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(Editor’s note: Rehab Continuum Report presents this special report about how current reimbursement changes, market forces, and demographic trends will have an impact on rehabilitation care in coming decades. Included in this issue are snapshot articles about various rehab trends and how they will impact rehab’s future. Articles about the future of rehab are presented in this issue and will be continued in the June 2001 issue.)
Some monumental changes now under way likely will have a big impact on how rehabilitation services are delivered in the next decade or two, predict 14 rehab industry experts who were asked by Rehab Continuum Report to provide snapshots of future trends.
Those working with or in the rehab industry say there are three major forces (and many smaller ones) that are changing the industry. Medicare reimbursement, staffing shortages, and the aging baby boomer generation will have the biggest impact on the industry. Close behind will be technological improvements, including the move to paperless documentation, increased emphasis on quality by regulators, changes in private health insurance, an increased push for wellness programs and diversification of services, and customized accreditation services.
Rehabilitation facilities will need to both improve their quality of care and cut the cost of delivering that care, says Kurt Hoppe, MD, medical director of rehabilitation and post-acute care services for the Iowa Health System and Iowa Methodist Medical Center in Des Moines. Hoppe also is the chair of the American Hospital Association section for long-term care and rehabilitation, and he’s the chair of the American Academy of Physical Medicine and Rehabilitation health policy and legislation committee. "It’s going to require a greater understanding of the balance between quality, costs, and access," Hoppe says.
No matter how it’s written, the final prospective payment system (PPS) rule for inpatient rehabilitation facilities will have an enormous impact on the way inpatient rehab operates in coming years, says Martin Schaeffer, MD, medical director of the department of physical medicine and rehabilitation at the DuBois (PA) Regional Medical Center. "Up until now, rehab has been under an old cost-based system, so the incentive for managing costs wasn’t there," Schaeffer says. "With the new payment system, it will greatly affect how all inpatient rehab facilities operate, and they’re going to have to be very cognizant of the efficiency of the care they are providing and the costs and outcomes related to costs."
This will be a major paradigm shift in how rehab facilities operate, Schaeffer adds. "There has never been a major change like this in the history of rehab systems."
Medicare’s reimbursement changes will have a dramatic effect on the industry, leading to more centralization and making it far more difficult for smaller rehab units to survive, predicts Gary Ulicny, PhD, chief executive officer and president of the Shepherd Center in Atlanta.
One of the changes PPS heralds is a push toward greater and more burdensome licensure regulation, says J. Scott Gebhard, senior vice president for Solaris Health System in Edison, NJ. "This is going to shape the way we have to structure our systems, and they are invariably going to have the potential to add overhead requirements for each of us, making it more and more difficult to produce a [profit] margin," Gebhard says.
Medicare and other reimbursement changes will result in rehab providers having to focus more on patient and family education than they have in the past, says Sheldon Herring, PhD, clinical director of the traumatic brain injury program of Roger C. Peace Rehabilitation Hospital, which is part of the Greenville (SC) Hospital System. "Under decreased length of stay, progressively sicker and sicker individuals are going home earlier and earlier, so the care demands on their families are going to continue to increase," Herring says. "Family training is an important part of rehabilitation, but in the future I think it will be of even greater importance because the family may be carrying the burden for what used to be seen as part of acute care rehabilitation."
While PPS and work-force shortages will have an immediate impact on rehab during the short term, one of the big trends to watch in the long term is the effect of the baby boom generation, typically defined as those born between 1946 and 1964, as they begin to age and need rehab services.
"Clearly there is the whole demographic issue of baby boomers getting older and having an impact on the whole health care continuum and needing more rehab services," says Carolyn Zollar, JD, vice president for government relations of the American Medical Rehabilitation Providers Association in Washington, DC.
Rehab services once were considered a separate health care entity, but now are ubiquitous throughout the health care system in both institutional and non-institutional settings, and this trend will only increase, says Susanne Sonik, director of the section for long-term care and rehabilitation of the American Hospital Association in Chicago.
The baby boom generation, which is a very sophisticated consumer group, recognizes the need for rehab in a variety of health situations and will ask for more flexibility and control about where and when their rehab services are offered, Sonik says. "And their preference is not to be hospitalized or institutionalized whenever possible, so the preference might be home health rehab services," Sonik adds.
Baby boomers also have far greater expectations for recovery than did previous generations, notes Nancy Beckley, MS, MBA, president of the Bloomingdale Consulting Group of Valrico, FL. "In our parents’ generation, when a doctor told them that they had a stroke and so now they’ll have to take it easy, they would take it easy," Beckley says. "People in the baby boom generation may have a stroke, but they’ll ask what they need to do to get back to work the next week." Baby boomers expect a lot from health care, and they think that whatever they want, health care should deliver, Beckley adds.
The baby boom also is more computer-savvy than previous generations. This means they have access to health care information on-line, which makes them more likely to ask tough questions of their health care providers, says Peggy Neale, MA, MBA, national director of medical rehabilitation for CARF The Rehabilitation Accreditation Commission in Tucson, AZ. "They want more information, and they have a lot of questions, and if they don’t ask for it, their children will," Neale adds.
Neale also notes that the rehab industry will need to become more technologically advanced itself for a multitude of reasons, including improving patient care, improving documentation, and making the accreditation or regulatory survey process easier. (See "Leadership panel identifies future trends," in this issue.) CARF recently began to experiment with web-based accreditation surveys and conducted a very successful intranet survey at Glancy Rehab Center of Gwinnett Hospital System in Duluth, GA, Neale says.
Glancy Rehab Center has reduced hours of staff time and paperwork by designing a web site, used in-house, that includes all of the center’s documentation, compliance records, and standards, says Katrina Stone, MA, education coordinator of post-acute services. A CARF surveyor had access to the facility’s web site and conducted the paperwork review portion of the survey entirely by reviewing the electronic files, Stone adds.
As the baby boomer generation ages and begins to experience health catastrophes, the sheer size of this group will require rehab facilities to offer more diverse rehab services, including cardiac-pulmonary rehab and rehab for patients with neurological deficits secondary to the effects of cancer, brain tumors, spinal tumors, and other problems, says Melinda Clark, president of SSM Rehab in St. Louis.
Expected growth in the need for rehab services also will have a big impact on staffing, which already is a major concern for some rehab providers. "It’s clear to me, when you simply look at the demographics, particularly in a state like Maine with a very aging population, we’ll have a greater demand for our services," says Greg Gravel, president of MaineGeneral Rehabilitation and Nursing Care in Augusta, ME. "The challenge for us is: Where will we find the professional staff?" Gravel says.
The American Occupational Therapy Association (AOTA) in Bethesda, MD, has observed a diminishing enrollment in occupational therapy schools, which could present future problems unless it’s reversed, says Maureen Freda Peterson, MS, OTR/L, practice department director for AOTA. Part of the reason for the decrease in enrollment may be that women — who account for close to 98% of all occupational therapists — have more professional opportunities today than ever before, so they may be choosing non-health care fields more frequently, Peterson explains.
Since 1998, the number of applicants to the 212 physical therapy schools has decreased, but the schools still have an adequate supply of qualified applicants, says Ben Massey Jr., PT, president of the American Physical Therapy Association in Alexandria, VA. "In the mid-1990s, physical therapists were in high demand, and then with the Balanced Budget Act of 1997, there have been quite a few changes," Massey says. "Up until a year ago, we had about 3.2% unemployment for physical therapists, and now it’s down to 1.8%, according to a recent survey, so in fact right now there are PTs that are looking for jobs."
J. Scott Gebhard, Senior Vice President, Solaris Health System, and Administrator, JFK Johnson Rehabilitation Institute, 65 James St., Edison, NJ 08820. Telephone: (732) 321-7050.
Kurt Hoppe, MD, Medical Director, Rehabilitation and Post-Acute Care Services, Iowa Health System, Iowa Methodist Medical Center, 1200 Pleasant St., Des Moines, Iowa 50309-1453. Telephone: (515) 241-8665.
Sheldon Herring, PhD, Clinical Director of Traumatic Brain Injury Program, Roger C. Peace Rehabilitation Hospital, Greenville Hospital System, 651 South Main St., Greenville, SC 29601. Telephone: (864) 241-2600.
Martin Schaeffer, MD, Medical Director, Department of Physical Medicine and Rehabilitation, DuBois Regional Medical Center, DuBois, PA. Telephone: (814) 375-4660.
Nancy Beckley, MS, MBA, President, Bloomingdale Consulting Group, 1421 Holleman Drive, Valrico, FL 33594. Telephone: (813) 654-4130.
Peggy Neale, MA, MBA, National Director of Medical Rehabilitation, CARF The Rehabilitation Accreditation Commission, 4891 East Grant Road, Tucson, AZ 85712. Telephone: (520) 325-1044, ext. 180.
Susanne Sonik, Director of the Section for Long Term Care and Rehabilitation, American Hospital Association, One North Franklin, Chicago, IL 60606. Telephone: (312) 422-3000.
Katrina Stone, MA, Education Coordinator/Post Acute Services, Glancy Rehab Center, Inpatient Program, Gwinnett Hospital System, 3215 McClure Bridge Road, Duluth, GA 30096. Telephone: (678) 584-6796.
Gary Ulicny, PhD, President and Chief Executive Officer, Shepherd Center, 2020 Peachtree Road, Atlanta, GA 30309. Telephone: (404) 350-7311.
Carolyn Zollar, JD, Vice President for Government Relations, American Medical Rehabilitation Providers Association, 1606 20th St. NW, Suite 300, Washington, DC 20009. Telephone: (202) 265-4404.
Melinda Clark, President, SSM Rehab, 6420 Clyton Road, St. Louis, MO 63126. Telephone: (314) 768-5362.
Greg Gravel, President, Maine General Rehabilitation and Nursing Care, 40 Glenridge Drive, Augusta, ME 04330. Telephone: (207) 623-2593.
Ben Massey, Jr., PT, President, American Physical Therapy Association, 1111 N. Fairfax St., Alexandria, VA 22314. Telephone: (703) 706-3248.
Maureen Freda Peterson, MS, OTR/L, Practice Department Director, American Occupational Therapy Association, 4720 Montgomery Lane, P.O. Box 31220, Bethesda, MD 20824-1220. Telephone: (301) 652-2682. Fax: (301) 652-7711.