Managed care environment raises concerns among rehab providers
Can your facility cope with a changing world?
As managed care began to roll across the country a few years ago, health care saw a series of rapid changes emerge that left providers struggling to understand how to make the dramatic shifts necessary for survival.
Where this period of rapid transition will ultimately lead remains unknown; but there’s no doubt that health care as we’ve known it is never coming back, and rehab services are now part of this new health care landscape.
In today’s world, the care a patient receives often is defined by contract the contract between the managed care company and the patient or the patient’s employer and the contract between the health care provider and the managed care company.
This means rehab providers must base a treatment plan on a patient’s financial resources, rather than what they believe is best for the patient regardless of cost. Inpatient lengths of stay are shrinking, and often insurance contracts stipulate a limited number of outpatient visits.
These constraints, while common in other health care fields, are troublesome to many rehab providers whose professional training emphasized doing everything possible for a patient.
With managed care, providers are no longer able to build excess into their charges for paying customers and shift it to cover bad debt or care for patients whose benefits have run out.
This puts you in the position of coming up with more efficient and effective ways of treating patients and moving them quickly through the rehab continuum.
At the Rehabilitation Institute of Chicago (RIC), an interdisciplinary ethics task force, formed in April 1995, emphasizes getting the staff to think creatively about patient care, says Kristi Kirschner, MD, medical director of the Institute’s Health Resource Center for Women with Disabilities, assistant director of the Center for Stroke Rehabilitation, and chairwoman of the ethics task force.
Thinking creatively
The RIC staff is drawing up a set of guiding principles on how to make the decisions for patient care.
"If we think creatively, we can come up with other options that are acceptable, and we can feel good about that. What we come up with may not be the very best option, but it’s an OK option," Kirschner explains.
But in cases where staff feel the payer’s decision is not in the patient’s best interest, they are ready to help the patient and family enter into the appeals process, she adds.
One option the RIC staff always explores is moving the patient from acute rehab into a less costly venue, Kirschner says.
"We have been encouraged in the past to treat whatever we are being paid for. Now managed care is saying get this patient out or move him to a less costly level of care, and that’s where it begins to get tough," declares Connie Burgess, MS, RN, president of Connie Burgess & Associates, a Lakewood, CA, consulting firm.
Colodia Owens, BS, MHA, a consultant who advises providers on managed care, has seen as much as a $250-a-day difference for the same services in a skilled nursing facility and an acute rehab facility.
"Under the traditional fee-for-service model, we were able to think of the clinical intervention beginning and terminating in our own environment. With the advent of managed care, the intervention may begin in one environment, but providers are expected to move the patient through the continuum," adds Owens who is a principal in Interface Health Care Systems, based in El Sobrante, CA.
Rehab providers should keep in mind that no matter how rich a patient’s benefits, there is usually a lifetime maximum, and it is imperative to move the patient quickly to a less expensive level of care, Owens says.
"If we are going to survive as an industry, we’ve got to put the patient in the right place at the right time based on cost and acuity," adds Jim Usdan, chief executive officer of The RehabCare Group in St. Louis.
RehabCare is moving into the subacute and outpatient arenas and is looking to purchase or align with home health companies, Usdan says.
Bad ethics or good business?
While the rehabilitation community may have difficulty accepting the changes mandated by reimbursement constraints, "we mustn’t confuse poor care and bad ethics with the inability to do things the way we’ve always done them. In the past, the way we did things was often [based on] our priorities and not the patient’s," Burgess comments.
As an example, Burgess tells of a friend who didn’t participate in occupational therapy and was accused of being noncompliant. The patient complained to Burgess that the occupational therapist was trying to force her to make tea when she disliked tea.
"And she was absolutely right. That wasn’t a good use of her resources or time. She wasn’t motivated because she didn’t care about it," Burgess says.
In rehabilitation the customized plan of care has always been the norm. Treatment plans have historically been developed based on patients’ physical, psychosocial, and community resources.
"I don’t call an individual plan of care discriminating. By individualizing care, we are using their benefits to the maximum," Burgess says. (For more on how your staff can individualize a plan of care, see related articles, at right and p. 4.)
Rehab providers should rethink automatically putting every patient on the same clinical pathway because it may not be flexible enough to meet individual needs, Burgess says.
A multiple approach
"We need to take a multiple approach to allow the team to choose what is best based on what they see, not something that was set up years ago. By sinking all our investments into a single plan, we’re losing other alternatives," she adds.
Because rehabilitation is a care paradigm, rather than a cure paradigm, rehab providers can be manipulated more easily by a patient’s reimbursement resources than their acute care counterparts, points out John Banja, PhD, associate professor at Emory University’s Center for Rehabilitation Medicine in Atlanta.
For instance, if a surgeon has a managed care contract that pays him half his usual fee for an appendectomy, he’s unlikely to do half the job, Banja says.
On the other hand, rehab providers may consider discharging a patient with a functional independence measure (FIM), administered by the Uniform Data System for Medical Rehabilitation in Buffalo, NY level of 82 when their money runs out even though they feel that in two more days, they could increase the FIM level to 89, Banja asserts.
"In rehab, we can be much more manipulated by the patient’s economic resources than can our acute care counterparts. In rehab if we are asked how much functional restoration can you bring about?’ the answer might be how much functional restoration could you pay for?’" he adds.
However, Banja is quick to point out that most providers do not simply discharge patients when reimbursement is over, but managed care is forcing them to make changes in how they deal with a shrinking reimbursement base.
As a not-for-profit organization, Reading (PA) Rehabilitation Hospital, a multivenue provider, allocates a certain amount of money each year to pay for uncompensated care "when there is no payer or when we don’t think the payer is doing the right thing for the patient," says Clint Kreitner, president and chief executive officer.
However, the hospital can’t make up for all shortfalls. While the staff is committed to a basic standard of care for each patient, they must bear in mind that different patients may be entitled to different levels of care, Kreitner adds.
"It’s unethical to provide anyone with less than a baseline standard of care, but what they are entitled to by virtue of their HMO plan is defined by contract. Managed care pressures are forcing us to design creative alternatives, and I consider that to be a healthy influence," he points out.
[Editor’s note: In next month’s Rehab Continuum Report: How to avoid failure in the changing health care world.
Connie Burgess may be reached at Connie Burgess & Associates, 5505 E. Carson St., Suite 305, Lakewood, CA 90713. Telephone: (310) 497-2050. Contact Colodia Owens at Interface Health Care Services, 5312 D’Avilla Way #G, El Sobrante, CA 94803. Telephone: (510) 669-1323.]
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