Health Services Policy and Systems for Therapists Third Edition Robert W. Sandstrom PhD, PT Department of Physical Therapy Center for Health Policy and Ethics Helene L. Lohman OTD, OTR/L, FAOTA Department of Occupational Therapy James D. Bramble PhD, MPH Department of Pharmacy Sciences Center for Health Services Research and Patient Safety School of Pharmacy and Health Professions Creighton University Omaha, Nebraska Publisher: Julie Levin Alexander Creative Director: Jayne Conte Publisher’s Assistant: Regina Bruno Cover Designer: Bruce Kenselaar Editor-in-Chief: Marlene McHugh Pratt Text Designer: Mary Siener Executive Editor: John Goucher Cover Art: aceshot1/Shutterstock, Inc. & kbuntu/Fotolia Editorial Program Manager: Monica Moosang Chapter Opener Art: DrHitch/Fotolia Editorial Assistant: Erica Viviani Media Director: Amy Peltier Director of Marketing: David Gesell Lead Media Project Manager: Lorena Cerisano Executive Marketing Manager: Katrin Beacom Full-Service Project Management: Anandakrishnan Natarajan Marketing Coordinator: Alicia Wozniak Composition: Integra Software Services, Ltd. 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To obtain permission(s) to use material from this work, please submit a written request to Pearson Education, Inc., Permissions Depart- ment, One Lake Street, Upper Saddle River, New Jersey 07458, or you may fax your request to 201-236-3290. Notice: The author and the publisher of this volume have taken care that the information and technical recommendations contained herein are based on research and expert consultation, and are accurate and compatible with the standards generally accepted at the time of publication. Nevertheless, as new information becomes available, changes in clinical and technical practices become necessary. The reader is advised to carefully consult manufacturers’ instructions and information material for all supplies and equipment before use, and to consult with a health care professional as necessary. This advice is especially important when using new supplies or equip- ment for clinical purposes. The authors and publisher disclaim all responsibility for any liability, loss, injury, or damage incurred as a consequence, directly or in directly, of the use and application of any of the contents of this volume. Many of the designations by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book, and the publisher was aware of a trademark claim, the designations have been printed in initial caps or all caps. Library of Congress Cataloging-in-Publication Data Sandstrom, Robert W. Health services : policy and systems for therapists / Robert W. Sandstrom, Helene L. Lohman, James D. Bramble.—3rd edition. p. cm Includes bibliographical references and index. ISBN-13: 978-0-13-311061-6 (alk. paper) ISBN-10: 0-13-311061-3 (alk. paper) I. Lohman, Helene, author. II. Bramble, James D., author. 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] RA395.A3 362.1068—dc23 2013010757 10 9 8 7 6 5 4 3 2 1 ISBN 10: 0-13-311061-3 ISBN 13: 978-0-13-311061-6 Contents Preface  v Chapter 10 The Acute Medical Care Reviewers  vii System 173 Chapter 1 Public Policy and Therapists 1 Chapter 11 The Post-Acute Health Care System 189 Chapter 2 Access and Cost of Health Care 15 Chapter 12 Special Education and Mental Health Systems 209 Chapter 3 Quality of Health Care 33 Chapter 13 Global and Population Chapter 4 Public Policies Addressing Social Health 229 Disablement 47 Chapter 5 Effecting Policy Change: Therapist Appendix A R esources on Policies Addressing as Advocate 71 Social Disablement 241 Chapter 6 Fundamentals of Insurance 95 Appendix B Advocacy Resources 242 Chapter 7 Private Insurance and Therapy Glossary 244 Practice 109 Index 249 Chapter 8 Medicare 127 Chapter 9 Medicaid, Military/Veterans Medical Insurance, and Indian Health Service 157 iii This page intentionally left blank Preface to the Third Edition Since the second edition was published in 2008, health policy has significantly changed. The enactment of the Patient Protection and Affordable Care Act of 2010 (PPACA) in March 2010 (followed by its legal affirmation by the United States Supreme Court in June 2012 and a political re-affirmation by the reelection of President Obama in Novem- ber 2012) is the largest regulatory overhaul of the United States health care system since the enactment of Medicare and Medicaid in 1965. The effects of the PPACA will be played out over several years, if not decades. In the years to come, this law is sure to affect the practice of all health care providers, including occupational therapists and physical thera- pists. In addition, a number of changes have occurred to other important public policies affecting therapist practice, for instance, in Medicare. Cumulatively, these developments have prompted this new edition of our textbook. The central purpose of the book remains unchanged from the first edition published in 2003. We have striven to produce a comprehensive introduction to the policies and sys- tems where occupational therapists, physical therapists, and therapist assistants find their work and provide their care. In doing so, we have made several changes in response to the users and reviewers of the book. We are very grateful to those persons who gave their time, expertise, and constructive criticism to help us improve this edition. The changes are as follows: • The book has been increased from twelve to thirteen chapters. In this edition, we created a new chapter on global and population health. The global health content provides an international perspective on the health care systems of several indus- trialized nations. We have moved the public health content into this chapter and emphasized its relationship to population health. We view population health as a growing area of importance for occupational therapists and physical therapists in our evolving health care system. • The advocacy chapter has moved from the end of the book to a position after the principles of health and public policy chapters. We believe that public policy advocacy skills need to have a stronger emphasis in occupational therapist and physical therapist entry-level curricula. We hope that this change will help students develop stronger policy analysis and advocacy skills by placing this content closer to the content that explains principles of policy. We encourage the use of the advocacy skills material to understand the reimbursement policy and systems chapters that follow this chapter. • We welcome two new contributors (Creighton colleagues) to this edition of the textbook. Anna Domina OTD and Katherine Young OTD wrote a new chapter on special education and the mental health care systems. We are grateful for their participation and believe this chapter offers a significant, positive contribution to this edition. We also thank Yolanda Griffiths OTD for her assistance with this chapter. • Several of the chapters on reimbursement policy (Chapters 6–9) had significant updates to reflect the statutory changes from the PPACA. As a result, we moved the content on casualty insurance, workers’ compensation, and long-term care insurance to the private insurance chapter (Chapter 7). The Medicare chapter was rewritten to better explain the reimbursement strategies to their different benefits. • All chapters have had content and emphasis updates and revisions that reflect changes in policy and the health care system since the second edition. We have tried to emphasize application to therapy practice. • Key terms for each chapter are updated and defined in the Glossary. We have tried to be sensitive to the appropriate use of “patient” and “client” terminology when writing the narrative. v vi PREFACE Increasingly, the challenge has been to make the book a comprehensive introduc- tion to health policy and the health care system experienced by physical therapists and occupational therapists without making it too specific or overwhelming in detail. This has been challenging with all of the regulatory changes of the past few years and in recogni- tion that many students have had little, if any, public policy or business background prior to encountering this content. There are outside resources that instructors will include that are not in this textbook and we recognize that there are portions of the book that will be excluded for one or more reasons. Given that a number of changes due to the PPACA have not yet occurred or are not widespread (e.g., health insurance exchanges or account- able care organizations), we expect that other resources will be accessed by instructors to provide students an appropriate education in these policy areas. Even as we conclude this edition, the Congress and president are considering Medicare and Medicaid reforms that may affect the content presented in this edition. For these still-to-be-determined changes, we have done our best to introduce concepts so as developments do occur the student will be able to recognize and understand the new policy or system landscape. We hope that we have been successful in meeting our primary goal to provide a strong foundation for a health services course in the therapy disciplines, apart from the traditional administration or management course. We offer this textbook as a tool to assist students and instructors in this endeavor. We recognize and thank Mark Cohen, John Goucher, and the people of Pearson Education for their ongoing support of this project. A special thanks to Melissa Kerian and Anandakrishnan Natarajan for their patience, expert guidance, and editorial work as we have completed this edition. To our families, we offer our deepest thanks and love for their partnership with us on this book. R.W.S. H. L. L. J.D.B. Omaha, Nebraska Reviewers Rhea Cohn, PT, DPT Theodore Peterson, OTR, ATP, DrOT George Washington University Idaho State University Washington, DC Pocatello, Idaho Gail Fisher, MPA, OTR/L, FAOTA Douglas Simmons, OTR/L, PhD University of Illinois at Chicago University of New Hampshire Chicago, Illinois Durham, New Hampshire Dory Marken, PhD Laurie Walsh, JD, PT Eastern Kentucky University Daemen College Richmond, Kentucky Amherst, New York M. Beth Merryman, PhD, OTR/L Debbie Waltermire, MHS, OTR/L Towson University Elizabethtown College Towson, Maryland Elizabethtown, Pennsylvania Rupal Patel, PT, MS Texas Woman’s University Houston, Texas vii This page intentionally left blank ❶ Public Policy and therapists Chapter objeCtives Key Words At the conclusion of this chapter, the reader will be able to: Biomedical Model ❶ Disablement Explain the interaction between policy, systems, and everyday practice in Distributive Justice occupational therapy and physical therapy. Dualism ❷ Define power and describe how policy is used to create and distribute Health Services power in a society. Marginalization ❸ Compare and contrast the uses of private policy and public policy as a Social Disability method to effect social change. Universalism ❹ Discuss the experience of disablement using the medical disablement, social disability, and universalism models. ❺ Differentiate medical care and human services systems as components of the health care system for persons with disabilities. 1