternatives include a
tracts" (Fig 1) demonstrates the range of
sliding scale discount on charges, which ties
potential information to be collected and
the discount to specific volume (days/admis-
updated. There is also a key interface be-
sion) projections; differential-by-day per di-
tween the facility's marketing and sales
ems, which front-load per diems to account
database and the plan profile, so all autho-
for higher acuity levels on admission; and
rized users can also be aware of all ongoing
package pricing, with or without profes-
contracts with the health plan, the profit-
sional services included. General rehabilita-
ability of the current contract, and the stra-
58
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Managed Care Contracts
Parent Organization
Contract Date
Address
Renewal Date
Current Enrollment
City
State
Zip
Medical Loss Ratio
Plans Billing Address
Phone
Fax
City
State
Zip
Catastrophic Rehab COE?
Billing Contact
Plan Location
Phone
Fax
HMO/PPO Products
Provider Network
Major Accounts
Products in Development
Payers Accessing Contract
Contract Contact
Phone
Title
Fax
Plan CEO
Phone
Description of
Competing Rehab Providers
Rehabilitation Benefits
Diagnosis-Related Specialty Networks
List of All
Current
Case Managers
Referral Preferences
CONTRACT OVERVIEW
Acute
Para
Quad
ABI
Trans Care
Day Hosp.
Durable Medical Equipment
Vent Add On
ICU Add On
O/P
MRI/CT
Exclusions
PHYSICIAN NETWORK
Representation Of Our Physicians In Plan
MDs Who Accept
# Primary/Speciality Physicians
Medicare/
Specific Groups Designated by Specialty
Medicaid
REFERRAL HISTORY
Program
FY 96
FY 97
FY 98
# Admits
Profitability
# Admits
Profitability
# Admits
Profitability
Inpatient:
SCI
ABI
ICU
Med/Surg
MS
Outpatient
Alternative Programs
Transitional Care
Day Program
Fig 1. Sample profile. CEO = chief executive officer; ICU = intensive care unit; MRI/CT =
magnetic resonance imaging/computed tomography; MD = doctor of medicine; FY = fiscal year;
ABI = acquired brain injury; Med/surg = medical/surgical; MS = multiple sclerosis.
Marketing Catastrophic Rehabilitation Services
59
tegic initiatives that are under way to en-
case managers (even theirs), and refer-
hance the relationship with the health plan.
ring hospitals
Whenever possible, outcome data that
Writing a proposal
would enable model system, uniform
data system, and other database com-
During the course of studying the man-
parisons
aged care dynamics of your service area and
Evidence of your own intent to create
specific payer network development phi-
networks for follow-up care for out-of-
losophies, you will begin to encounter issues
area patients and otherwise fill gaps in
that directly affect the scope and types of
your own continuum of service
rehabilitation agreements you will be able to
Description of all communication tools
negotiate. These issues include attempts by
you use to keep health plans informed
integrated delivery systems to negotiate ex-
about catastrophic cases (ie, team confer-
clusive contracts for all services, recognition
ence reports, plan-specific "report cards")
that pieces of the rehabilitation continuum
How you approach the coordination of
have already been "carved out" to other pro-
care, maintain family involvement, and
viders (eg, outpatient therapy, vent weaning,
provide information and referral re-
and community re-entry programs), relation-
sources and medical call center support
ships with capitated specialists that could
after discharge
intrude on your historical utilization of phy-
Services or support programs you can
sician consultants, increased pressure on
provide to plan members and corporate
price negotiations when a number of reha-
clients that will make you more a part-
bilitation options exist in a service area, and
ner than a vendor
increased use of subacute programs and
Pricing that reflects the true value of
long-term acute care hospitals by case man-
the services you are providing, with
agers looking to maximize the value of con-
some novel incentives built in for en-
tracts with lower cost settings. As part of the
rollee satisfaction, durability of out-
contract acquisition and renewal process,
comes, or other important indicators.
rehabilitation service providers need to dem-
To the extent that providers have
onstrate and create competitive advantages
strong medical, operations, and finan-
that will encourage health plans to build their
cial management, consideration
catastrophic delivery systems around the re-
should be given to types of reimburse-
habilitation facility. One of the best tools to
ment that are higher on the "risk lad-
accomplish this is a comprehensive proposal
der," including global rates similar to
that introduces the facility to the payers you
the bundled payment approach that
are interested in partnering with. Proposals
Medicare has experimented with for
should include the following:
open heart procedures and hip replace-
Overview of all services, particularly
ment surgery
those that may be unique or better per-
Hopefully, the proposal will create inter-
formed by your facility
est in pursuing a contractual relationship
Key survey evidence of preferences for
with your organization. You will need to
your facility by consumers, physicians,
prepare your negotiation strategy geared to
60
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
whether the payer is an integrated delivery
Postcontract support
system with insurance functions or a man-
aged care organization. I have experienced
negotiations that have taken several weeks to
The last aspect of contract administration
several years to conclude. Be prepared to
to consider is postcontract support, In all
justify pricing by identifying financial off-
likelihood, networks will continue to feature
sets produced by low complication rates and
multiple rehäbilitation options to provide
by demonstrating a willingness to admit un-
consumers with maximum choice, since re-
insured or patients with challenging dis-
strictive networks have not demonstrated
charge plans or to provide other value-added
expected cost savings. This means that pro-
services to patients or their caregivers. As-
viders who are interested in increasing mar-
sess the financial impact of rates received as
ket share must be willing to demonstrate
a counteroffer from the payer to determine if
superior service and have dedicated account
they meet your threshold for profitability.
teams assigned to specific payers.
REFERENCES
1. Hospitals & Health Networks. 1995;69:48.
2. The Interstudy Competitive Edge. St. Paul;
Minn: Interstudy Publications; 1996.
BIBLIOGRAPHY
Conrad D, Bonney R, Sachs M, Smith R. Managed
Grimm A, Wilk T. The Managed Care Contracting
Care Contracting: Concepts and Applications
Manual: A Strategic Guide to Maximizing Op-
for the Health Care Executive. Chicago, III:
portunities and Minimizing Risks. Alexandria,
Health Administrator Press; 1996.
Va: Capital Publications; 1994.
Fox PD, Fama T. Managed Care and Chronic III-
Kongstvedt PR. The Managed Health Care Hand-
ness: Challenges and Opportunities.
book. 3rd ed. Gaithersburg, Md: Aspen Publish-
Gaithersburg, Md: Aspen Publishers; 1996.
ers; 1996.
Outcomes in a Managed Care
Environment
Michael L. Jones and Randall W. Evans
Managed care represents an opportunity rather than a crisis with respect to the acute and chronic care needs
of people who have experienced catastrophic injuries. Opportunities exist to establish innovative payment
models incorporating risk-adjusted pricing, incentives for achieving and maintaining meaningful outcomes,
and "extended warranties" covering the durability of outcomes and treatment for preventable secondary
complications. These opportunities are predicated on the availability of valid, reliable, and widely accepted
measures for classifying patients according to severity of need and for documenting primary and secondary
outcomes. Functional status measures are suited to this dual purpose if supplemented with additional
measures focused on the impact of care as it affects the quality of life for those served. Key words: health care
payment systems, managed care, outcomes research in catastrophic injury, risk adjustment
I
N ANY discussion of managed care and
dramatic reduction in funding for postacute,
health-related services for people who
"transitional living" programs and services;
have experienced catastrophic injuries
and a corresponding increase in "secondary
(eg, traumatic brain and spinal cord injuries),
complications" and chronic care needs.¹
it is important to acknowledge the continuum
Managed care may have its most pro-
of care from trauma care to initial rehabilita-
nounced influence-and offer the greatest
tion efforts and long-term management of
opportunity for positive change-in the
disability-related health concerns. In the ma-
long-term management of chronic condi-
jority of casès, people experiencing cata-
tions following catastrophic injury. Survival
strophic injuries will have significant and
rates among individuals experiencing se-
permanent functional impairments, resulting
vere, debilitating illness and injury have
in lifelong, chronic care needs.
risen steadily thanks to technological ad-
Looking across this continuum, the influ-
vances in the American system of care. This,
ence of managed care has been less dramatic
in combination with other societal changes,
during the early stages of medical interven-
such as the aging US population (with asso-
tion for catastrophic injuries. To date at least,
ciated comorbidities), means that more and
access to emergency medical services fol-
lowing serious trauma has not been under the
influence of managed care "gatekeepers" (of
Michael L. Jones, PhD, is Director, Virginia C.
course, the availability of a Level I trauma
Crawford Research Institute, Shepherd Center, At-
center in a given service area is influenced
lanta, Georgia.
ultimately by reimbursement practices).
Randall W. Evans, PhD, is President and Chief Oper-
However, the influence farther "down-
ating Officer, Learning Services Corporation,
stream" is significant, as witnessed by a
Durham, North Carolina.
steady decrease in lengths of stay during the
Top Spinal Cord Inj Rehabil 1998;3(4):61-73
acute medical and rehabilitation phases; a
© 1998 Aspen Publishers, Inc.
61
62
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
more Americans are living extended lives
sions about the impact of managed care.
with chronic disease and disability.²
More troubling is the fact that this trend
Effective management of chronic care
actually means enhanced revenue potential
needs, however, is not the primary focus of
for our hospital, thanks to reimbursement
the current system of health care delivery and
practices focused on treatment of acute
reimbursement. The health care system in the
health needs rather than long-term manage-
US is predominantly geared to acute medical
ment of disability-related conditions. Most
care, with a focus on cure versus care, using
payers will reimburse the cure of skin sores,
approaches that treat the event and not the
although virtually no coverage is available
overall condition. Reimbursement prac-
for preventive care efforts.
tices-tied to the acute care paradigm-con-
Many of the services essential for manage-
tinue to focus on singular health events and
ment of chronic conditions, including sup-
component resource management around
portive care, rehabilitation, and prevention
those events, rather than on a more holistic
of secondary conditions, are nonmedical in
and long-term view of managing chronic
nature. Most elements of our current system
conditions.³,⁴
of care, including the allocation of resources,
A case in point is provided by the preven-
training of professionals, and incentives in-
tion and treatment of pressure ulcers second-
herent in its financing, are contradictory or at
ary to spinal cord injury. With aggressive
least out of sorts with these chronic care
management, early detection, and interven-
needs.4
tion, serious pressure sores can be prevented
Although most professionals in the reha-
in the vast majority of cases. However, as
bilitation field have been alarmed by both the
lengths of stay for initial rehabilitation have
speed and magnitude of managed care's im-
decreased in recent years, there has been a
pact on health care for people with disabili-
corresponding increase in the incidence of
ties, it is important to recognize this period of
pressure ulcers within 1 year of discharge.
dramatic change as a window of opportunity.
Fig 1 shows data reported for the Model SCI
We approach this article with the optimistic
Systems of Care concerning length of stay in
view that managed care will lead to a greater
initial rehabilitation and the percentage of
emphasis on the "value" derived from com-
patients who had an active pressure ulcer
prehensive management of both acute and
when they were seen for their 1-year
chronic care needs following catastrophic
postinjury follow-up examination. Length of
injury. With that in mind, the purpose of this
stay is reported since 1973 (the first year of
article is to examine the central role of out-
the Model SCI Systems of Care). Pressure
comes research in demonstrating the value of
ulcer information is available since 1986.
rehabilitation and long-term disability man-
Two trends are obvious: a steady decrease in
agement. We will discuss the selection of
length of stay, particularly since the late
data elements necessary for effective out-
1980s, and a steady increase in the preva-
comes research in managed care and the
lence of pressure ulcers. The correlation be-
importance of outcomes information in com-
tween length of stay and prevalence of pres-
paring performance among providers and
sure ulcers (r = -65, P < .025) is statistically
health plans, and will recommend outcomes-
reliable and supports our anecdotal impres-
based payment strategies for both acute reha-
Outcomes in a Managed Care Environment
63
Figure 1. Average Rehab Stay & Pressure Ulcers 1-yr Post-Injury
120
18
110
16
100
14
90
12
80
10
Rehab LOS
70
8
Percent of Patients w/ Ulcers
60
6
50
4
40
2
30
0
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
Fig 1. Average rehabilitation length of stay and incidence of pressure ulcers among patients seen
for examination 1 year after injury. Data are from participating rehabilitation centers in the Model
Spinal Cord Injury System of Care, reported to the National Spinal Cord Injury Statistical Center,
University of Alabama at Birmingham.
bilitation and long-term disability manage-
and disabilities, managed care will either
ment following catastrophic injury.
exclude these individuals from coverage or
greatly restrict access to services.
Defining Value
A central question in managed care is how
Kronick and colleagues point out that the
to obtain the greatest value for each health
managed care concept, if practiced with a
care dollar expended. The simplest way to
focus on achieving better health care out-
conceptualize value is the ratio of outcome to
comes as well as containing costs, has the
cost (V = O/C, where V = value, O = out-
ideal elements- of a health care system for
come, and C = cost). Historically, much of
people with chronic illness, disease, or dis-
the concern for value in managed care has
ability.⁵ These elements include coordina-
been cost driven. Regardless of differences
tion of services, including specialist care and
in outcomes or assuming that equivalent out-
a focus on wellness, preventive care, early
comes will be achieved from alternative
intervention, and greater self management of
treatments or providers, value has been de-
health needs. However, there are also legiti-
fined in managed care as lower cost: with no
mate concerns that managed care is really
difference in outcome (O) between alterna-
managed cost, and rather than improve
tive treatments or providers, decreasing cost
health care for people with chronic diseases
(C) produces a greater value (V).
64
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
The ability to document outcomes in the
What Outcomes are Important?
rehabilitation field has (or should have)
come of age to the point that we can now
From a clinical outcomes perspective, the
argue for comparison of differences in the
field of rehabilitation has enjoyed a long-
numerator as well as the denominator of this
standing, generally positive history. While
value equation. It is now possible to make
arguments could certainly be made that
performance comparisons among treatment
many effectiveness studies offer a relatively
alternatives or alternative providers with re-
narrow view of the person (ie, neurologic
spect to associated costs and outcomes. Ar-
status), recent studies are beginning to show
guably, we have reached consensus concern-
the relationship between current functional
ing what are considered important outcome
status and long-term outcome on more global
indicators. However, undeniably, continued
measures.⁸
refinement in outcome measurement, meth-
Outcome studies that focus solely on clini-
odology, and applications is needed. For ex-
cal effectiveness of various treatment ap-
ample, the Uniform Data System for Medical
proaches hold limited value to the payer of
Rehabilitation (UDS) is now used by over
services if the provider cannot reliably. pre-
550 rehabilitation programs throughout the
dict cost of current and future care as well. So
US.⁶ The UDS uses changes in the Func-
what are the important outcomes to demon-
tional Independence Measure (FIM) from
strate in judging the value of initial rehabili-
admission to discharge as a measure of effec-
tation and long-term disability management?
tiveness for programs. Participating provid-
Wilkerson presents a useful distinction be-
ers are compared to other providers in the
tween micro, meso, and macro levels of func-
region and nationally on their average FIM
tion as an organizing framework for identify-
change and length of stay (LOS) efficiency
ing rehabilitation outcomes.⁹ Micro-level
(an average derived from patient-specific
outcomes are the traditional clinical mea-
calculations of FIM change/length of stay)
sures of outcome and are familiar at least
for each impairment group. LOS is used as a
within each of the rehabilitation professions.
proxy measure of the cost of rehabilitation.⁷
Micro-level functions consist of the "build-
FIM change and LOS efficiency may be
ing blocks" of function, such as range of
appropriate measures of effectiveness and
motion, endurance, and standing balance.
subsequent value for initial rehabilitation but
Meso-level functions are the application of a
not for long-term disease/disability manage-
number of these micro-level functions-for
ment. In long-term management, the numera-
example, activities of daily living (bathing,
tor is not the degree of improvement, but
dressing) that require use of a combination of
rather the degree to which level of functioning
building blocks. The FIM provides a com-
is maintained over time, preferably measured
posite score of the important meso-level out-
at repeated intervals. In addition to the cost of
comes typically targeted in medical rehabili-
disability management efforts, the denomina-
tation. Macro-level functions require the
tor should reflect the cost savings resulting
accomplishment of many meso-level func-
from effective demand management (eg, pre-
tions. They include functions commonly re-
vention of secondary complications).
ferred to as "instrumental activities of daily
Outcomes in a Managed Care Environment
65
living" because they are instrumental in
rehabilitation is to permit patients to return
maintaining independence at home and in the
home or to the least restrictive (and least
community. Examples include homemak-
expensive) living setting possible. Once
ing, work, and shopping for goods and ser-
home, the objective of long-term disability
vices in the community.
management is to allow the patient to remain
In a similar vein, Batterham et al have
in the living setting of his or her choosing.
made a cogent argument for the identifica-
A second common objective of rehabilita-
tion and validation of macro indicators of
tion is to increase patients' independence and
long-term outcome to which rehabilitation
thus reduce the amount of assistance-paid
providers should be held accountable. 10 They
or unpaid-they need from others to com-
present as an example of a macro indicator
plete activities of daily living and ensure
the proportion of stroke patients who 1 year
their personal safety. A third desired goal of
after stroke are living at home and leaving
rehabilitation is to improve patients' health
their home at least twice weekly to pursue
status and reduce immediate medical care
activities of their own choosing. They sug-
needs by, for example, promoting better self-
gest the following criteria to guide empirical
care. The goal in long-term management is to
validation of macro indicators:
maintain health status, preventing or at least
Does the indicator represent an impor-
minimizing the impact of secondary compli-
tant element of quality of life for the
cations. A fourth goal of rehabilitation is to
population in question?
permit patients to resume the highest level of
What are the preconditions for attain-
productive activity possible, which gener-
ment of this indicator, and are they
ally is return to work or school. When this is
ameliorable to intervention?
not a realistic option, the goal is to maximize
Do people who meet the threshold indi-
independent and productive use of leisure
cator have demonstrably better quality
time so that patients can enjoy activities of
of life than those who do not?
their own choosing. Long-term disability
Is meeting the threshold indicator asso-
management should include the supports
ciated with future progress, or is failing
necessary to maintain optimal productivity
to meet it associated with likely deterio-
over the lifetime.
ration?
These macro indicators have face validity
In our own work in outcomes manage-
as outcomes of functional utility, based on
ment, we have identified four macro-level
their frequency of use in medical rehabilita-
indicators related to four primary domains of
tion outcomes studies. 16,17 Their consistent
patient functioning: living setting, need for
use also suggests that these variables can be
assistance, health status, and productive
reliably measured. Moreover, these vari-
activity. 11-15 Initial rehabilitation efforts
ables are judged to be important outcomes by
should focus on improving function in one or
clients, family members, and financial pro-
more of these domains. Maintenance of opti-
viders. 18 Unlike more clinically focused
mal functioning in these domains should also
measures of outcome, it is easy for everyone
be the goal of long-term disability manage-
to understand what it means to return home,
ment. For example, one common goal of
return to work, or require less assistance from
66
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
others. As a result, it is easier to align
ticularly important is in conducting formal
everyone's expectations about the antici-
cost-effectiveness analyses of different reha-
pated outcome of treatment.
bilitation or long-term management inter-
A third advantage to these macro-level
ventions. The use of standardized cost-effec-
outcomes is that each variable can be directly
tiveness analysis (CEA) methods has been
linked to costs. It is a straightforward process
recommended in epidemiologic research to
to calculate the cost of having to live in a
facilitate comparisons among different stud-
nursing home versus the cost of going home,
ies. 19-21 The traditional measure of effective-
the cost of treating secondary complications,
ness in health-related CEAs is life-years
the cost of care or supervision required from
gained as a result of an intervention. 19 How-
another person, and the cost of missed work.
ever, life-years gained does not provide an
By examining improvements in each of these
adequate assessment of improvements in the
functional domains resulting from rehabili-
quality of life associated with interventions,
tation, we can calculate the cost savings
such as rehabilitation and long-term disabil-
resulting from improved functioning and,
ity management, which improve morbidity if
therefore, the cost-effectiveness of care.
not mortality. 20 Investigators have developed
measurement strategies that permit calcula-
What About Patients' Satisfaction and
tion of health-related quality of life (HRQL)
Quality of Life?
associated with interventions. 22 These mea-
sures classify people into health states de-
As with any service industry, rehabilita-
fined on a continuum from least to most
tion professionals should place a high prior-
desirable. The most common measures are
ity on customer satisfaction, not only with the
preference-based and capture people's val-
structure and process, but also with the out-
ues for states of health or well-being. In
come of service delivery. Recently attention
general, health states are scaled from 0 (dead)
in outcomes research has turned to longer-
to 1 (optimal quality of life).
term and less direct benefits such as improve-
A preference-based system is useful for
ments in quality of life. These factors are
CEA in two respects. First, judgments about
definitely important outcomes of rehabilita-
desirable or undesirable outcomes are deter-
tion and perhaps the only outcomes that mat-
mined by the consumer-or, in the case of
ter ultimately. However, can providers be
rehabilitation outcomes, by the patient or
held directly accountable for improving the
family. Since the purpose of care is to im-
individual patient's quality of life, or is this a
prove and maintain function, it makes sense
hoped-for benefit of improved or maintained
that the consumers of care should be the
functional outcomes? Improved well-being
judges of what constitutes a better or worse
and satisfaction with quality of life may best
outcome and the relative magnitude of im-
be viewed as secondary or ultimate outcomes
proved function. 19
that derive from achievement of the primary
The second advantage of a preference-
or immediate outcomes of care: improved/
based system is that it makes it possible to
maintained functioning.
combine length of time health states are ex-
Where quality-of-life outcomes are par-
perienced with the perceived quality of that
Outcomes in a Managed Care Environment
67
Optimal Health 1.0
2. With
HEALTH RELATED QUALITY OF LIFE
1. Without
A
QUALITY ADJUSTED
LIFE YEARS
B
Dead 0.0
Death 1
Death
DURATION (Years)
Adapted from Gold, Patrick, Torrance et al. (1996)
Fig 2. Hypothetical comparison of QALYs. Adapted with permission from Gold MR, Patrick DL,
Torrance GW, et al. Identifying and valuing outcomes. Cost Effective Health Med. 1996;4:83-133.
time to create a common summary metric,
Comparing Performance
the quality-adjusted life-year (QALY).
QAL Ys can be used to estimate the effective-
One constant in the continuing evolution
ness of a particular intervention (versus no
of managed care has been the interest in
intervention) or to compare the effects of
comparative analyses of provider perfor-
different interventions. 23 For example, Fig 2
mance-from payers, consumers, and regu-
presents a hypothetical comparison of
latory bodies. Although historically com-
QALYs. Without a given intervention, an
parisons have largely been made on the basis
individual's health-related quality of life
of cost, there is growing interest, at least from
would deteriorate according to the lower
consumers and regulatory bodies, in com-
curve and the individual would die at time
parisons based on quality or value. Regula-
Death 1. With the intervention, the indi-
tory requirements for providers (Joint Com-
vidual would deteriorate more slowly, live
mission on Accreditation of Healthcare
longer, and die at Death 2. The area between
Organizations [Joint Commission]) and
the curves is the number of QALYs gained by
health plans (Health Care Financing Admin-
the intervention. Part A is the amount of
istration) now include participation in a
QALY gained due to quality improvements
shared database of performance indicators
(improved quality of life during the period of
from which benchmarks can be established
time the individual would have been alive
and comparisons made.
without the intervention). Part B is increased
For example, the Joint Commission will
QALY due to quantity improvements
require in 1998 that each accredited hospital
(amount of extended life adjusted by the
and long-term care organization enroll in at
quality of life).
least one approved performance measure-
68
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
ment system and select at least two standard-
ingly, most payment models include a stan-
ized, clinical performance indicators applied
dardized base reimbursement rate with ad-
to at least 20% of the patients served. By
justments to account for differences in case
April 1999, each accredited provider must
mix, geographic area, and other variables
submit (through the approved performance
associated with higher costs.
measurement system) third quarter 1998 data
Diagnosis related groups (DRGs) have
to the Joint Commission. The National Cen-
been used since 1983 to set prospective pay-
ter for Quality Assurance (NCQA) has estab-
ment rates for Medicare, but rehabilitation
lished the Health Plan Employer Data and
has been exempted from this process. Studies
Information Set (HEDIS 3.0), a tool used by
suggest that patient diagnosis (used to estab-
health maintenance organizations to issue
lish DRGs) is not a good predictor of reha-
quality-of-care report cards. Using its Qual-
bilitation costs. On the other hand, severity of
ity Compass database, NCQA also makes
impairment and functional status upon ad-
comparative information available, through
mission are strongly associated with reha-
its web site, about managed care plans that
bilitation LOS and resource utilization. 24,25
provide care to more than 28 million people.
There is considerable support for and several
The mandate for comparative value analy-
models proposed to establish functional re-
sis increases the need for uniformity in out-
lated groups (FRGs) for risk adjustment in
comes measurement. With growing interest
rehabilitation. Instead of being based on di-
in comparisons, variations in case mix must
agnosis, FRGs are based on a functional
also be accounted for, since not all patients
assessment measure administered at pro-
within a particular diagnostic category are
gram admission.
equal. ("Sure provider X's outcomes are bet-
Although FRGs could be established from
ter-or costs are lower-than mine, but
any standardized and widely used functional
that's because we deal with only the most
assessment measure, 26 the FIM-based FRG is
difficult cases.")
most likely to become the industry standard.
Using data reported to the UDS from ap-
Risk Adjustment Based on Functional
proximately 37,000 rehabilitation patients,
Assessment
Stineman and colleagues developed 53 FIM-
FRGs and demonstrated their utility in pre-
Standard managed care payment models
dicting rehabilitation LOS.⁷ The FRGs were
base capitation or prospective payment
derived from three variables included in the
(case) rates on the average cost for a group of
UDS database: patient age, diagnosis leading
enrollees, with the assumption that the pro-
to disability (impairment code), and func-
vider or health plan will make money on each
tional status (motor and cognitive FIM
patient whose costs are below the average
scores) at program admission. FRGs were
and lose money on those whose costs are
developed for each of 18 rehabilitation im-
above the average. Without some mecha-
pairment categories (RICs), which are deter-
nism for risk adjustment, the provider who
mined from the diagnosis leading to disabil-
serves a disproportionate number of more
ity. For example, traumatic spinal cord
severely impaired and higher-cost patients
dysfunction is one RIC with five FRGs, each
will suffer greater financial risk. Accord-
based on a range of motor FIM scores.
Outcomes in a Managed Care Environment
69
Stineman and colleagues found that the FIM-
average. Accordingly, SC had a substantially
FRGs accounted for 32% of the variance in
lower LOS efficiency ratio, suggesting a
LOS among patients in the model-building
lower value than other providers nationally.
sample; diagnosis leading to disability ex-
The second section of Table 1 compares
plained only 14% of the variance in LOS.⁷
results for all patients with traumatic spinal
For purposes of risk adjustment the FIM-
cord dysfunction. Forty-nine percent of SC
FRG system is perfectly acceptable and has
patients are in this RIC, compared with only
the advantage of administrative simplicity
2% of the national samples. The admit FIM
since it is currently the most widely used
suggests that SC patients in this RIC are, on
functional status measure.²⁷ However, it is
average, more functionally impaired; FIM
important to acknowledge the limitations of
change differences suggest that SC patients,
FIM as an outcome measure (eg, ceiling ef-
on average, achieve greater gains and are
fects with certain patient populations, not sen-
discharged at about the same level of func-
sitive to functional gains with other popula-
tioning as other patients in this RIC. LOSs
tions, and micro-level versus macro-level
are comparable, but because of the greater
indicators of function). Although useful for
FIM change, the FIM efficiency ratio for SC
comparative purposes and necessary for FRG
is higher than the national average for pa-
risk adjustment, the FIM is not sufficient as an
tients with traumatic spinal cord dysfunc-
outcome measure in rehabilitation.
tions. Table 1 also shows that a greater pro-
In addition to its use in a payment system,
portion (93%) of SC patients in this RIC
risk adjustment of outcomes information is
are discharged to the community, compared
important so that fair comparisons can be
with the national (81%) average.
made among providers with respect to qual-
Although fairer comparisons can be made
ity and value. An example is provided from
by examining only those patients within a
Shepherd Center's UDS report for fiscal year
particular RIC, this categorization alone
1996 (April 1, 1996 through March 31,
does not fully adjust the case mix. The lower
1997). Table 1 presents the FIM and LOS
portion of Table 1 shows that SC has a
information reported by Shepherd Center
significantly higher percentage of patients
(SC) and 550 rehabilitation programs nation-
within this RIC with complete spinal cord
ally. Data are from 310 SC, and 223,339
lesions (54% versus 31% nationally) and a
national first-time rehabilitation admissions.
greater proportion of higher level complete
The first section of Table 1 includes all
injuries (29% C1-C8 versus 14% nation-
admissions and shows an average admit FIM
ally).
of 50.3 for SC, and 73 for the nation, suggest-
ing that SC patients are significantly more
Risk-Adjusted and Outcomes-Based
impaired functionally at admission. This is
Payment Systems
no surprise since SC specializes in treatment
of catastrophic injuries. Shepherd patients
A risk-adjusted payment system is needed
showed greater average FIM gain from ad-
to avoid penalizing the provider who is re-
mission to discharge (9 points higher than the
sponsive to the needs of more severely im-
nation) but also had longer average LOS,
paired patients and therefore attracts a
almost two weeks higher than the national
greater proportion of more costly cases.
70
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Table 1. Comparisons of Shepherd Center and national UDS data for 1996
Shepherd Center
Nation (550)
All first time rehabilitation admissions
N
310
223,339
Admit FIM
50.3
73
FIM change
32.6
23.0
LOS
31
18
LOS efficiency
1.32
1.76
Discharged to community
90%
81%
Traumatic spinal cord injury RIC (rehab impairment category)
N
(49%) 151
(2%) 4,321
Admit FIM
54.4
63.6
FIM change
29.1
25.3
LOS
31
35
LOS efficiency
1.24
1.18
Discharged to community
93%
81%
Complete C1-C4
14
177
Complete C5-C8
30
413
Complete paraplegia
37
741
Percentage of total SCI
(54%) 81
(31%) 1,331
Compiled from FY 1996 Uniform Data System for Medical Rehabilitation. Buffalo, NY: State University of New York at Buffalo,
School of Medicine & Biomedical Sciences; 1997; 11(1).
However, if risk adjustment is based solely
would be shared annually among providers
on differences in case mix, there are no
who meet or exceed predesignated, case
incentives for the provider to maximize func-
mix-adjusted, facility-wide outcomes.
tional outcomes over the long term. Without
Another alternative payment strategy that
some modification in the payment scheme,
would provide an incentive to providers to
such as payment for reaching an agreed-on
achieve and maintain optimal functional out-
FIM change at patient discharge or a desig-
comes during acute rehabilitation is the 2- or
nated follow-up interval, the provider is not
5-year "extended warranty" on outcomes
directly rewarded for patient outcomes and
and preventable, secondary complications.
has no incentive to continue treatment until
In this approach, the provider and payer
patients achieve optimal functional status. 28
negotiate an FRG-adjusted case rate that
Sutton, DeJong, and Wilkerson proposed
covers both initial rehabilitation and disabil-
an innovative approach of linking reimburse-
ity management for 2 to 5 years after injury.
ment to outcomes by withholding a fixed
Under such a scenario (and with shared risk
proportion of the standard FRG-based pay-
agreements for certain unforeseen complica-
ment and reserving that amount in a regional
tions), the payer is compelled to achieve the
or national "quality of care" pool. 27 The pool
best possible functional outcome for the pa-
Outcomes in a Managed Care Environment
71
tient, because greater independence reduces
Predicting and managing risk in complex
the resources needed for long-term manage-
medical cases are business cornerstones of
ment. This extended warranty arrangement
Paradigm Health Corporation.²⁹ Paradigm, a
also encourages optimal cost-effectiveness
company that initially focused on managing
in health services delivery, which in most
cases involving catastrophic injuries, con-
cases will translate into a faster return, to the
tracts with rehabilitation providers in a
home and community setting as the venue for
shared risk partnership. In this model, after a
rehabilitation. With the need to balance re-
service provider has undergone an extensive
source utilization and expected benefits, pro-
preferred provider approval process, Para-
viders are more likely to make placement
digm and the service provider collaborate on
decisions, based on cost and effectiveness,
a rehabilitation plan that facilitates achieving
not just cost savings. 27 For certain conditions,
the following goals:
such as traumatic brain injury, in which func-
Change of system focus from technical
tional gains do not always progress at the
clinical processes to meaningful func-
same pace, this arrangement would permit
tional patient outcomes
the provider to discharge the patient home or
Change care delivery from generalist
to a group care setting during "plateaus" in
providers to specialist providers
functioning and re-intensify rehabilitation
Change the basis of decision making
once the patient "clears" sufficiently to ben-
from art to science-from dependence
efit from the effort.
on individuals who rely on their own
Moreover, the provider has a strong incen-
clinical experience (art) to decision
tive to minimize preventable secondary com-
making based on large volumes of
plications (eg, pressure ulcers), because the
meaningful data (science).
cost of treatment is significantly higher than
Change the nature of the working rela-
the cost of prevention (which can be covered
tionship between providers and payers
under the global case rate). Maximizing the
from adversarial to collaborative.
durability of outcomes also becomes an im-
Paradigm engages the service provider to
portant priority, because the provider bears
assume a specified amount of financial risk
the responsibility and the cost for rehabilita-
while attempting to produce a mutually
tion "upgrades."
agreed on outcome vis à vis a "risk corridor."
This system of reimbursement would con-
By assigning each patient a "clinical com-
tribute to greater coordination across the care
plexity score," Paradigm and the service pro-
continuum and better integrated care for both
vider develop functional outcome levels
the acute and chronic needs of those who
relative to the clinical characteristics of the
have experienced catastrophic injuries. The
case and the relatedness of each case to
benefits of coordinated services would far
Paradigm's database. These outcome levels
outweigh the costs of poor outcomes. With
are continuously reviewed and amended
the opportunity to focus on comprehensive
based on the patient's progress (or lack
management of both acute and chronic
thereof).
health needs, this integrated system would
Paradigm literature also supports a "case
likely reduce the cost of both initial rehabili-
rate" approach to service delivery based on
tation and long-term support.
the statistical profiling methods. Paradigm
72
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
presents an argument that case rate àp-
and widely accepted measures for classify-
proaches can be supported only by a large
ing patients according to severity of need,
database, which solidifies the validity of
whether acute or chronic, and for document-
short- and long-term outcome projections. A
ing primary and secondary outcomes. Func-
similar approach is being developed for non-
tional status measures are suited to this dual
neurologic catastrophic conditions, includ-
purpose if supplemented with additional
ing burns, premature births, and multiple
measures focused on the impact of care on
trauma.
the quality of life of the persons served.
The critical element currently missing is
meaningful dialogue between providers and
The managed care revolution represents
(public and private) managed care entities
an opportunity to change the overall ap-
about our shared obligations to the acute and
proach to addressing the acute and chronic
long-term care needs of people with disabili-
care needs of people who have experienced
ties. 30 Until financial providers show genuine
catastrophic injuries, resulting in greater in-
and consistent interests in working with ser-
tegration between "upstream" and "down-
vice providers not only in discussing price
stream" providers. As managed care moves
points, but also in developing algorithms,
closer to true shared risk agreements (ie, for
care paths, and disability management proto-
both costs and results) between payers and
cols, outcome statistics will be discounted. It
providers, opportunities exist to establish
is equally incumbent on service providers to
innovative payment models incorporating
conduct outcome research that has clear and
risk-adjusted pricing, incentives for achiev-
meaningful relevance to all consumers of
ing and maintaining primary and secondary
services, payers and patients alike. On some
outcomes, and "extended warranties" cover-
level, the payer community has a valid argu-
ing the durability of outcomes and treatment
ment in that most rehabilitation studies fall
for preventable secondary complications.
short of making, long-term, financially ori-
These opportunities are predicated on the
ented conclusions about the value-added
availability of valid, reliable, standardized,
contribution of the rehabilitation effort.
REFERENCES
1. Annual Report for the Model Spinal Cord
Challenge. Princeton, NJ: Robert Wood
Injury Care Systems. Birmingham, Ala: Na-
Johnson Foundation; August 1996.
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5. Kronick R, Zhou Z, Dreyfus T. Making risk
1996.
adjustment work for everyone. Inquiry.
2. Jones ML, Sanford JA. People with mobility
1995;32:41-55.
impairments in the United States today and in
6. Uniform Data System for Medical Rehabilita-
2010. Assist Technol. 1996;8:43-53.
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3. Dixon TP. Rehabilitation across the con-
at Buffalo, School of Medicine and Biomedical
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Med Rehabil. 1997;78:115-119.
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4. Chronic Care in America: A 21st Century
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al. Four methods for characterizing disability
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medicine. JAMA. 1996;276:1,172-1,177.
Arch Phys Med Rehabil. 1994;75:1277-1283.
20. Weinstein MC, Siegel JE, Gold MR, et al.
8. Corrigan JD, Smith-Knapp K, Granger CV.
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Validity of the Functional Independence Mea-
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Arch Phys Med Rehabil. 1997;78:828-834.
21. Siegel JE, Weinstein MC, Russell LB, et al.
9. Wilkerson DL. Level of function as an organiz-
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22. Ware JE, Sherbourne CD. The MOS 36-Item
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Short-Form Health Survey (SF-36): Conceptual
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23. Gold MR, Patrick DL, Torrance, et al. Identify-
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Health Med. 1996;4:83-133.
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24. Hosek S, Kane R, Carney M, et al. Charges and
tem for post-acute rehabilitation programs. J
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Insurance Med. 1991;23:192-196.
for the prospective payment system. Santa
12. Jones ML, Evans RW. Outcome validation in
Monica, Calif: RAND; 1986.
post-acute rehabilitation: Trends and corre-
25. McGinnis G, Osberg S DeJong G, Seward M,
lates in treatment and outcome. / Insurance
Branch L. Predicting charges. for inpatient
Med. 1992;24:186-192.
medical rehabilitation services using severity,
13. Program Evaluation System. Raleigh, NC:
DRG, age, and function. Am / Public Health.
Wake Rehabilitation Institute; 1992.
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14. Shepherd Center Outcomes Research System.
26. Fisher WP, Harvey RF, Taylor P, Kilgore KM,
Atlanta, Ga: Shepherd Center; 1.996.
Kelly CK. Rehabits: A common language of
15. Evans RW. Postacute neurorehabilitation:
functional. assessment. Arch Phys Med
Roles and responsibilities within a national
Rehabil. 1995;76:113-122.
information systèm. Arch Phys Med Rehabil.
27. Sutton JP, Dejong G, Wilkerson DL. Function-
1997;78:SC-001-SC-009
based payment model for inpatient medical
16. Evans RW, Ruff RM. Outcome and value: A
rehabilitation: An evaluation. Arch Phys Med
perspective on rehabilitation outcomes
Rehabil. 1996;77:693-701.
achieved in acquired brain injury. / Head
28. Wilkerson DL, Batavia AI, DeJong G. Use of
Trauma Rehabil. 1992;7:24-36.
functional status measures for payment of
17. Jones ML, Evans RW. Outcome validation
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Med Rehabil. 1992;73:111-120.
The Shortest Distance: The Pursuit of Indepen-
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30. Cervelli L. The missing link: structured dia-
18. Jones ML, Evans RW. Rating outcomes in post-
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19. Russell LB, Gold MR, Siegel JE, et al. The roles
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Accreditation and Managed Care:
Partnering for Success
Christine M. MacDonell
The new health care environment means the delivery of value-driven rehabilitation is paramount for
providers. The necessity for rehabilitation providers to be willing and able to disclose the outcomes of their
services and programs and to be accountable for such programs will mean survival for many. Refusal to share
information is no longer viewed as acceptable or wise behavior for any provider of health care. The public
and payer community are demanding that leaders in all health care arenas assume the role of proactive
leadership and begin the task of disclosing information about outcomes and the value of their services. Key
words: accountability, accreditation, collaboration, leadership, managed care, outcomes, value
HE DELIVERY of health care has
will be spent. One would hope that account-
T
changed dramatically in the past 10
ability and responsibility are key in all of
years. Partners within the health
these decisions. Accountability can be de-
care industry-people who receive services,
fined as the requirement for providers of care
people who provide services, people who
to document the results of their programs and
pay for services, and organizations that ac-
to allow consumers, purchasers, and payers
credit-have had to take an introspective
access to this outcome information so they
look at their missions and core values. When
can make wise decisions about where their
an environment is in flux, there are many
health care dollars belong. Many may feel
excellent ways to deal with the opportunities
that this disclosure on performance is a new
presented during the change process. Unfor-
concept.
tunately, there are just as many challenges
What key components of managed care
that may cloud one's perception of the posi-
are positive influences for providers of reha-
tive aspect of the changes. Many in health
bilitation? If we look at the reaction of pro-
care felt that the trends seen in California,
viders to managed care, we see that providers
Minnesota, and Oregon more than 10 years
are now managing their risks, money, data,
ago were fads that had no staying power.
time, and staffs. This is a positive move,
Many believed that the way to deliver re-
since many in the rehabilitation industry fo-
habilitation services had been perfected and
that the "goodness" of providers and having
as many services as possible were the hall-
Christine M. MacDonell, is National Director, Medi-
marks of quality.
cal Rehabilitation Division, The Rehabilitation Ac-
The reality is that in every arena of the
creditation Commission, Tucson, Arizona.
health care industry, important decisions are
Top Spinal Cord Inj Rehabil 1998;3(4):74-79
being made about where health care dollars
© 1998 Aspen Publishers, Inc.
74
Accreditation and Managed Care
75
cused not on the issues of value, access, and
service delivery, but on the "quality" of their
A collaborative approach among all
services; the amount of space, equipment, or
stakeholders is vital to the effective and
materials they provided; and the prestige of
efficient delivery of rehabilitation
past accolades.
services in a managed care
The health care delivery system is one
environment.
where consumers are the focus and their
concerns about access, quality, service, and
value are being heard. For providers, this
Darling, a health benefits executive at the
means that the days of guessing at results of
Xerox Corporation. "I get rave reviews about
services are gone; performance results must
it." The article also stated that in Minneapo-
be validated. The expectations are that there
lis, Minn, where HMOs are firmly en-
will be high-quality practitioners and provid-
trenched, Medica Health Plans says it has
ers, that accountability will supersede au-
seen no substantive difference in costs or
tonomy, and expectations of outcomes will
frequency of visits to hospitals and physi-
be aligned among the patient, family, physi-
cians between plans that have gatekeepers
cians, clinical providers and the health plan.¹
and plans that do not. This information is
Another trend that is important to mention
good news for providers, who have weighed
in a positive light is that managed care ap-
consumer education about these issues as an
pears to be growing up. The February 2,
important part of the rehabilitation care pro-
1997, edition of the Wall Street Journal con-
vided.
tained an article about health maintenance
Another positive component of managed
organizations (HMOs) loosening the rules on
care for rehabilitation is that the field has had
referrals to specialists. The article stated that
to adopt qualities long used in the private
"Health maintenance organizations origi-
sector, relying on the value of performance.
nally installed gatekeepers, a concept popu-
The outcome performance trends will not be
larized by the U.S. Healthcare Corporation in
going away, nor will the rapid access of
the early 1980s, to save money and to im-
medical information to the consumer.
prove care. The idea was to reduce the num-
Telemedicine, rapid access to information,
ber of unnecessary consultations with spe-
and a more educated consumer have de-
cialists, as well as the accompanying
creased the number of procedures and visits.
procedures and tests, and to raise the quality
Educated consumers are also being held ac-
of care by coordinating the actions of various
countable for more of their own health and
doctors."2 The article went on to say that
for the prevention side of care.³
"Blue Shield of California said that com-
There must be recognition of certain facts
plaints about access to specialists fell 30%
when discussing managed care and reha-
after it introduced a plan last summer that
bilitation. First, managed care is here to
permits members to go directly to doctors in
stay. Second, a collaborative approach
certain high-demand fields."2 "Our most
among all stakeholders is vital to the effec-
popular model in Connecticut is an HMO
tive and efficient delivery of rehabilitation
that doesn't have gatekeepers," said Helen
services in a managed care environment.
76
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
Third, a common language is necessary to
1 and 2 while controlling costs. This
facilitate dialogue and exchange of ideas
involves making savvy business deci-
with stakeholders. With these thoughts in
sions for providers and payers alike.
mind, the Commission on Accreditation of
4. Accountability. All stakeholders con-
Rehabilitation Facilities (CARF) hosted a
curred that their behavior was moti-
Quality Forum in November 1996. The fo-
vated by the entities to which they
rum was a 2-day session conducted with
were accountable. Successfully achiev-
stakeholders to promote rehabilitation in a
ing accountability involves skillful ne-
managed care environment. It was a time for
gotiation and communication among
all parties-providers, consumers, policy
all parties involved.
makers, purchasers, payers, and accrediting
In the Quality Forum the key issues iden-
bodies-to sit in the same room, around the
tified and agreed on have been used in the
same table, putting their agendas aside to
development and revision of standards and in
arrive at a "reasoned consensus" on the
the work of the Commission on Performance
issues and concerns important to all rel-
Indicators. The 10 consensus issues are as
evant stakeholders. There is a need to accel-
follows:
erate integration and alignment of medical
1. The promise of managed care (quality
rehabilitation for it to be successful in the
care delivered efficiently and effec-
new health care environment. Gregory L.
tively) is yet to be realized.
Thomsen, Chair of the CARF Board of
2. A new definition of "customized" care
Trustees, stated in his opening remarks that
needs to be agreed on. Such agreement
"Never before in history has there been the
must convey that care is suited to the
need for the kind of partnership to talk about
individual's needs, that the process is
quality issues and outcomes-it is impera-
cost-effective, and that providers are
tive that we come to consensus about what
accountable for outcomes. It must also
that means."⁴
be understood that there are limits to
Out of the Quality Forum came a listing of
the resources available to achieve these
four common incentives for all stakeholders.
results.
Also there was consensus on the develop-
3. Attention is shifting from a discussion
ment of 10 key issues for all stakeholders.
of quality to a discussion of value.
This information has been used in the devel-
4. The definition of "customer" must be
opment and revision of CARF standards,
more broadly defined to reflect pur-
since accreditation is one of the tools of
chasers as well as patients. Expecta-
accountability that many now require as a
tions for outcomes and return on in-
beginning level of accountability.
vestment should be realistically estab-
The four common incentives that motivate
lished and achieved.
the behavior of stakeholders are as follows:
5. Focus should be on function rather than
1. High-quality, appropriate care for each
impairment. Function may also be
person served
termed productivity. They all are look-
2. Improved functional outcomes
ing at self-care, work, and life roles.
3. Securing adequate resources to achieve
6. There is value in the collaborative,
Accreditation and Managed Care
77
team approach of medical rehabilita-
the language of CARF standards. There is a
tion. The establishment of these teams
new look at the leadership of the organiza-
should be cost-effective and selec-
tion and its responsibility for accountability
tive. The selection of team members
on all levels of the organization. For the first
should be outcome-driven, not pro-
time, organizations will also be defining
cess-driven.
their core values, the essential and enduring
7. There is value in the full continuum of
tenets of the organization. These are a small
care, not just episodic catastrophic care.
set of timeless, guiding principles that re-
8. There is common concern among all
quire no external justifications. They have
stakeholders regarding payment for
intrinsic value and importance to those in-
care that has no evidentiary effect.
side the organization.
9. Change can be effectively managed
Leadership is defined as creating and
through effective communication and
sustaining a focus on the person served, the
unbiased education of all stakeholders.
core values and mission, and the pursuit of
10. The concept of "shared control" is
organizational and programmatic perfor-
agreed on by all stakeholders.
mance excellence. Leadership is respon-
sible for integrating core values and perfor-
Necessary Shifts
mance expectations into the organization's
management system. Leadership promotes
From adversaries to partners
and advocates for both the organization's
What shifts must occur for these issues to
and the community's commitment to people
be addressed and for a new generation of
with disabilities.
medical rehabilitation to emerge? The first
shift must be a change in attitude from
From process orientation to outcomes
orientation
adversaries to partners, and a recognition
that no one party will be able to have full
The second shift is from process orienta-
control. Performance by all stakeholders
tion to outcomes orientation. CARF has of-
will be a natural part of doing business. All
ten been seen as process-oriented rather than
stakeholders must stop guessing and start
outcome- or performance-oriented. The
validating their outcomes. Randall W.
CARF Board of Trustees, in their Strategic
Evans, President/Chief Operating Officer
Outcome Initiative; NCQA's HEDIS 3.0;
of Learning Services Corporation, has
and the Joint Commission on Accreditation
stated, "We have been able to work in part-
of Healthcare Organizations' ORYX-project
nership with (a health plan) to devise mod-
all indicate that the accreditation business is
els of care which are both clinically and
moving toward systems. that will address
fiscally responsible. It has taken a lot of give
performance and predictors of outcome. In a
and take by us as providers to be more
recent Performance Indicator conference
efficient. We have positively influenced
held in July 1997 by CARF, leading stake-
length of stay and we have proved that
holders of medical rehabilitation identified
rehab works. "5(p4)
the top three performance indicators for per-
In 1998 this shift will become apparent in
sons served, providers, policy makers, pur-
78
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
chasers, and payers as (1) cost of care, (2)
selectively in order to achieve the appropriate
durability of outcomes, and (3) productivity
functional outcome. Jim Braun, CEO of the
(work, home, and school). Ruth Brannon,
Employee Division of United Health Care,
Director of Managed Disability for the
stated, "When we see others who would short-
Washington Business Group on Health,
cut appropriate quality care in return for short-
commented that as purchasers, they are not
term gains, it is a bad business decision. It is a
concerned about the process. They want the
bad human decision. We're seeing emerge
outcome. How well is that employee func-
slowly an evolution in the industry."
tioning after rehabilitation? Is return to work
possible? How much did it cost?6
Consumers: From passive recipients to
From cost orientation to a discussion of
active participants
value
The last shift will be from the consumer as
The third shift is from cost orientation to a
a passive recipient to the consumer as an
discussion of value. Redefining this orienta-
active participant in care, including the selec-
tion toward value reflects a shift in philosophy
tion of benefits and providers. Regina
and in accountability. In evolution it is said
Herzlinger, in a recent book entitled, Market-
that true adaptability is demonstrated by an
Driven Health Care: Who Wins, Who Loses
organism's ability to change in response to
in the Transformation of America's Largest
dramatic changes in the environment. It is not
Service Industry, said that consumers have
only the ability to change that is important, but
become increasingly demanding and well
also the ability to change in a fashion that
educated.⁸ This trend is unstoppable. Con-
increases the likelihood of future success.
sumers want choice, service, and healthy
outcomes. They want information. Many
From a benefit-driven decision-making
have become better educated through the
process to patient-centered use of benefits
widespread use of the Internet for education
on health issues.
The fourth shift will be from a benefit-
The new 1998 CARF Comprehensive In-
driven decision-making process to patient-
tegrated Inpatient Rehabilitation Programs
centered use of benefits. Often the defined
will be required to publicly disclose, prior to
health or disability benefit has been used to
admission or at time of admission, the diag-
dictate treatment. This makes little sense, ei-
nostic categories served, the numbers of per-
ther medically or financially. In the new
sons served per diagnostic category within a
method of delivery of rehabilitation care, ben-
stated time frame, average hours of treatment
efits would be made available in a customized
per day, disposition at discharge, satisfaction
and standardized way to all consumers when
of persons served with the services received,
medical necessity dictates. Both opportunities
and any other information that a consumer
and obstacles would be assessed and the plan
may request.
of care modified to meet specific goals. Ser-
In looking at the challenges that are ahead
vices would be case-managed and available
for rehabilitation providers, there are many
Accreditation and Managed Care
79
approaches one may take. Donald Galvin,
habilitation services. As Kenneth Parsons,
President and CEO of CARF, has stated that
Medical Director, The Texas Institute for
providers face a Kubler-Ross-like syndrome
Rehabilitation and Research, has said, "We
in today's marketplace, with providers dem-
must be better prepared for the future than we
onstrating classic examples of the stages of
were for the past. "10
denial, anger, depression, and bargaining on
CARF looks forward to its unique position
the way to acceptance.⁹ In many cases, for
in assisting in changes in rehabilitation care.
rehabilitation providers it has become a life-
It has had a recognized leadership role in
and-death business of survival as they at-
responding to new health care environments,
tempt to make sense of the health care envi-
and with its long-standing commitment to
ronment.
the provision of quality rehabilitation ser-
Accreditating organizations believe that
vices for people with disabilities, it willingly
change is inevitable and have made an at-
accepts its role as facilitator and moving
tempt to change through their willingness to
force to implement change in the delivery of
advocate for the delivery of value-laden re-
rehabilitation care.
REFERENCES
1. Forzley G. A health plan perspective on man-
7. Braun J. Presented at CARF Quality Forum;
aged care, priority health. Presented at the
November 5-6, 1996; Washington, DC.
Western Michigan Brain Injury Network Sym-
8. Herzlinger R. Market-Driven Health Care:
posium; April 24, 1997; Grand Rapids, Mich.
Who Wins, Who Loses in the Transformation
2. Wall Street Journal. 1997; February 2:p .
of America's Largest Service Industry. Read-
3. Burke G. Health Sys Rev. 1996;29(4):21-24.
ing, Mass: Addison-Wesley Publishers, 1997.
4. Thomsen G. Presented at FACHE, CARF Qual-
9. Galvin D. Presented at CARF Quality Forum;
ity Forum; November 5-6, 1996; Washington,
November 5-6, 1996; Washington, DC.
DC.
10. Parsons K. Presented at CARF Quality Forum;
5. Evans R. Presented at CARF Quality Forum;
November 5-6, 1996; Washington, DC.
November 5-6, 1996; Washington, DC.
6. Brannon R. Presented at CARF Quality Forum;
November 5-6, 1996; Washington, DC.
Consumer Viewpoint
Gary M. Yarkony, MD, Editor
Spinal Cord Injury and Managed Care:
A Consumer Viewpoint
Lex Frieden, Laura Smith, Wendy Wilkinson, Laurie Redd, and Quentin Smith
T
HE ADVENT of managed care as an
differences in the quality of care provided
increasingly pervasive phenomenon
enrollees in managed health care plans as
on America's health care scene has
compared with enrollees in more traditional
affected delivery of health care to tens of
indemnity type plans, there have also been
millions of people across the country. While
reports of problems experienced by persons
there have been reports of reduced costs.
in accessing needed services through man-
resulting from managed care and a number of
aged care plans. Some reports suggest that
studies indicating no reportable significant
problems reported with managed care plans
Lex Frieden, MA, is Director of the Research and
gram at The Institute for Rehabilitation and Research,
Training Center on Independent Living, ILRU Pro-
Houston, Texas.
gram at The Institute for Rehabilitation and Research;
Co-director, Research and Training Center on Man-
Quentin Smith, MS, is Associate Professor in Physical
aged Care and Disability; and Professor in Physical
Medicine and Rehabilitation and Family and Community
Medicine and Rehabilitation, Baylor College of Medi-
Medicine, Baylor College of Medicine, Houston, Texas.
cine, Houston, Texas.
This article was supported in part by the Research and
Laura Smith, MS, is Associate Director of Training
Training Center on Independent Living, sponsored by
with the Commission on Accreditation of Rehabilita-
The National Institute on Disability and Rehabilitation
tion Facilities, Tucson, Arizona.
Research (NIDRR) and by the Rehabilitation Services
Administration (RSA); and in part by the Research and
Wendy Wilkinson, JD, is Program Associate, Re-
Training Center on Managed Care and Disability, spon-
search and Training Center on Independent Living,
sored by NIDRR. The perspectives and opinions con-
tained in this article are those of the authors and do not
ILRU Program at The Institute for Rehabilitation and
Research, Houston, Texas.
reflect those of the sponsoring organizations or of any
other organizations or individuals.
Laurie Redd is Program Associate, Research and
Top Spinal Cord Inj Rehabil 1998;3(4):80-88
Training Center on Independent Living, ILRU Pro-
© 1998 Aspen Publishers, Inc.
80
Consumer Viewpoint
81
have had a greater impact on individuals who
thors. We encourage readers, including per-
are higher than average users of health care
sons whose values are shaped by cultural,
services-such as people with spinal cord.
economic, and personal experiences differ-
injury (SCI)-than on the average health
ent from those of the authors, to become
care user.
engaged in the discussion on health care
This article provides a perspective on the
services and the impact of managed care on
advent of managed care as it relates to people
persons with disabilities. The only way that
with SCI. It intersperses findings from both
the health care system will improve is for all
the research and lay literature with observa-
of us to take a hand in identifying problems
tions from the authors, all but one of whom
and posing solutions.
have an SCI and three of whom have had
personal experience with managed health
care plans. A deliberate effort has been made
Overview: Involvement of People with
to differentiate between information gleaned
Disabilities in Health Care Reform
from the literature and information or obser-
vations based on the personal experiences of
one or more of the authors.
With the push for some sort of health care
Readers may take issue with some of the
reform after the election of President Clinton
views and opinions expressed in this article,
in 1992, various constituencies became
and it is not the intent of the authors to imply
aware of the need for involvement in the
that the views expressed here are representa-
debate about health care needs and the most
tive of the views of all people with SCI or of all
appropriate ways to address those needs
people who are enrolled in managed care
through reform in the health care system. As
plans. In fact, we welcome comments from
Watson¹ pointed out, the diverse community
readers regarding their experiences with man-
comprising persons with disabilities was
aged care plans and encourage readers-in-
largely unorganized and disenfranchised
cluding those who concur with views ex-
from the political process that influences
pressed herein and those with opposing views
commitment of public resources to programs
regarding managed care and persons with
and services. Also, the disability community
SCI-to comment on this article. The issues
had, to a large degree, spent much of the
relative to health care delivery in general and
preceding few decades creating distance be-
to managed care in particular are complex and,
tween their needs for community support and
to some degree, value laden. The individual's
the traditional health care system with its
perspective of the value and effectiveness of
spiraling costs for ever more sophisticated
health care services available to him or her is,
and technologically advanced services. This
to a large extent, shaped not only by the degree
distancing effort often included espousing
to which he or she relies on such services, but
the position that the health care needs of
also by a complex array of personal, cultural,
persons with disabilities were no different
economic, and political factors that affect ev-
from those of the general population. Until
ery human being.
recently, most disability advocates saw any
This article reflects the values of the au-
assertion that people with disabilities have
82
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
higher than average health care costs as in-
Council on Disability (NCD), for people
correct and even heretical.¹
with disabilities and chronic illnesses, incen-
The lack of organization among and be-
tives built into managed care often run
tween different disability constituencies,
counter to effective rehabilitation, preven-
coupled with historical efforts to create dis-
tion of secondary disabilities and complica-
tance between disability issues and health
tions, and independent living.³
care issues and the need to direct attention to
what many believed were more pressing is-
sues, including passage of the Americans
How Are People with SCI Faring Under
with Disabilities Act, left the disability com-
Managed Care Plans?
munity ill prepared to become a major force
in health care reform initiatives. The result
was that the disability community had only
The last observation in the preceding para-
modest success in framing its issues in the
graph suggests that people with disabilities,
face of efforts by the organized health care
including people with SCI, are probably not
industry and other special interests which,
getting the scope and quality of health care
according to estimates cited by Mechanic,²
services that they need in order to sustain
spent more than $100 million trying to influ-
optimal health and live independently. The
ence public opinion regarding health care
question that must be raised is, Is there any
reform.
empirical evidence that the quality of health
With the failure to attain significant health
care being provided people with SCI through
care reform-a failure that Mechanic² attrib-
managed care plans is different-better or
uted to a number of factors, including Ameri-
worse-than the quality of care received by
can individualism, lack of community re-
people with SCI who are enrolled in tradi-
sponsibility, the power of special interest
tional indemnity, or fee-for-service, health
groups, and a flawed process employed by
care programs? Answering this question,
the Clinton administration-many people
however, poses some problems.
with disabilities, including people with SCI,
Perhaps because of the relatively recent
found themselves coping with the rapidly
advent of the managed care phenomenon,
growing phenomenon of managed care. As
there are few articles in health services re-
noted in a recent report from the National
search publications regarding the impact that
managed care has had on specific population
segments, such as people with disabilities.
Perhaps the most comprehensive effort to
For people with disabilities and
examine the impact of managed care on
chronic illnesses, incentives built into
people with disabilities has been undertaken
managed care often run counter to
by the Government Accounting Office
effective rehabilitation, prevention of
(GAO). In July 1996 the GAO issued a
secondary disabilities and
lengthy report entitled Medicaid Managed
complications, and independent living.
Care: Serving the Disabled Challenges State
Programs.⁴ The report examined data from
Consumer Viewpoint
83
five states-Arizona, Delaware, Oregon,
mechanisms, including payment by the indi-
Tennessee, Utah, and Virginia-that required
vidual. A growing number of people with
some or all of their beneficiaries with disabili-
SCI and other types of disabilities are finding
ties to participate in prepaid care programs
themselves in managed care as employers
that included features of managed care.
struggle to bring costs for employee benefits
The GAO report acknowledged that data
under control. Between 1992 and 1996, the
available on access, scope, and quality of
proportion of private sector employees par-
services provided to Medicaid recipients en-
ticipating in managed care plans grew from
rolled in managed care programs were inad-
49% to 77%.5 This growth is expected to
equate to draw conclusions about the effi-
continue, with the proportion of persons in
cacy of managed care programs, as currently
the private health care sector who are cov-
configured and operated in these five states,
ered under managed care projected to be 85%
in addressing the health care needs of people
to 95% by the year 2000.6
with disabilities.
Although data on the quality of care pro-
Among the reasons cited by the GAO for
vided to people with disabilities covered un-
the lack of adequate data to determine the
der Medicaid are sparse, much more data are
efficaciousness of managed care in address-
available on people with disabilities enrolled
ing the health care needs of people with
in publicly funded managed care programs
disabilities was the relatively low frequency
than are available on those in private man-
of serious disabling conditions, such as quad-
aged care plans. Often information on the
riplegia, in the general population, making it
scope and quality of services provided
unlikely that data on quality of care would be
through private sector managed care plans is
secured from such individuals through the
denied people who are faced with choices
random sampling procedures typically used
among health care plan options. Inquiries on
by health care plans in their evaluation ef-
the part of one of the authors regarding such
forts.4 The report suggested some strategies
basic service parameters as schedule of ben-
for enhancing evaluation processes used in
efits (eg, what services are covered under
determining the quality of care provided to
specific plans) garnered no response from
people with disabilities under managed care
representatives of most of the private man-
plans; these will be summarized later in this
aged care plans operating in the Houston,
article.
Tex, area. The rationale most often cited for
In considering the issue of the quality of
not responding to these requests was based
services provided to people with SCI who are
on the assertion that the information re-
enrolled in managed care plans, it is worth
quested was proprietary. The lack of mecha-
noting that the lack of quality-of-care data on
nisms for accountability and consumer re-
Medicaid beneficiaries with disabilities en-
sponsiveness in many managed care
rolled under managed care programs is only
programs was tacitly acknowledged in the
a part of the problem. Many people with SCI
1996 NCD report. The report recommended
and other severe disabilities are enrolled in
that all managed care plans, including those
private health care plans provided either by
that service only privately insured persons,
an employer or through other payment
should be required to meet federal standards
84
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
to ensure access to specialty care; adequate
the people making decisions regarding ap-
grievance and appeals procedures, including
propriate pharmacotherapy often appear to
ombudspersons; and equitable utilization re-
have little clinical training on which to base
view criteria.³
decisions about the best treatments for spe-
cific conditions.
Anecdotal Data on the Quality of
Third, hospitalization can be an ordeal for
Managed Care Services for People with
the person with SCI who is enrolled in a
SCI
managed care plan. If a hospital stay is ap-
proved, then the person with SCI may face
Much of what is known about the scope
discharge well before he or she is capable of
and quality of managed care services avail-
resuming full responsibility for health care.
able to people with SCI is based on anecdotal
One of the authors was denied any home
data gathered through focus groups and other
health care following major back surgery,
activities that rely primarily on qualitative
even though a body jacket was required for 6
research methods. All of the authors of this
months after the surgery, severely restricting
article have been involved as conveners of or
the person's ability to perform self-care ac-
participants in focus groups dealing with
tivities that were routine prior to the surgery.
managed care issues. Five major themes
Also, the managed care plan tried to deny
emerge consistently in the findings gener-
payment for the hospitalization because the
ated from such activities.
admitting physician was not a member of the
First, most people with SCI who are en-
managed care plan. This problem arose when
rolled in managed care plans have experi-
the surgeon, who was a plan member, was
enced delays or denials in obtaining care
late arriving to the hospital. In order not to
from a medical specialist in situations when,
lose the scheduled operating room time, the
based on prior experience, the individual
consulting surgeon-who was not a member
knew that a health care problem was devel-
of the managed care plan that was paying for
oping that required a timely response to re-
the service-wrote the admitting orders. Al-
duce the risks for more serious health care
though the person with SCI, who had already
problems. Such problems often involved uri-
received preoperative medication at the time
nary tract infection, but other examples cited
that the admission orders were written, had
by focus group participants involved respira-
no control over the admission process, the
tory problems or problems related to man-
managed care plan treated her as if actions
agement of chronic pain.
taken while she was under medication were
Second, people with SCI who are enrolled
made at her direction. Through aggressive
in managed care plans often encounter diffi-
advocacy on her own behalf, she finally
culty in securing specific pharmaceutical
forced acceptance of responsibility for the
products that they have found to be effective
hospital bill by the managed care plan, but
in treating health care problems that they
only after receiving denial notices from the
have dealt with previously. Many managed
plan and threatening letters from the hospital.
care plans use lists of approved drugs to make
Fourth, difficulties in obtaining durable
decisions about pharmaceutical agents, and
medical equipment (ie, wheelchairs and
Consumer Viewpoint
85
orthotic devices) are commonplace for
claims multiple times before having any ac-
people with SCI enrolled in managed care
tion taken by the managed care plan, it be-
plans. If approval can be secured for pur-
came standard practice to make multiple
chase of equipment, the amount allowed by
copies of all service documents in prepara-
managed care plans is often based on the
tion for resubmission before any action was
lowest cost model of the equipment available
taken in response to the claim.
on the market. There appears to be little
acknowledgment on the part of many man-
Implications of Anecdotal Data for the
aged care plan representatives that people
Future of Managed Care: The Need for
with SCI, and those with other types of physi-
Research
cal disabilities, often rely on their equipment
to carry out their day-to-day activities and
The examples cited above are admittedly
that appropriately designed and fitted equip-
anecdotal in nature and represent the experi-
ment can make the difference between de-
ences and views of individuals-in this case
pendence and independence. As with other
people with SCI who are consumers of health
aspects of managed care operations, the driv-
care services. However, in the absence of
ing factor in decisions regarding medical
more thorough empirical data about how
equipment appears to be cost, typically in the
people with SCI are being treated under man-
absence of concerns about quality.
aged care plans, these perspectives provide
Finally, denial of claims for health care
some insight into how people with disabilities
services and products, even when pre-
are faring in a managed care environment.
approved by a primary care physician, ap-
An important point should be made in
pears to be standard operating procedure for
weighing the value and implications of the
many managed care plans. People with SCI
perspectives reflected in this article: The
who participated in focus groups typically
individuals with SCI who participated in
reported that claims were denied routinely by
preparation of this article are all people who
their managed care plans. One of the authors
have a higher than average understanding of
who was enrolled in a managed care plan had
the way in which health care systems operate
the experience of having every claim submit-
and who have developed strong self-advo-
ted over a 9-month period lost by the claims
cacy skills. All three of the authors with SCI
division of the managed care plan. Because
who have had experience with managed care
of her experience in having to resubmit
plans affirm that it is only through aggressive
self-advocacy and perseverance in challeng-
ing decisions by managed care plan repre-
sentatives that they have been able to obtain
It is unclear how people with SCI who
many of the services they need in a timely
are less articulate in presenting their
way without incurring excessive cost-al-
cases-or more susceptible to
though often with much aggravation. It is
intimidation tactics-are faring under
unclear how people with SCI who are less
managed care.
articulate in presenting their cases-or more
susceptible to intimidation tactics, which
86
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
appear to be used commonly by some
pation in these focus groups by people with
plans-are faring under managed care. A
SCI is critical. Also, the RTC-MCD will be
systematic look at the way in which people
establishing a World Wide Web site on the
with SCI are dealing with problems associ-
Internet that people with SCI can access to
ated with managed care-and with other
secure information about managed care and
aspects of the larger health care system-is
to provide information about their own expe-
much needed. The work of the Research and
riences with managed care plans.
Training Center on Managed Care and Dis-
Perhaps most importantly, people with
ability (RTC-MCD), based at the National
SCI need to become fully engaged in the
Rehabilitation Hospital Research Center and
debate on health care services in a variety of
funded through the National Institute on Dis-
ways. In addition to participating in research
ability and Rehabilitation Research, will be
activities, people with SCI need to be ready
critical in determining whether the anecdotal
and willing to communicate their experiences
evidence offered here is exceptional or is
and thoughts on managed care to legislators
typical of the problems that people with SCI
and others who are engaged in formulation of
are faced with in the world of managed care.
public policy. This communication could take
the form of letter writing, volunteering to
Where Do We Go From Here?
appear at public hearings and other fact-find-
ing sessions, and using electronic media (eg,
The question of what can be done to ensure
the World Wide Web and the Internet) effec-
that people with SCI can access appropriate,
tively to provide information to people who
timely, and affordable health care services,
can make a difference in fostering change in
whether they are enrolled in managed care or
the health care system. An important aspect of
in some other form of health care plan, can-
communication by people with disabilities
not be answered in a simple manner. The
with respect to managed care must focus on
problems are complex. The solutions are
greater accountability on the part of both
opaque. The pathways to positive change
public and private sector managed care plans
have not been clearly illuminated. What is
in elucidating how they are responding to the
certain is that improvements in the way that
needs of all enrollees, including people with
managed care plans operate and in their re-
SCI or other types of disabilities.
sponsiveness to people with atypical health
Because of the federal government's role
care needs are not likely to occur unless
in the administration of Medicaid managed
people with SCI and those with other types of
care programs, the impetus for more exten-
disabilities become more actively engaged in
sive data gathering needed to foster positive
the activities of the RTC-MCD and other
change in managed care programs is coming
organizations working to change the nation's
from the public sector. As the GAO report
health care system.
noted, states could extend their current ef-
As part of its research activities, the RTC-
forts to assess specific aspects of health care
MCD will be conducting focus groups in
delivery to enrollees with disabilities.4 The
different parts of the country to obtain infor-
report cited some examples of efforts being
mation from people with disabilities on is-
made in different states to ensure quality in
sues related to managed care. Active partici-
the services provided to people with disabili-
Consumer Viewpoint
87
ties. These efforts include the following:
that has come about in recent years. Under
In Massachusetts: A program initiated
the fee-for-service system that prevailed a
in one prepaid plan to monitor manage-
decade ago, more was better: the more ser-
ment of pressure sores, a health care
vice rendered, the more revenue produced. In
problem of particular concern to people
the emerging fixed-fee or fixed-cost environ-
with SCI. This initiative resulted in de-
ment, less is better: the less service provided,
velopment of a variety of methods, in-
the more net income is produced. Managed
cluding new screening protocols for
care has reversed the financial incentives
earlier intervention and an accelerated
governing provider behavior in the past. The
schedule for wheelchair seating evalua-
question remains whether quality and out-
tions, as a means of improving care.
comes are being sacrificed when financial
In Oregon: Weekly meetings of the staff
incentives are reversed.⁷
of the Medicaid program with represen-
Anecdotal data suggest that efforts to
tatives of health care plans, advocates
lower costs by restricting access to services
for persons with disabilities, and others
may have a disproportionate impact on per-
to plan the program. These meetings
sons who are higher than average users of
occurred over a period of a year before
health care. This article presents the perspec-
the program was implemented.
tives of some people with SCI who have
In Wisconsin: Designation of an advo-
experienced managed care. More thorough
cate on the staff of prepaid plans serving
quantitative and qualitative research on these
people with disabilities in the state.
issues is necessary to determine the full im-
Wisconsin also requires that case man-
pact that changes in the nation's health care
agers conduct needs assessments within
system are having on persons with SCI. In
55 days of enrollment in a plan by a
closing this article, it is worth reiterating
person with a disability.
some of the recommendations included in
In Massachusetts: Allowance of spe-
the NCDs 1996 report.³ In its recommenda-
cialists to act as primary care providers.
tions aimed at fostering a consumer-driven
Massachusetts also employs a health
health care system, the report said:
needs assessment to assist enrollment
staff in helping beneficiaries to select a
Congress should ensure that all health care
health care plan.
reforms and changes, in both the private and
Unfortunately, many of the safeguards
public sectors, make health care more consumer
that are being built into publicly funded man-
driven and include the following features:
aged care programs to ensure that people
a) adequate consumer information to em-
power consumers to make informed decisions
with SCI or other types of disabilities obtain
when choosing a health plan or provider;
adequate and appropriate care are not finding
b) quality standards (eg, health care report
their way into private sector managed care
cards) that are developed in collaboration with
programs. An obvious reason for this is the
people with disabilities and are responsive to the
bottom-line orientation that most private sec-
clinical and information needs of consumers with
tor managed care organizations have adopted
disabilities;
in their operations. DeJong and Sutton⁷ noted
c) adequate appeals and grievance processes
the dramatic change in health care services
to enable consumers to challenge health plans and
88
TOPICS IN SPINAL CORD INJURY REHABILITATION/SPRING 1998
health provider decisions, including arbitration
However, available evidence continues to
mechanisms, ombudsmen independent of health
suggest that many managed care plans sup-
plans, and private rights of action;
ported through the private sector continue
d) consumer governance in which consumers
to be unresponsive to the needs of people
and purchasers, not providers and payers, domi-
with atypical health care needs, including
nate the governing of the health care system
through purchasing cooperatives and various
people with SCI. Perhaps true change will
oversight mechanisms. 3(p89)
occur only when the last of the four NCD
recommendations becomes reality and con-
It appears that, at least in publicly sup-
sumers-including people with disabili-
ported managed care programs (ie, those
ties-dominate the governance of the
covered under Medicaid and Medicare),
health care systems that have a powerful
some progress is being made toward at least
influence on the quality of life that all
the first three of these recommendations.
people can attain.
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