Abstract:
The impact of third party payers on health care service delivery, especially with the rapid growth of managed care in the 1990s, is a subject of regular comment and lament among providers as insurers continue to ratchet down reimbursable charges. For TBI, insurance companies increasingly question the value of certain kinds of treatment, e.g. cognitive remediation. Decisions about treatment for individuals with TBI are being made by insurers as well as, or instead of, clinicians to a greater extent than ever before.Studying the impact of variations in service availability is exceedingly difficult, since those who receive a given service typically differ from those who do not (e.g., in premorbid employment, education, and other factors that affect the degree of healthcare coverage), in ways that confound the comparison of their outcomes. In this research project, we are using qualitative methods to assess outcomes of individuals with TBI and the experiences of them and their primary caregivers as they move through various treatment programs that have been approved by insurers. Subjects are 16 individuals and family members who are nearing completion of their inpatient rehabilitation, selected to exhibit a range of functioning, to have large variations in the types of services that their specific health insurers will cover (e.g., Workers Comp, on the one hand, vs. HMO with a 60-day limit of outpatient therapy and no coverage for durable medical equipment, on the other), and to have a caregiver willing to participate in the interview process.At the time the subject and caregiver are identified, the treatment team is asked to identify specific follow-up services that are recommended irrespective of whether the patient's insurance is anticipated to cover them. The specific functional goals to be achieved through those services are also identified by the treatment team. Armed with this background, clients and caregivers are interviewed using qualitative methods at two points in time. The first is just prior to enrollment in the next service component (if approved by the payor) or alternative care plan (if not). The second interview is conducted upon completion of the recommended plan of treatment (if approved) or at the approximate time that treatment would be expected to conclude. The interviews focus on the subject and caregiver's perception of the services received, their functional goals, and the outcomes achieved.Data are collected through audiotaped, direct, open ended interviews. Qualitative methods will be used to understand the relationships among the availability of the recommended treatment program, anticipated and achieved outcomes, severity of injury, and client and family resources.