Health Services: Policy and Systems for Therapists

328 Pages·2008·2.091 MB·English

by  Robert Sandstrom, Helene Lohman, James D. Bramble

Health Services
P S
OLICY AND YSTEMS FOR
T
HERAPISTS
2nd Edition
Robert W. Sandstrom PhD, PT
Department of Physical Therapy
Helene Lohman OTD, OTR/L
Department of Occupational Therapy
James D. Bramble PhD
Department of Pharmacy Sciences
Center for Health Services Research
School of Pharmacy and Health Professions
Creighton University
Omaha, Nebraska
Upper Saddle River, New Jersey
Library of Congress Cataloging-in-Publication Data
Sandstrom, Robert W., 1957-
Health services : policy and systems for therapists / Robert
Sandstrom, Helene Lohman, James Bramble. — 2nd ed.
p.; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-13-514652-1
ISBN-10: 0-13-514652-6
1. Medical policy—United States. 2. Public health—United States. 3. Physical therapy—Practice.
4. Occupational therapy–Practice. I. Lohman, Helene. II. Bramble, James D. III. Title.
[DNLM: 1. Health Services Accessibility—organization & administration—United States.
2. Health Policy—United States. 3. Occupational Therapy—organization & administration—United States.
4. Physical Therapy (Specialty)—organization & administration—United States. W 76 S221h 2009]
RA395.A3S366 2009
362.1068—dc22
2008021783
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Copyright © 2009 by Pearson Education, Inc., Upper Saddle River, New Jersey, 07458.
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10 9 8 7 6 5 4 3 2 1
ISBN-13: 978-0-13-514652-1
ISBN-10: 0-13-514652-6
Brief of Contents
1 Disablement, Policy, and Systems 1
2 Access and Cost of Health Care 18
3 Quality of Health Care 40
4 Public Policies Addressing Social Disablement 59
5 Fundamentals of Insurance 86
6 Managed Care and Beyond 107
7 Medicare 131
8 Medicaid, SCHIP, Military/Veterans Medical Insurance,
and Indian Health Service 173
9 The Acute Medical Care System 190
10 The Post-Acute Health Care System 210
11 Special Education, Public Health, and Complementary/
Alternative Medicine 241
12 Effecting Policy Change: Therapist as Advocate 261
Appendix 288
Glossary 296
Index 303
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Contents
Preface xiii
Reviewers xv
1 Disablement, Policy, and Systems 1
Chapter Objectives 1
Introduction 2
Policy and Power 3
Sources of Power 4
Government 4
Political Process 5
Private Enterprise 6
Ethics and Values 7
Experience of Disablement 8
Biomedical Model 10
Social Disability Model 11
Universalism 12
Therapists and the Health Care System 13
Conclusion 15
Chapter Review Questions 16
Chapter Discussion Questions 16
References 16
2 Access and Cost of Health Care 18
Chapter Objectives 18
Introduction 19
Access to Health Care Services 20
Availability 20
Accessibility 20
Accomodation 21
Acceptability 21
Affordability 21
Access and Health Insurance 22
Characteristics of the Uninsured 22
Health Status of the Uninsured 24
The Working Uninsured 25
Cost of Health Care 27
Health Care Financing: Where It Comes From 28
vi Contents
Health Care Financing: Where It Goes 29
The Growth of Health Care Expenditures 30
Payment Mechanisms and Health Care Expenditures 32
Access and Cost: A Therapist Perspective 33
Effects of Direct Access on Therapy Practice 35
Conclusion 35
Chapter Review Questions 36
Chapter Discussion Questions 36
References 37
3 Quality of Health Care 40
Chapter Objectives 40
Introduction 41
Perspectives on Health Care Quality 41
Structure, Process, and Outcomes 43
Structure 44
Process 45
Outcomes 46
Accreditation 48
Joint Commission on the Accreditation of Healthcare Organizations 49
Commission on Accreditation of Rehabilitation Facilities 49
National Committee on Quality Assurance 50
Legal Issues and Quality 50
The Future of Health Care Quality 52
Conclusion 53
Chapter Review Questions 54
Chapter Discussion Questions 55
References 55
4 Public Policies Addressing Social Disablement 59
Chapter Objectives 59
Introduction 60
Public Policies Supporting Youths and Older Adults 63
The Individuals with Disabilities Education Act (IDEA) 63
IDEA and Therapy 65
The Developmental Disabilities Act (DDA) 66
The DDA and Therapy 67
The Older Americans Act (OAA) 68
Work-Related Policy Acts 69
The Workforce Investment Act (WIA) (Rehabilitation Act, [RA]) 69
The Workforce Investment Act and Therapy 70
Work Incentives Improvement Act of 1999 (P.L. 106-170) and Ticket to Work and
Self-Sufficiency Program 71
The Future of Work-Related Public Policies 71
The Americans with Disabilities Act (ADA) 72
Therapy and the ADA 73
Contents vii
Social Security Income Programs 75
Housing Programs for Persons with Disabilities 76
Technology and Persons with Disabling Conditions 76
The Assistive Technology Act of 1998 76
The Assistive Technology Act of 2004 77
Therapists and the ATA 77
Working with Policies Addressing Social Disablement 78
Conclusion 80
Chapter Review Questions 81
Chapter Discussion Questions 81
Internet Resources 81
Reference 82
5 Fundamentals of Insurance 86
Chapter Objectives 86
Introduction 87
Why Have Health Care Insurance? 87
Purpose of Insurance 87
Risk and Insurance 88
Organization and Administration of Health Care Insurance 88
Actuarial Adjustment and Insurance 89
Moral Hazard and Insurance 89
Basics of an Insurance Contract 90
Eligibility 90
Covered Events 91
Covered Services 91
Cost Limits 91
Beneficiary Cost Limits 92
Provider Cost Limits 92
Coordination of Benefits 93
Types of Insurance 94
Sponsorship 94
Private Insurance 94
Self-Insurance 95
Direct Contracting 95
Method of Cost Sharing 96
Indemnity Insurance 96
Service Benefit Plans 96
Covered Events/Services 96
Long-Term-Care Insurance 96
Workers’ Compensation 98
Casualty Insurance 100
Regulation of Insurance 100
Insurance Regulation 100
Employee Retirement Income Security Act of 1974 101
Continuation Issues 101
viii Contents
Conclusion 102
Chapter Review Questions 103
Chapter Discussion Questions 103
References 104
6 Managed Care and Beyond 107
Chapter Objectives 107
Introduction 108
Defining Managed Care 109
Managed Care Principles 110
Limited Access to the Universe of Providers 110
Payment Mechanisms That Reward Efficiency 111
Enhanced Quality Improvement Monitoring 112
Managed Care Products 113
Managed Indemnity 113
Preferred Provider Organizations 113
Health Maintenance Organizations 114
Point of Service (POS) 114
Market Shares of Health Plan Types 115
Managed Care Provider Structures 116
Staff Model 116
Group Model 117
Network Model 117
Independent Practice Associations 117
Effect of Managed Care on Physical Therapy and Occupational
Therapy Practice 117
MCOs: Benefits and Concerns for Therapists 118
Managed Care Benefits 118
Managed Care Concerns 119
Adapting to the Changes Brought About by Managed Care 120
Importance of Good Communication 120
Case Managers and Managed Care 121
Health Care Environment Trends Related to Managed Care 123
Patient Bill of Rights 123
Pay for Performance 124
Consumer-Directed Health Plans 124
Conclusion 127
Chapter Review Questions 127
Chapter Discussion Questions 128
References 128
7 Medicare 131
Chapter Objectives 131
Introduction 133
History of Medicare 133
Scope and Organization of Medicare 135
Contents ix
Medicare Eligibility 137
Part A Eligibility 137
Part B Eligibility 137
Original MedicarePart A: Hospital Insurance 138
Benefits 138
Benefit Period 138
Skilled Nursing Facility Benefit 140
Home Health Care Benefit 142
Inpatient Rehabilitation Facility Benefit 144
Hospice Benefit 145
Part B: Supplementary Medical Insurance (SMI) 145
Benefits 145
Provider Types 145
Medicare and Therapy Services 146
“Incident To” Therapy Procedures 150
Part A: Payment Structures 151
Hospital Prospective Payment 151
Part A Prospective Payment for Post-Hospital Services 153
Inpatient Rehabilitation Facility Prospective Payment 157
Case Example of a Part A Prospective Payment System Calculation 157
Medicare Part B: Payment Structure 159
Fee Schedule 159
Provider Participation 161
Financial Limitations on Medicare Part B Therapy Services 161
Medicare Advantage Plans 162
Medicare Part D 163
Private Health Insurance and Medicare 163
Quality and Medicare 164
Fraud and Abuse 164
Physician Self-Referral Restrictions 166
Medicare Reform 166
Conclusion 167
Chapter Review Questions 168
Chapter Discussion Questions 168
References 169
8 Medicaid, SCHIP, Military/Veterans Medical Insurance,
and Indian Health Service 173
Chapter Objectives 173
Introduction 174
Medicaid 174
What Is Medicaid? 174
Who Is Eligible for Medicaid? 176
Medicaid Managed Care 179
Medicaid Services 179