Abstract:
Changes in the organization of health care have heightened issues of the cost of rehabilitative care, and their relationships to quality and outcomes to persons served. The provider-dominated system of the past has given way to increased initiative and dominance of payers. Managed care companies frequently enter into risk sharing or other contractual arrangements with rehabilitation programs to which they refer selected individuals. Capitated payment systems entail powerful incentives to deliver less care to persons with disabilities and chronic conditions, who are actuarially likely to require much more care than the average enrollee. Managed care and government cutbacks have decimated rehabilitation in some parts of the country (e.g., California). Other parts of the country (e.g., New Jersey) have only recently begun to experience such changes. The question of the degree of impact on necessary rehabilitative treatments and on functional outcomes is still unclear.
Nationwide costs. The lifetime cost of TBI has been estimated to be $115,300 per person. With 327,907 hospital admissions in 1985, this amounted to $37.8 billion dollars. “Direct” costs of hospital care are only a small part of this; lost work is the main quantifiable economic support. Stress to family and their lost productivity are difficult to quantify.
The effects of variations in the intensity and quality of rehabilitation programs on long-term support costs as well as on long-term productivity of the person with TBI have not been definitely established in the research literature. A few studies have attempted to elucidate correlations between quality or intensity of rehabilitation and patient gains in TBI. These exploratory investigations yielded no evidence that very expensive programs produce better outcomes than do less expensive ones, but their results are far from definitive.
Authors from the National TBI Model Systems report that a multiplicity of factors is involved in understanding treatment effort and costs. A limitation was that cost estimates (e.g. cost/charge ratios) were unavailable. Motorcycle and gunshot injuries are reportedly the most expensive of external causes of injury. Certain acute medical complications decrease likely functional outcomes and increase hospital costs.
This study will address the need for more information on how perceived financial factors and perceived clinical needs interact to affect the type and intensity of rehabilitation treatment provided. It will investigate relationships to cost and functional outcomes using methods based on the simple causal model below.
The general goal is to examine the relationship of financial factors to rehabilitative treatments delivered and their correlation with functional disability and community participation outcomes. Objectives are: (1) to describe financial factors and incentives quantitatively; (2) to describe correlations between financial factors (e.g., estimated total payment resources) and treatment efforts (LOS, charges, estimated costs); (3) to investigate the correlation of non-financial factors with treatment efforts and patient outcomes; (4) to identify groups with problems of access to needed care (e.g., on the basis of race, Medicaid status); and to (5) to estimate effects of financial factors on functional, controlling for confounding factors such as injury severity and race.