Health Services: Policy and Systems for Therapists

Cover
Contents
Preface
Reviewers
1 Disablement, Policy, and Systems
	Chapter Objectives
	Introduction
	Policy and Power
	Sources of Power
		Government
		Political Process
		Private Enterprise
	Ethics and Values
	Experience of Disablement
		Biomedical Model
		Social Disability Model
		Universalism
	Therapists and the Health Care System
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
2 Access and Cost of Health Care
	Chapter Objectives
	Introduction
	Access to Health Care Services
		Availability
		Accessibility
		Accomodation
		Acceptability
		Affordability
	Access and Health Insurance
		Characteristics of the Uninsured
		Health Status of the Uninsured
		The Working Uninsured
	Cost of Health Care
		Health Care Financing: Where It Comes From
		Health Care Financing: Where It Goes
		The Growth of Health Care Expenditures
	Payment Mechanisms and Health Care Expenditures
	Access and Cost: A Therapist Perspective
		Effects of Direct Access on Therapy Practice
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
3 Quality of Health Care
	Chapter Objectives
	Introduction
	Perspectives on Health Care Quality
	Structure, Process, and Outcomes
		Structure
		Process
		Outcomes
	Accreditation
		Joint Commission on the Accreditation of Healthcare Organizations
		Commission on Accreditation of Rehabilitation Facilities
		National Committee on Quality Assurance
	Legal Issues and Quality
	The Future of Health Care Quality
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
4 Public Policies Addressing Social Disablement
	Chapter Objectives
	Introduction
	Public Policies Supporting Youths and Older Adults
		The Individuals with Disabilities Education Act (IDEA)
		IDEA and Therapy
		The Developmental Disabilities Act (DDA)
		The DDA and Therapy
		The Older Americans Act (OAA)
	Work-Related Policy Acts
		The Workforce Investment Act (WIA) (Rehabilitation Act, [RA])
		The Workforce Investment Act and Therapy
		Work Incentives Improvement Act of 1999 (P.L. 106-170) and Ticket to Work and Self-Sufficiency Program
		The Future of Work-Related Public Policies
		The Americans with Disabilities Act (ADA)
		Therapy and the ADA
		Social Security Income Programs
		Housing Programs for Persons with Disabilities
	Technology and Persons with Disabling Conditions
		The Assistive Technology Act of 1998
		The Assistive Technology Act of 2004
		Therapists and the ATA
	Working with Policies Addressing Social Disablement
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	Internet Resources
	Reference
5 Fundamentals of Insurance
	Chapter Objectives
	Introduction
	Why Have Health Care Insurance?
		Purpose of Insurance
		Risk and Insurance
	Organization and Administration of Health Care Insurance
		Actuarial Adjustment and Insurance
		Moral Hazard and Insurance
	Basics of an Insurance Contract
		Eligibility
		Covered Events
		Covered Services
		Cost Limits
		Beneficiary Cost Limits
		Provider Cost Limits
		Coordination of Benefits
	Types of Insurance
	Sponsorship
		Private Insurance
		Self-Insurance
		Direct Contracting
	Method of Cost Sharing
		Indemnity Insurance
		Service Benefit Plans
	Covered Events/Services
		Long-Term-Care Insurance
		Workers' Compensation
		Casualty Insurance
	Regulation of Insurance
		Insurance Regulation
		Employee Retirement Income Security Act of 1974
		Continuation Issues
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
6 Managed Care and Beyond
	Chapter Objectives
	Introduction
	Defining Managed Care
	Managed Care Principles
		Limited Access to the Universe of Providers
		Payment Mechanisms That Reward Efficiency
		Enhanced Quality Improvement Monitoring
	Managed Care Products
		Managed Indemnity
		Preferred Provider Organizations
		Health Maintenance Organizations
		Point of Service (POS)
		Market Shares of Health Plan Types
	Managed Care Provider Structures
		Staff Model
		Group Model
		Network Model
		Independent Practice Associations
	Effect of Managed Care on Physical Therapy and Occupational Therapy Practice
		MCOs: Benefits and Concerns for Therapists
		Managed Care Benefits
		Managed Care Concerns
	Adapting to the Changes Brought About by Managed Care
		Importance of Good Communication
		Case Managers and Managed Care
	Health Care Environment Trends Related to Managed Care
		Patient Bill of Rights
		Pay for Performance
		Consumer-Directed Health Plans
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
7 Medicare
	Chapter Objectives
	Introduction
	History of Medicare
	Scope and Organization of Medicare
	Medicare Eligibility
		Part A: Eligibility
		Part B: Eligibility
	Original Medicare Part A: Hospital Insurance
		Benefits
		Benefit Period
		Skilled Nursing Facility Benefit
		Home Health Care Benefit
		Inpatient Rehabilitation Facility Benefit
		Hospice Benefit
	Part B: Supplementary Medical Insurance (SMI)
		Benefits
		Provider Types
	Medicare and Therapy Services
		“Incident To” Therapy Procedures
	Part A: Payment Structures
		Hospital Prospective Payment
	Part A: Prospective Payment for Post-Hospital Services
		Inpatient Rehabilitation Facility Prospective Payment
	Case Example of a Part A Prospective Payment System Calculation
	Medicare Part B: Payment Structure
		Fee Schedule
		Provider Participation
		Financial Limitations on Medicare Part B Therapy Services
	Medicare Advantage Plans
	Medicare Part D
	Private Health Insurance and Medicare
	Quality and Medicare
	Fraud and Abuse
		Physician Self-Referral Restrictions
	Medicare Reform
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
8 Medicaid, SCHIP, Military/Veterans Medical Insurance, and Indian Health Service
	Chapter Objectives
	Introduction
	Medicaid
		What Is Medicaid?
		Who Is Eligible for Medicaid?
		Medicaid Managed Care
		Medicaid Services
	State Children's Health Insurance Program (SCHIP)
	Veterans Administration and Military Health Insurance Programs
	Indian Health Service
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
9 The Acute Medical Care System
	Chapter Objectives
	Introduction
	Hospitals
		Historical Development
		Hospital Structure
		Hospital Characteristics
		Size
		Ownership
		General vs. Specialty
		Acute Care vs. Long-Term Care
		Teaching Hospitals
		Safety-net Hospitals
		Multihospital Systems and Networks
		Professionals Working in Hospitals
	Levels of Care
		Primary Care
		Therapists Working in Primary Care
		Secondary Care
		Tertiary and Quaternary Care
	Hospital Integration
		Physician–Hospital Relationships
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
10 The Post-Acute Health Care System
	Chapter Objectives
		Introduction
		Informal Care
		Formal Care
		Nonresidential Formal Care
			Home Health Care
			Hospice Care
			Adult Day Services
		Residential Formal Care
			Assisted Living
		Skilled Nursing Facilities
		Subacute Care
		Inpatient Rehabilitation Facilities
	Community-Based Mental Health Practice
		Community Health Centers
		Clubhouse Models
		Adult Day Care Programs
		Nursing Homes
		Nontraditional Settings
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
11 Special Education, Public Health, and Complementary/ Alternative Medicine
	Chapter Objectives
	Introduction
	Special Education
	What Is Public Health?
	Organization of Public Health Services
	Assessment
	Policy Development
	Assurance
	Public Health and Therapy Services
	Complementary and Alternative Medicine
	Conclusion
	Chapter Review Questions
	Chapter Discussion Questions
	References
12 Effecting Policy Change: Therapist as Advocate
	Chapter Objectives
	Introduction
	Advocacy and Ethics
	Therapist Skills for Advocacy
		Assertive Communication
		Patient/Client Advocacy Skills
		Professional Level of Advocacy
		Advocacy with Professional Organizations
		Advocacy with the Health Care Environment
	Sequence for Advocacy
		Step I: Knowledge
		Step II: Research
		Step III: Implementing Political Action
		A Legislative Visit
		Appearing at Hearings and Preparing Testimony
	Conference Action
	Presidential Action
		Advocacy on the State Level
		Step IV: Reflection
	Conclusion
	Advocacy Resources
	Chapter Review Questions
	Chapter Discussion Questions
	References
Appendix
Glossary
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	D
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	G
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Index
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