Academic journal article The Journal of Rehabilitation

Ethical Rehabilitation Counseling in a Managed-Care Environment

Academic journal article The Journal of Rehabilitation

Ethical Rehabilitation Counseling in a Managed-Care Environment

Article excerpt

Ethical practice in the field of vocational rehabilitation (VR) has been an issue since the beginnings of the profession (Brubaker, 1977; Obermann, 1971, 1973). However, with the arrival of managed care organizations (MCOs) and their direct and pervasive influence on insurance-based VR practice, ethical problems are affecting service delivery (Ashbaugh and Smith, 1996; Birenbaum, 1995; HPP, 1997; Kohlenberg, 1994). For example, in the Ohio and California workers' compensation systems, MCO-type cost-containment practices have been adopted (HPP, 1997; Kohlenberg, 1994).

This article looks at ethical concerns that the profession has historically faced, their relationship to the unified code of ethics, and current professional rehabilitation practice within a MCO environment. It discusses MCO cost-containment strategies and implications for practice.

Historical Perspectives

In the 1970's, the primary ethical problem facing VR practice focused on a relationship triad. This triad comprised the client (accepted, then and now, as the person receiving VR services), the rehabilitation counselor (RC), and the agency (i.e., the counselor's employer) through which services would be delivered. Two central questions were: (1) Is a rehabilitation counselor's advocacy role limited by the employee-employer relationship? (2) Is there an ethical compromise that negatively affects the counselor's obligation to the client/consumer? Geist, Curin, Prestridge and Schelb (1973) held that these concerns arose out of the relationship between the agency and the counselor and the relationship's effect on the advocacy role of the counselor on behalf of the consumer. However, by the end of the decade, new concerns developed. With the rise of proprietary rehabilitation, the traditional relationships between the consumer, agency/employer and RC had become more complicated. The addition of new sources of payment for services, and the potential for profit in VR service provision, created new ethical problems for the RC in private practice (Cottone, 1982, 1985; Pape & Klien, 1986; Sher, 1979).

In the 1980's, ethical issues were raised for RCs regarding the identity of their clients. Were they the consumers or the payers of service? Workers' compensation and third-party payers (e.g., insurance companies) fueled the demand for services to injured workers and the dominance of private, for-profit rehabilitation companies in service provision. Ethical problems arose in plan development. Should the consumer's needs or the payer's willingness to pay determine service provision? Were RCs becoming arbitrators for third-party payers to resolve legal issues surrounding injury? Nadolsky (1986) offered the following:

   As private rehabilitation achieves visibility and becomes a dominant force
   in the rehabilitation movement, the general public will begin to identity
   the entire field of rehabilitation as a service designed to assist
   organizations in resolving the legal issues associated with accidental or
   industrial injury. Rehabilitation will no longer be viewed as a
   people-oriented field, whose services are designed to assist in restoring
   the productive capacity of people with disabilities. (p. 6)

By the 1990's, ethical issues in both the public and private VR sectors focused on consumer decision making, access to services, and choice in the VR process (Fry, 1995). MCOs, as part of the healthcare delivery system and as payers of VR services, have become the concern of many authors because MCOs limit consumer choice and access to needed services (Ashbaugh & Smith, 1996; Birenbaum, 1995; HPP, 1997; Kohlenberg, 1994; Rother, 1996; Thomas, 1994).

As powerful MCOs cap costs and limit services, RCs continue to need a reliable guideline for ethical behavior. The Code of Professional Ethics for Rehabilitation Counselors (Code, 1988; Commission, 1995) retains critical importance as the service delivery and payer systems undergo historic changes. …

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