The United States economy is experiencing an environment of diminishing resources for social and human service programs. Government expenditures for such programs, as a percentage of the Gross National Product (GNP) and as a percentage of total funds, has remained static despite the increasing demands on the system for additional resources (Heimerdinger, 1993; U.S. Bureau of the Census, 1991). With a shift toward rugged individualism, soaring health care costs, and decreased funding for human service agencies, the priority of the political agenda of 1997 is to solve the crisis in health care, education, and welfare reform. The State-federal Rehabilitation Program has evoked a challenge to policy developers in the face of health reform and dwindling financial support.
The purpose of this article is to discuss health care policy development and reform as it relates to persons with disabilities in both medical rehabilitation and vocational rehabilitation service delivery. Areas that are addressed include trends in acute rehabilitation, financial issues, implications for rehabilitation, and recommendations. In a time of scarce resources, an increasing demand for services, and an uncertain political climate, the most challenging aspect of service provision in vocational and medical rehabilitation is to manage the needs of the medically complex rehabilitation consumer (Mahoney, 1995). The combination of factors previously mentioned places rehabilitation [medical organizations in a politically vulnerable position.
Trends in Acute Rehabilitation
Medical rehabilitation has experienced enormous growth in the last decade. According to Carrillo (1993), medical rehabilitation is market driven, resulting in specialized programs (e.g. spinal cord injury, orthopedic injury, pain management) that have cost-effective outcomes. While there is consensus that cost reduction and achieving efficiency are necessary, the question is at what point in the process will quality of care be compromised (Duchene, 1995). One area in which this question is continually at the forefront is in acute care units. Mahoney (1995) indicates that "the rehabilitation patient with medical complexity adds a new dimension to traditional interdisciplinary issues in rehabilitation" because "patients are transferred quicker and sicker' to rehabilitation program " to facilitate "health care reform, prospective payment, functional related groups, capitation, and managed care" (p. 152). However, with the facilitation of cost-containment, using this paradigm, quality of care can be certainly threatened.
Another trend in acute care is that consumers are leaving acute care and transitioning to long term care settings without emphasis on outcome accountability (Duchene, 1995). This trend contradicts the call for accountability through outcome measurement (Carrillo, 1993). Additionally, Carrillo points out that amid charges of high costs, poor care, and, in some cases fraudulent practices, medical rehabilitation will continue to receive critical scrutiny by policy makers, funding sources, and accrediting and licensing agencies.
Decreased lengths of stay in most acute rehabilitation programs is a third trend. Over a three year period, the average length of stay (ALOS) for all patients in rehabilitation hospitals decreased 12% (Suplitt, 1993). Specifically, in 1988, ALOS decreased 7% over the same time period: 1988, 25 days; 1989, 25 days; and 1990, 24.2 days. Likewise, Faraci, Leiter, and Weeks (1996) report the ALOS decreased 6.3 days (18%) over four time periods (1987/88-1990/91) for all patients and each subgroup. Furthermore, "individuals with complex stroke, spinal cord injury or traumatic brain injury are treated in the rehabilitation setting for less than 30 days" (half of the ALOS of a few years ago) (Duchene, 1995, p.252). This decrease in ALOS raises several questions: Was quality sacrificed? Is this a reflection of a well coordinated program? How were outcomes defined? and What type of services were delivered?
Finally, the health maintenance organization (HMO) determines the manner in which rehabilitation professionals deliver care (Duchene, 1994). The ALOS, program components, and discharge disposition are all influenced by the HMO case manager. …