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Lessons from the great battle: Health care reform, 1992–1994
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Lessons From the Great Battle: Health Care Reform, 1992-1994 Robert G. Frank, PhD
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N AWARD SUCH AS THIS provides a rare opportunity to examine issues from a highly personal perspective. In my time today I would like to discuss lessons I have learned while working on federal and state health care reform legislation, especially during the period from 1992 to 1994 when it appeared that health care reform was imminent in the United States. Unfortunately, the promise of comprehensive health care reform vaporized like the carmel light of an autumn evening only to be replaced by the harsh reality of incremental reform, really insurance reform, as we saw in the 104th Congress. Despite the demise of the great promise of comprehensive reform, there is much to learn from what occurred in this chapter of health care reform. My experiencesas a participant and observer seem to have value in considering the challenges that are ahead in the creation of an effective, equitable health care system in the United States. Before discussing the specific lessons, let me help you understand how I ended up in the halls of Congress and the Missouri State Capitol. Although I have had a long-standing interest in policy, my journey to actually being a participant began with my clinical work. I took my first faculty position as the only psychologist in PM&R in the School of Medicine. I had the opportunity to work in a wide array of areas, but I spent most of my time trying to establish a chronic pain service and working with individuals with spinal cord injury. Several years later we hired a second psychologist, Dr. SusanBuckelew. With Susan’s addition to the faculty, I diversified and began to do more work in brain injury. Traumatic brain injury had become a problem of increasing importance in rehabilitation and was beginning to be an issue at the national level. In Missouri, the chair of the Missouri Senate Finance and Government Operations Committee, Senator Ed Dirk, became interested in the issue of traumatic head injury after seeing the struggles of his neighbor’s child, who sustained a head injury. Teaming with Representative Marvin Proffer, who was the chair of the House Appropriations Committee, they created a Joint Committee on head injury to investigate the status of head injury in Missouri. The Joint Committee held hearings throughout the state. When there were hearings in Columbia, I testified regarding the need for community-based treatment programs that focused on reintegration of individuals into the community. The next year, acting on recommendations of the Joint Committee, the General Assembly created the Head Injury Advisory Council. I was asked to serve on the Council, which was chaired by Senator Dirk. Representative Proffer was also appointed, as were an array of influential and thoughtful individuals from every aspect of the head injury provider and advocacy community. With the able guidance of its Executive Director, Susan Vaughn, the Head Injury Council enjoyed remarkable success. From the College of Health Professions, University of Florida, Gainesville. Presented at the 73rd Annual Meeting of the American Congress of Rehabilitation Medicine, Chicago, IL, October 15, 1996. Reprint requests to Robert G. Frank, PhD, University of Florida College of Health Professions, PO Box 100185, Gainesville, FL 32610-0185. 0 1997 bv the American Conmess of Rehabilitation Medicine and the American Academy of Physical Medicine-and Rehabilitation 0003-9993/97/7802-4266$3.00/O
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During its first years, it was instrumental in passing legislation that created a registry for brain and spinal cord injury, supported a series of innovative programs for individuals with head injury, and was part of a coalition that passed mandatory seat belt legislation and a helmet law. On a personal level, my work on the Head Injury Council was an epiphany. After working for weeks and months with individuals who sustained head injuries to make small gains, I was stunned by the ability of legislators, with the stroke of a pen, to create significant differences in the quality of lives for individuals who sustained catastrophic injury. The broad power of policy and legislation to affect entire communities became apparent to me in a way I had never appreciated. In the late 198Os, I became aware of a program sponsored by the Robert Wood Johnson Foundation designed to bring faculty in academic health centers to Washington to spend a year working on health policy, a “hands-on” approach. Mike Whitcomb, who was the Dean of the School of Medicine, told me of his experience as an RWJ Fellow. He worked with a Senator from Indiana who was unknown to me at that time, Dan Quayle. I applied for the Fellowship in 1988, only to be rejected. Somewhat chagrined, I put aside my hopes for a policy experience and focused on the opportunities I had in Missouri through work on the Head Injury Council, my research, and clinical work. In 1990, at the urging of Patrick DeLeon, who is Chief of Staff for Senator Daniel Inouye of Hawaii, I reapplied to the Robert Wood Johnson’s Health Policy Fellows Program. This time, having learned something from my exposure to politics, I took a much more political approach. I sought the counsel of previous fellows and enjoyed the mentoring of Dr. Danny Wedding, who was the first psychologist selected for the Robert Wood Johnson Health Policy Fellowship. I was selected. In September of 1991, with the extraordinary support of my dean, Lester Bryant, I found myself and my family living in Bethesda, MD. From September through December, I attended the Robert Wood Johnson Fellow orientation program, which is a remarkable, intense immersion in health policy, tutored by the foremost experts in the country. I determined that I was interested in working in the Senate because I believed the smaller size made it more likely I would develop a comprehensive picture of the functioning of that house within the fellowship year. After much consideration, I decided that I was interested in working on a Senator’s personal staff as opposed to working on a committee staff. Although a committee position was in many ways more compatible with my background, I was interested in understanding the life of a Senator and seeing how a Senate office works. Also, I decided that I was interested in working on one of the the health authorizing committees in the Senate, the Senate Finance Committee or the Senate Labor and Human Resources Committee. There were no opportunities available with Senators from Missouri on either committee, but Senator Jeff Bingaman, a Democrat from New Mexico in his second term had recently been assigned to the Senate Labor and Human Resources Committee. My interview with Senator Bingaman and his Health Legislative Assistant, Carrie Billy, led me to believe that they were interested in having a Robert
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Wood Johnson Health Policy Fellow in their office. Although I did not recognize it at the time, my decision to work with Senator Bingaman and Carrie Billy opened the door to a number of incredible experiences. I would work with both of them long beyond the end of my fellowship. Because of their support and their ability to involve me in health policy, I had the opportunity to work on an array of health reform legislation, to participate in both the office and committee functions in the Senate, and to help craft both incremental and comprehensive legislation. I sat on the Senate floor and listened to Senator Bingaman introduce a bill that I played a major role in authoring, I attended the Joint Sessionof Congress when President Clinton introduced his health care reform plan, I worked through the night to help the Senate Labor and Human Resources Committee pass a version of that bill out of committee, and I got to hear about health care reform from a host of people, from ranchers to optometrists to physicians and every other type of provider. At the end of my fellowship I returned to the University of Missouri where Dean Lester Bryant asked me to serve, parttime, as his advisor on health policy issues.In this role, I continued to work with Senator Bingaman and also began to learn about state health policy issues. In 1994, Governor Mel Carnahan was inaugurated Governor of Missouri and appointed Dr. Coleen Kivlahan to be the Director of the Department of Health. Dr. Kivlahan was energetic, passionate, and deeply committed to improving Missouri’s health care delivery system. My first meeting with her stretched into a two-hour discussion on how we could develop health reform initiatives in Missouri. Over a series of months we developed a plan to review Missouri’s health care needs and to devise legislation to address those areas. With the backing of Governor Camahan, Dr. Kivlahan launched the ShowMe Health Reform Initiative. Over the next year, working with a team of 48 individuals, the ShowMe Health Reform Initiative would recommend a series of legislative initiatives that led to the introduction of House Bill 1622, a comprehensive health care reform bill. For me, this was an extraordinary period. While serving as the Director of the ShowMe Health Reform Initiative, I returned to Washington to work in Senator Bingaman’s office on his health reform initiatives and the Clinton health reform process. In the spring of 1994, I spent 10 weeks working in Washington for Senator Bingaman on the Labor Committee markup of the Clinton Healthcare Reform Bill. Together, these experiences provided me with some insight into the nature of health care reform. I have summarized this learning with seven principles. Principle 1: Health care reform is an ongoing phenomenon marked by occasional periods of public interest. Although it is tempting to conclude that interest in reforming our health care system is a relatively new passion, a careful review of the history of health care systems reveals that the current debate has echoes dating back at least 100 years. Indeed, the very development of academic health centers stems from moral conflict at the end of the last century regarding stark differences between relatively affluent individuals served in community hospitals and the “have-riots.” A solution to this dilemma was the creation of teaching hospitals that provided service to those without money in return for their willingness to serve as “teaching material.“’ Our ambivalence over society’s obligation to the uninsured has continued to reverberate throughout the 20th century. Now, 100 years later, the United Statesstill lacks a method for providing health care for individuals without resources. In the 1992 presidential campaign, concerns over ever-escalating costs and poor quality of health services led to calls for reform of the health care system. This interest in reform marked the latest in a cycle of efforts to modify the health care system. Roughly
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every 15 to 20 years, there is renewed interest in reforming the health care system. In 1992, President Clinton led an effort for comprehensive reform. In 1972, President Nixon supported a comprehensive reform package that came close to winning approval, but fell apart when the Wilbur Mills scandal occurred. In 1965, comprehensive legislation was passed creating Medicare/ Medicaid. In the 1940s President Truman urged universal health care coverage for all Americans. In the 1930s President Roosevelt considered health care as part of the New Deal with Social Security, but decided it would prove too controversial for the package. Recently, extensive attention has been directed to managed care systems that focus on controlling health care costs largely by managing access to health care specialists who are more expensive. The irony of managed care is that only a few programs have focused on controlling costs through more effective treatment programs for individuals with chronic illness. Instead, the emphasis has been on denying care through gatekeepers. Review of health care costs reveals that individuals with one or more chronic conditions account for only about 15.7% of the population, but more than 41% of health spending.2 Although health costs have moderated over the last few years, continued cost pressures, the aging of the population, and our failure to find adequate solutions to health coverage for all Americans guarantee health reform discussions will continue well into the future. Principle 2: The rush to market reform will moderate and chronic health care issues will dominate. Efforts to develop affordable, quality care for individuals with chronic and disabling conditions is the biggest challenge facing the health care system. The demise of health care reform in 1994 led to the implementation of a laissez-faire policy in which the market has been allowed to drive reform of the health care system. This approach, which relies extensively on the control of costs through managed care systems, has focused almost entirely on acute care sectors. An apt generalization is where there has been attention to chronic disorders, the focus has been on limiting accessto services rather than developing innovative programs that reduce overall consumption and utilization of resources. The development of the market-driven reform has led to an emphasis on “for-profit health care.” A consequence of the dominance of for-profit health care has been a radical shift in the premises that have guided clinical care. A major shift resulting from this new philosophical approach has been that effective treatments may be viewed as proprietary. When a health plan is more effective at treating a chronic disorder, plan managers become concerned that public knowledge of this effectiveness will lead to “adverse selection,” in which sicker people choose the plan in hopes of receiving more effective care. Becausesicker people will have higher resource utilization and capitated models are based on the control of resources, plan managers actively discourage dissemination of effective treatment protocols that may inform high-cost populations of a plan’s success.Thus, a paradox of the current market-driven model is that there can be minimal dissemination of knowledge regarding cost-effective treatments to individuals with high-cost disorders. It is to the advantage of a health plan to label such information proprietary so that it does not lead to higher utilization that can be disastrous to the health plan. For a society committed to the open exchange of information and a societal code that treats all individuals as equals, there is an undeniable pathos in recognizing how the market-driven health care system has veered from our fundamental values. The growth of market-driven systems has led to the development of “organized delivery systems.“3 Organized delivery systems Arch
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have been defined by Shortell and colleagues3 as “a network of organizations that provides or arranges to provide a coordinating continuum of services to a defined population, is willing to be held clinically and fiscally accountable for outcomes and health status in another population served.” Organized delivery systems may be created through virtual integration or through a series of contracts and strategic alliances. While most health care systems focus on the financial health of the enterprise, organized delivery systems are much more than the sum of their financial report. Organized delivery systems “are social and organizational mechanisms for improving community health and well being through disease prevention, health promotion, illness treatment, rehabilitation, chronic disease management, and a provision of palliative care.“3 Organized delivery systems, in theory, address many of the ills affecting a market-driven system. Responsibility for health outcomes is placed on the provider system, along with financial responsibility. Before the proliferation of organized delivery systems, hospital delivery systems focused on the growth and success of facilities. The advent of organized delivery systems shifts focus from the health of the hospital to the health of the population served. Increasingly, health systems are held accountable for the overall population served and for the preventive and palliative services provided to those individuals. Organized delivery systems must be able to accept risk while having mechanisms to measure outcomes and assure the health of the population served. Fundamental to this process is the development of a comprehensive, broad continuum of care. This continuum typically includes prevention, primary care, acute care, rehabilitation, and health maintenance. The inclusion of rehabilitation as a distinct component of organized delivery systems emphasizes the importance of our profession and the opportunities for rehabilitation professionals to influence and have an impact on the development and management of organized delivery systems. The inclusion of rehabilitation as a distinct component of organized delivery systems will be ever more important as health systems try to the reign in the cost of chronic conditions. At this point, most efforts come under the rubric of disease management. Disease management focuses on episodes of care. This model begins to approach what rehabilitation provides, but falls short. Chronic conditions that have ongoing medical and disabling aspects are often amenable to rehabilitation models. Unfortunately, this model has not been well tested, nor the results widely disseminated.
Principle 3: All politics are local and all issues are political. The outcome of health care reform will he consensual and imperfect. When I worked on Capitol Hill, it was common for staffers to describe visits with health professionals as the “provider whine.” This dismissive appellation was used to describe health professionals who came to a senator’s office to explain the value of his or her specialty and how the senator should support that specialty’s right to a level of reimbursement that exceeds the average American’s income many times. Obviously, there was little sympathy among Hill staff, who are notoriously underpaid, for this view. The flip side to the provider whine, however, is provider clout. Provider clout is manifested, in my experience, in two ways. First, when organizations such as the American Medical Association or the American Congress of Rehabilitation Medicine, that are recognized as legitimate, though biased, spokespersons for a specific sector throw their weight behind an approach, these groups, and others like them, influence policy by speaking on behalf of a large number of individuals and often delivering significant levels of political contributions.
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A second way that provider clout can be manifested effectively is when patients speak on behalf of providers. During Missouri’s ShowMe Health Reform Initiative, chiropractors were fearful that they would be excluded from the list of reimbursed services. When Governor Carnahan held hearings throughout the state, chiropractors made sure that the audience was packed with patients who stood up and gave moving testimonials to their belief that chiropractors were primary care providers, were accessible, and were effective. Moreover, chiropractors assured that each and every one of these patients (probably while waiting to see them for an appointment) sent a letter describing their concerns. We received approximately 10 letters from chiropractors’ patients for every single letter we received from any other medical or health profession’s patient. This type of tough, comprehensive, long-term commitment to advocacy turns heads in Congress and in state capitols. Witness the effectiveness of chiropractors in gaining inclusion in provider panels as evidence of the success of this approach. I know that many of us struggle with the compromises required in politics. To paraphrase the saying, too often a perfect goal becomes the enemy of a good outcome. Effective politics requires compromise and the willingness to work with individuals and groups representing alternative, even antagonistic views. For example, a senior legislator, even with some unacceptable views, may do more for a cause than an opponent who lacks seniority and political experience.
Principle 4: In the future, changes in our health delivery system may he heralded by changes in the Medicaid system, especially for individuals with disability. Medicaid, as you know, is a joint state and federal program designed to provide health insurance for low income families and people with disabilities. Each state establishes its own eligibility standards, the type and amount and duration of services, payment rates, and administers its own programs. There are large variations among states with the federal government contributing 50% to 80% of the cost of Medicaid. The federal contribution is based on the average income of state residents.4 In 1994, 18.2 million children, 7.6 million adults who care for these children, 4.3 million elderly, and 5.4 million people with blindness and disability were covered by Medicaid. Medicaid is the largest insurer of long-term care for all Americans, including the middle class. Sixty-eight percent of all nursing home residents and 50% of all nursing home costs are covered through Medicaid. In 1994, states spent approximately $3,400 per person on participants in Medicaid. When a person was on Medicaid and also had a disability, states spent an average of $8,400. Nursing home programs are extraordinarily expensive, with an average cost of $9,100 per elderly person. Interestingly, 16% of the individuals meet the criteria for disability or blindness under Medicaid, but they account for 39% of total expenditures.’ Medicaid is the primary insurer for people with disabilities, covering six million people. In contrast, in 1985, only three million people received coverage under Medicaid’s criteria for individuals with blindness and disabilities. People with disabilities receive Medicaid coverage in several ways: first, in most states, if they are poor enough to qualify for Supplemental Security Income; second, in some states, if they have medical expenses that reduce income to a state designated level; third, in some states, if they reside in an institution and have income less than $13,074 per year; and fourth, if they are entitled to Medicaid Part A as a Social Security benefit and have income slightly above poverty level. Payments for individuals through Medicaid have grown substantially over the last decade. In 1985 Medicaid cost $13 billion, By 1995 that cost had grown to $42 billion. Because of
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these staggering growths, the Health Care Financing Administration has approved a number of home and community-based waivers that allow elderly, mentally and physically disabled beneficiaries to receive care in their homes. These waivers were first approved in 1981. The number of waivers has increased steadily, now numbering 204 in 49 states (Arizona functions under an 1115 Research Demonstration Waiver). Overall, Medicaid is a significant payer of health care expenses in the United States, accounting for 13% of all health care expenditures in 1993. Medicaid is the only safety net for individuals in poverty. Indeed, Medicaid is slowing the growth of the uninsured. From 1988 to 1994, there was a six point increase in the number of uninsured, from 61% to 67%.5 The growth of Medicaid and the breadth of services provided to individuals with disabilities makes this delivery system particularly important to individuals with interest in rehabilitation. Paradoxically, there seems to be little interest by rehabilitation providers to assume a leadership role in the development of innovative Medicaid projects. Rather than assessing local needs and working with Medicaid agency officials to develop innovative projects, rehabilitation providers have focused their efforts on Medicare and commercial payment streams. While this is understandable, the breadth of Medicaid, its importance as a safety net program, and the overall aggregate magnitude of its payments suggest that rehabilitation professionals must address Medicaid in the immediate future. Failure to recognize the importance of Medicaid and play a instrumental role will further marginalize the value of rehabilitation in the future. There are, however, a few bright spots for rehabilitation. The innovative programs at the University of Missouri, at the Ohio State University, and the Rehabilitation Institute of Michigan are stellar examples, but, unfortunately, there are few other models that can be pointed to as ways of involving rehabilitation in the Medicaid delivery system. The program at Missouri is particularly promising. This program utilizes a delivery system that focuses on “cardinal symptoms.” In this model, a disabling condition is recognized as the dominant health factor. Health care is then focused on the disabling condition. This model is a variant of the primary care approach. It recognizes that some health conditions, especially in chronic disorders, are so pervasive that health care needs should focus on that condition. Consumers can designate their primary provider who coordinates all care. Obviously, physiatry is well prepared to provide this type of care. The Missouri, Ohio State, and Rehabilitation Institute of Michigan models aside, our shortsightedness in failing to become actively and comprehensively involved in Medicaid, reflects, unfortunately, a long history. Like most medical specialties, rehabilitation’s interest in healthcare reform has been largely parochial. Unlike groups such as the American Academy of Pediatrics, (AAP) which has espoused truly altruistic programs, rehabilitation too often has focused on reimbursement issues, failing to address the needs of individuals with disability. This may be because rehabilitation continues to be poorly understood at both the federal and state levels. Whatever the cause, rehabilitation will succeed only when it focuses on health policy for individuals with disability, not narrower, self-serving insurers. Shortly after going to Capitol Hill in 1991, I was impressed by the “Women and Children First” legislative proposal of the American Academy of Pediatrics. In this nascent period of health care reform, the AAP put forth an incremental bill that, for a relatively small amount of money, provided comprehensive health benefits for women and children. What was remarkable about this bill was that although pediatricians would benefit by this legislation, it was not viewed with jaundiced eyes by
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members of Congress. Because the AAP had a long, ongoing, intense commitment to advocating on behalf of children on Capitol Hill, its political message was viewed as part of a social message that had a higher valence. Rehabilitation must assume this same position on behalf of adults and children with disability. TO do this, we must develop a cogent policy initiative.
Principle 5: The nature of political change: right time, right place, right leadership, right information. In politics, as in the rest of life, timing is everything. The best prepared legislation will flounder if it is not supported by effective political management and effective information dissemination and if the time for the view and values expressed in the legislation is not optimal. It is widely unappreciated among the public but is generally accepted in legislative circles that passage of legislation requires many years. Successful members of Congress and of state legislatures recognize that commitment and passion for a topic is critical to create the energy needed to repetitively introduce bills over multiple sessions. For example, while I was working with Senator Bingaman, he introduced a series of legislative initiatives that were ahead of the time. In 1992 he introduced an amendment to a bill in the Labor Committee that would have created a global budget for health care spending. Senator Kennedy, the Chair of the Labor Committee at that point, roundly dismissed this concept. Interestingly, two years later this same concept appeared in Senator Kennedy’s mark (the Committee Chair’s version of a bill) for the Clinton Health Bill. Similarly, in the same session of Congress, Senator Bingaman introduced the first managed competition legislation in the Senate, the Health Insurance Cooperative Act. Again, this met fierce resistance, especially from Democrats on the Labor Committee. Again, two years later, purchasing cooperatives were a fundamental part of the Labor Committee markup of the Clinton bill. Indeed, the final passage of the bill rested on the ability to forge a compromise on the size of purchasing cooperatives and whether purchasing cooperatives included Multiple Employee Welfare System programs (MEWAs).
Principle 6: The enduring nature of reform enhances the importance of professional groups and the ability to influence the process. Upon arriving on Capitol Hill, I was immediately impressed by the high value placed on health professionals’ views. Although there was a tendency to dismiss health professionals’ constant complaints about reimbursement, there was a fundamental respect for their thoughts on issues relating to the development of health care delivery systems, graduate medical education, etc. A consequence of this is that almost every member is interested and willing to hear the ideas of health professionals when these ideas are presented with an emphasis on the needs of patients or consumers. When these are presented in a more self-serving reimbursement-oriented manner, there is less interest and tolerance with the message. This does not mean that messages that benefit a profession cannot be conveyed successfully to Congress. In the 104th Congress, a provision of the Welfare Reform Act affected child day care centers. Advocates of this proposal deluged members of Congress with cutout doll figures colored with crayons by children. The comprehensiveness, pervasiveness, and salience of this message assured that their message was heard and, in fact, incorporated into legislation. Obviously, rehabilitation providers speaking with genuine concern and interest in the welfare of individuals with disability also carry a potent message. Too often, however, the image of rehabilitation providers, even when they are known on the Hill, is of groups viciously fighting for their piece of the pie while denying other parallel interests their share.
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Principle 7: Critical to the process of effective lobbying is a clear core identity and enabling vision that allow a profession to effectively pilot the political process.
The successof groups such as the AAP or chiropractors in conveying their message to legislators reflects their clear core purpose and core values that remain fixed while their strategies and practices change in a competitive market. Recently, Collins and Porras’j wrote a cogent review of the importance of an enduring vision in determining the long-term successof businesses.To adapt to rapid changes, almost every business needs to have a clearly defined senseof purpose. This senseof purpose can be defined as a vision that declares what the company can become and determines what can be changed and what must be preserved. The vision complements a core ideology that combines a company’s core values and core purpose. Although there is clear common purpose for professionals in rehabilitation, in our political activities we are too often focused on our need to educate politicians on what we provide, ignoring our clear core values and our shared vision of improving the lives of individuals with disabilities. Successful political action of groups such as ACRM requires a long-term commitment, extraordinarily innovative vision, and a clear core value that focuses on the development of innovative and effective health delivery systems for individuals with disability. Although I have taken great pains to describe how my experience allowed me to develop the concepts and principles that I have presented, there is nothing intrinsically complex about these issues. I imagine many of you could have generated a similar set of principles without the experiences I have been fortunate to enjoy. Indeed, my comments may simply reflect observations of the obvious. Even if that is the case, I hope that this opportunity will serve as a forum to help us focus on the next epic of health care reform. Clearly, there will be reform of Medicaid, and likely of Medicare, in the 105th Congress. The Clinton Administration, the Prospective Payment Assessment Commission (ProPac), and the Physician Payment Review Commission (PPRC) all have recommended that systems be
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implemented to address the current gaming of the subacute and rehabilitation systems by the transfer of patients from acute hospitals to rehabilitation and subacute units?.’ This likely reform provides our profession with the opportunity to begin developing innovative, effective models of rehabilitation based on single episodes of payment. As an association, we are capable of coming together and working with foundations and the Health Care Financing Administration to develop these types of models. Among our members are individuals with substantial expertise in developing both the financial and clinical delivery systemsnecessaryto test new and effective models of providing rehabilitation care. Rather than letting laissez-faire market dynamics drive rehabilitation into unfriendly constellations, we should attempt to determine our fate by actively recognizing the principles governing political action and the opportunities we have to leverage this process. Acknowledgment: I thank Dr. Timothy Elliott for the comments he provided on an earlier draft of this manuscript. References 1. Stevens R. In sickness and in wealth: American hospitals in the twentieth century. New York: Basic Books, Inc., 1989. 2. Pope AM, Tarlov AR, editors. Disability in America: toward a national agenda for prevention. Washington (DC): National Academy Press, 1991. 3. Shortell SM, Gillies RM, Anderson DA, Erikson KM, Mitchell JB. Remaking healthcare in America. San Francisco: Jossey-Bass Publishers, 1996. 4. Frank RG, Sullivan MJ, DeLeon PH. Health care reform in the states. American Psychologist 1994;49:855-67. 5. Medicaid: An overview. Health and Human Services Health Care
FinancingAdministration.Washington(DC): GovernmentPrinting Office, 1995. 6. Collins JC, Porras JI. Building your company’s vision. Harvard Business Review 1996; September/October:65-77. 7. Annual report to Congress 1996. Physician Payment Review Commission. Washington, (DC): Government Printing Office, 1996. 8. Report and recommendations to the Congress. Prospective Payment Assessment Commission. March, 1996. Washington (DC): Govemment Printing Office, 1996.
THE 46TH ANNUAL
JOHN STANLEY
COULTER LECTURE
Lessons From the Great Battle: Health Care Reform, 1992-1994 Robert G. Frank, PhD
A
N AWARD SUCH AS THIS provides a rare opportunity to examine issues from a highly personal perspective. In my time today I would like to discuss lessons I have learned while working on federal and state health care reform legislation, especially during the period from 1992 to 1994 when it appeared that health care reform was imminent in the United States. Unfortunately, the promise of comprehensive health care reform vaporized like the carmel light of an autumn evening only to be replaced by the harsh reality of incremental reform, really insurance reform, as we saw in the 104th Congress. Despite the demise of the great promise of comprehensive reform, there is much to learn from what occurred in this chapter of health care reform. My experiencesas a participant and observer seem to have value in considering the challenges that are ahead in the creation of an effective, equitable health care system in the United States. Before discussing the specific lessons, let me help you understand how I ended up in the halls of Congress and the Missouri State Capitol. Although I have had a long-standing interest in policy, my journey to actually being a participant began with my clinical work. I took my first faculty position as the only psychologist in PM&R in the School of Medicine. I had the opportunity to work in a wide array of areas, but I spent most of my time trying to establish a chronic pain service and working with individuals with spinal cord injury. Several years later we hired a second psychologist, Dr. SusanBuckelew. With Susan’s addition to the faculty, I diversified and began to do more work in brain injury. Traumatic brain injury had become a problem of increasing importance in rehabilitation and was beginning to be an issue at the national level. In Missouri, the chair of the Missouri Senate Finance and Government Operations Committee, Senator Ed Dirk, became interested in the issue of traumatic head injury after seeing the struggles of his neighbor’s child, who sustained a head injury. Teaming with Representative Marvin Proffer, who was the chair of the House Appropriations Committee, they created a Joint Committee on head injury to investigate the status of head injury in Missouri. The Joint Committee held hearings throughout the state. When there were hearings in Columbia, I testified regarding the need for community-based treatment programs that focused on reintegration of individuals into the community. The next year, acting on recommendations of the Joint Committee, the General Assembly created the Head Injury Advisory Council. I was asked to serve on the Council, which was chaired by Senator Dirk. Representative Proffer was also appointed, as were an array of influential and thoughtful individuals from every aspect of the head injury provider and advocacy community. With the able guidance of its Executive Director, Susan Vaughn, the Head Injury Council enjoyed remarkable success. From the College of Health Professions, University of Florida, Gainesville. Presented at the 73rd Annual Meeting of the American Congress of Rehabilitation Medicine, Chicago, IL, October 15, 1996. Reprint requests to Robert G. Frank, PhD, University of Florida College of Health Professions, PO Box 100185, Gainesville, FL 32610-0185. 0 1997 bv the American Conmess of Rehabilitation Medicine and the American Academy of Physical Medicine-and Rehabilitation 0003-9993/97/7802-4266$3.00/O
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During its first years, it was instrumental in passing legislation that created a registry for brain and spinal cord injury, supported a series of innovative programs for individuals with head injury, and was part of a coalition that passed mandatory seat belt legislation and a helmet law. On a personal level, my work on the Head Injury Council was an epiphany. After working for weeks and months with individuals who sustained head injuries to make small gains, I was stunned by the ability of legislators, with the stroke of a pen, to create significant differences in the quality of lives for individuals who sustained catastrophic injury. The broad power of policy and legislation to affect entire communities became apparent to me in a way I had never appreciated. In the late 198Os, I became aware of a program sponsored by the Robert Wood Johnson Foundation designed to bring faculty in academic health centers to Washington to spend a year working on health policy, a “hands-on” approach. Mike Whitcomb, who was the Dean of the School of Medicine, told me of his experience as an RWJ Fellow. He worked with a Senator from Indiana who was unknown to me at that time, Dan Quayle. I applied for the Fellowship in 1988, only to be rejected. Somewhat chagrined, I put aside my hopes for a policy experience and focused on the opportunities I had in Missouri through work on the Head Injury Council, my research, and clinical work. In 1990, at the urging of Patrick DeLeon, who is Chief of Staff for Senator Daniel Inouye of Hawaii, I reapplied to the Robert Wood Johnson’s Health Policy Fellows Program. This time, having learned something from my exposure to politics, I took a much more political approach. I sought the counsel of previous fellows and enjoyed the mentoring of Dr. Danny Wedding, who was the first psychologist selected for the Robert Wood Johnson Health Policy Fellowship. I was selected. In September of 1991, with the extraordinary support of my dean, Lester Bryant, I found myself and my family living in Bethesda, MD. From September through December, I attended the Robert Wood Johnson Fellow orientation program, which is a remarkable, intense immersion in health policy, tutored by the foremost experts in the country. I determined that I was interested in working in the Senate because I believed the smaller size made it more likely I would develop a comprehensive picture of the functioning of that house within the fellowship year. After much consideration, I decided that I was interested in working on a Senator’s personal staff as opposed to working on a committee staff. Although a committee position was in many ways more compatible with my background, I was interested in understanding the life of a Senator and seeing how a Senate office works. Also, I decided that I was interested in working on one of the the health authorizing committees in the Senate, the Senate Finance Committee or the Senate Labor and Human Resources Committee. There were no opportunities available with Senators from Missouri on either committee, but Senator Jeff Bingaman, a Democrat from New Mexico in his second term had recently been assigned to the Senate Labor and Human Resources Committee. My interview with Senator Bingaman and his Health Legislative Assistant, Carrie Billy, led me to believe that they were interested in having a Robert
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Wood Johnson Health Policy Fellow in their office. Although I did not recognize it at the time, my decision to work with Senator Bingaman and Carrie Billy opened the door to a number of incredible experiences. I would work with both of them long beyond the end of my fellowship. Because of their support and their ability to involve me in health policy, I had the opportunity to work on an array of health reform legislation, to participate in both the office and committee functions in the Senate, and to help craft both incremental and comprehensive legislation. I sat on the Senate floor and listened to Senator Bingaman introduce a bill that I played a major role in authoring, I attended the Joint Sessionof Congress when President Clinton introduced his health care reform plan, I worked through the night to help the Senate Labor and Human Resources Committee pass a version of that bill out of committee, and I got to hear about health care reform from a host of people, from ranchers to optometrists to physicians and every other type of provider. At the end of my fellowship I returned to the University of Missouri where Dean Lester Bryant asked me to serve, parttime, as his advisor on health policy issues.In this role, I continued to work with Senator Bingaman and also began to learn about state health policy issues. In 1994, Governor Mel Carnahan was inaugurated Governor of Missouri and appointed Dr. Coleen Kivlahan to be the Director of the Department of Health. Dr. Kivlahan was energetic, passionate, and deeply committed to improving Missouri’s health care delivery system. My first meeting with her stretched into a two-hour discussion on how we could develop health reform initiatives in Missouri. Over a series of months we developed a plan to review Missouri’s health care needs and to devise legislation to address those areas. With the backing of Governor Camahan, Dr. Kivlahan launched the ShowMe Health Reform Initiative. Over the next year, working with a team of 48 individuals, the ShowMe Health Reform Initiative would recommend a series of legislative initiatives that led to the introduction of House Bill 1622, a comprehensive health care reform bill. For me, this was an extraordinary period. While serving as the Director of the ShowMe Health Reform Initiative, I returned to Washington to work in Senator Bingaman’s office on his health reform initiatives and the Clinton health reform process. In the spring of 1994, I spent 10 weeks working in Washington for Senator Bingaman on the Labor Committee markup of the Clinton Healthcare Reform Bill. Together, these experiences provided me with some insight into the nature of health care reform. I have summarized this learning with seven principles. Principle 1: Health care reform is an ongoing phenomenon marked by occasional periods of public interest. Although it is tempting to conclude that interest in reforming our health care system is a relatively new passion, a careful review of the history of health care systems reveals that the current debate has echoes dating back at least 100 years. Indeed, the very development of academic health centers stems from moral conflict at the end of the last century regarding stark differences between relatively affluent individuals served in community hospitals and the “have-riots.” A solution to this dilemma was the creation of teaching hospitals that provided service to those without money in return for their willingness to serve as “teaching material.“’ Our ambivalence over society’s obligation to the uninsured has continued to reverberate throughout the 20th century. Now, 100 years later, the United Statesstill lacks a method for providing health care for individuals without resources. In the 1992 presidential campaign, concerns over ever-escalating costs and poor quality of health services led to calls for reform of the health care system. This interest in reform marked the latest in a cycle of efforts to modify the health care system. Roughly
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every 15 to 20 years, there is renewed interest in reforming the health care system. In 1992, President Clinton led an effort for comprehensive reform. In 1972, President Nixon supported a comprehensive reform package that came close to winning approval, but fell apart when the Wilbur Mills scandal occurred. In 1965, comprehensive legislation was passed creating Medicare/ Medicaid. In the 1940s President Truman urged universal health care coverage for all Americans. In the 1930s President Roosevelt considered health care as part of the New Deal with Social Security, but decided it would prove too controversial for the package. Recently, extensive attention has been directed to managed care systems that focus on controlling health care costs largely by managing access to health care specialists who are more expensive. The irony of managed care is that only a few programs have focused on controlling costs through more effective treatment programs for individuals with chronic illness. Instead, the emphasis has been on denying care through gatekeepers. Review of health care costs reveals that individuals with one or more chronic conditions account for only about 15.7% of the population, but more than 41% of health spending.2 Although health costs have moderated over the last few years, continued cost pressures, the aging of the population, and our failure to find adequate solutions to health coverage for all Americans guarantee health reform discussions will continue well into the future. Principle 2: The rush to market reform will moderate and chronic health care issues will dominate. Efforts to develop affordable, quality care for individuals with chronic and disabling conditions is the biggest challenge facing the health care system. The demise of health care reform in 1994 led to the implementation of a laissez-faire policy in which the market has been allowed to drive reform of the health care system. This approach, which relies extensively on the control of costs through managed care systems, has focused almost entirely on acute care sectors. An apt generalization is where there has been attention to chronic disorders, the focus has been on limiting accessto services rather than developing innovative programs that reduce overall consumption and utilization of resources. The development of the market-driven reform has led to an emphasis on “for-profit health care.” A consequence of the dominance of for-profit health care has been a radical shift in the premises that have guided clinical care. A major shift resulting from this new philosophical approach has been that effective treatments may be viewed as proprietary. When a health plan is more effective at treating a chronic disorder, plan managers become concerned that public knowledge of this effectiveness will lead to “adverse selection,” in which sicker people choose the plan in hopes of receiving more effective care. Becausesicker people will have higher resource utilization and capitated models are based on the control of resources, plan managers actively discourage dissemination of effective treatment protocols that may inform high-cost populations of a plan’s success.Thus, a paradox of the current market-driven model is that there can be minimal dissemination of knowledge regarding cost-effective treatments to individuals with high-cost disorders. It is to the advantage of a health plan to label such information proprietary so that it does not lead to higher utilization that can be disastrous to the health plan. For a society committed to the open exchange of information and a societal code that treats all individuals as equals, there is an undeniable pathos in recognizing how the market-driven health care system has veered from our fundamental values. The growth of market-driven systems has led to the development of “organized delivery systems.“3 Organized delivery systems Arch
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have been defined by Shortell and colleagues3 as “a network of organizations that provides or arranges to provide a coordinating continuum of services to a defined population, is willing to be held clinically and fiscally accountable for outcomes and health status in another population served.” Organized delivery systems may be created through virtual integration or through a series of contracts and strategic alliances. While most health care systems focus on the financial health of the enterprise, organized delivery systems are much more than the sum of their financial report. Organized delivery systems “are social and organizational mechanisms for improving community health and well being through disease prevention, health promotion, illness treatment, rehabilitation, chronic disease management, and a provision of palliative care.“3 Organized delivery systems, in theory, address many of the ills affecting a market-driven system. Responsibility for health outcomes is placed on the provider system, along with financial responsibility. Before the proliferation of organized delivery systems, hospital delivery systems focused on the growth and success of facilities. The advent of organized delivery systems shifts focus from the health of the hospital to the health of the population served. Increasingly, health systems are held accountable for the overall population served and for the preventive and palliative services provided to those individuals. Organized delivery systems must be able to accept risk while having mechanisms to measure outcomes and assure the health of the population served. Fundamental to this process is the development of a comprehensive, broad continuum of care. This continuum typically includes prevention, primary care, acute care, rehabilitation, and health maintenance. The inclusion of rehabilitation as a distinct component of organized delivery systems emphasizes the importance of our profession and the opportunities for rehabilitation professionals to influence and have an impact on the development and management of organized delivery systems. The inclusion of rehabilitation as a distinct component of organized delivery systems will be ever more important as health systems try to the reign in the cost of chronic conditions. At this point, most efforts come under the rubric of disease management. Disease management focuses on episodes of care. This model begins to approach what rehabilitation provides, but falls short. Chronic conditions that have ongoing medical and disabling aspects are often amenable to rehabilitation models. Unfortunately, this model has not been well tested, nor the results widely disseminated.
Principle 3: All politics are local and all issues are political. The outcome of health care reform will he consensual and imperfect. When I worked on Capitol Hill, it was common for staffers to describe visits with health professionals as the “provider whine.” This dismissive appellation was used to describe health professionals who came to a senator’s office to explain the value of his or her specialty and how the senator should support that specialty’s right to a level of reimbursement that exceeds the average American’s income many times. Obviously, there was little sympathy among Hill staff, who are notoriously underpaid, for this view. The flip side to the provider whine, however, is provider clout. Provider clout is manifested, in my experience, in two ways. First, when organizations such as the American Medical Association or the American Congress of Rehabilitation Medicine, that are recognized as legitimate, though biased, spokespersons for a specific sector throw their weight behind an approach, these groups, and others like them, influence policy by speaking on behalf of a large number of individuals and often delivering significant levels of political contributions.
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A second way that provider clout can be manifested effectively is when patients speak on behalf of providers. During Missouri’s ShowMe Health Reform Initiative, chiropractors were fearful that they would be excluded from the list of reimbursed services. When Governor Carnahan held hearings throughout the state, chiropractors made sure that the audience was packed with patients who stood up and gave moving testimonials to their belief that chiropractors were primary care providers, were accessible, and were effective. Moreover, chiropractors assured that each and every one of these patients (probably while waiting to see them for an appointment) sent a letter describing their concerns. We received approximately 10 letters from chiropractors’ patients for every single letter we received from any other medical or health profession’s patient. This type of tough, comprehensive, long-term commitment to advocacy turns heads in Congress and in state capitols. Witness the effectiveness of chiropractors in gaining inclusion in provider panels as evidence of the success of this approach. I know that many of us struggle with the compromises required in politics. To paraphrase the saying, too often a perfect goal becomes the enemy of a good outcome. Effective politics requires compromise and the willingness to work with individuals and groups representing alternative, even antagonistic views. For example, a senior legislator, even with some unacceptable views, may do more for a cause than an opponent who lacks seniority and political experience.
Principle 4: In the future, changes in our health delivery system may he heralded by changes in the Medicaid system, especially for individuals with disability. Medicaid, as you know, is a joint state and federal program designed to provide health insurance for low income families and people with disabilities. Each state establishes its own eligibility standards, the type and amount and duration of services, payment rates, and administers its own programs. There are large variations among states with the federal government contributing 50% to 80% of the cost of Medicaid. The federal contribution is based on the average income of state residents.4 In 1994, 18.2 million children, 7.6 million adults who care for these children, 4.3 million elderly, and 5.4 million people with blindness and disability were covered by Medicaid. Medicaid is the largest insurer of long-term care for all Americans, including the middle class. Sixty-eight percent of all nursing home residents and 50% of all nursing home costs are covered through Medicaid. In 1994, states spent approximately $3,400 per person on participants in Medicaid. When a person was on Medicaid and also had a disability, states spent an average of $8,400. Nursing home programs are extraordinarily expensive, with an average cost of $9,100 per elderly person. Interestingly, 16% of the individuals meet the criteria for disability or blindness under Medicaid, but they account for 39% of total expenditures.’ Medicaid is the primary insurer for people with disabilities, covering six million people. In contrast, in 1985, only three million people received coverage under Medicaid’s criteria for individuals with blindness and disabilities. People with disabilities receive Medicaid coverage in several ways: first, in most states, if they are poor enough to qualify for Supplemental Security Income; second, in some states, if they have medical expenses that reduce income to a state designated level; third, in some states, if they reside in an institution and have income less than $13,074 per year; and fourth, if they are entitled to Medicaid Part A as a Social Security benefit and have income slightly above poverty level. Payments for individuals through Medicaid have grown substantially over the last decade. In 1985 Medicaid cost $13 billion, By 1995 that cost had grown to $42 billion. Because of
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these staggering growths, the Health Care Financing Administration has approved a number of home and community-based waivers that allow elderly, mentally and physically disabled beneficiaries to receive care in their homes. These waivers were first approved in 1981. The number of waivers has increased steadily, now numbering 204 in 49 states (Arizona functions under an 1115 Research Demonstration Waiver). Overall, Medicaid is a significant payer of health care expenses in the United States, accounting for 13% of all health care expenditures in 1993. Medicaid is the only safety net for individuals in poverty. Indeed, Medicaid is slowing the growth of the uninsured. From 1988 to 1994, there was a six point increase in the number of uninsured, from 61% to 67%.5 The growth of Medicaid and the breadth of services provided to individuals with disabilities makes this delivery system particularly important to individuals with interest in rehabilitation. Paradoxically, there seems to be little interest by rehabilitation providers to assume a leadership role in the development of innovative Medicaid projects. Rather than assessing local needs and working with Medicaid agency officials to develop innovative projects, rehabilitation providers have focused their efforts on Medicare and commercial payment streams. While this is understandable, the breadth of Medicaid, its importance as a safety net program, and the overall aggregate magnitude of its payments suggest that rehabilitation professionals must address Medicaid in the immediate future. Failure to recognize the importance of Medicaid and play a instrumental role will further marginalize the value of rehabilitation in the future. There are, however, a few bright spots for rehabilitation. The innovative programs at the University of Missouri, at the Ohio State University, and the Rehabilitation Institute of Michigan are stellar examples, but, unfortunately, there are few other models that can be pointed to as ways of involving rehabilitation in the Medicaid delivery system. The program at Missouri is particularly promising. This program utilizes a delivery system that focuses on “cardinal symptoms.” In this model, a disabling condition is recognized as the dominant health factor. Health care is then focused on the disabling condition. This model is a variant of the primary care approach. It recognizes that some health conditions, especially in chronic disorders, are so pervasive that health care needs should focus on that condition. Consumers can designate their primary provider who coordinates all care. Obviously, physiatry is well prepared to provide this type of care. The Missouri, Ohio State, and Rehabilitation Institute of Michigan models aside, our shortsightedness in failing to become actively and comprehensively involved in Medicaid, reflects, unfortunately, a long history. Like most medical specialties, rehabilitation’s interest in healthcare reform has been largely parochial. Unlike groups such as the American Academy of Pediatrics, (AAP) which has espoused truly altruistic programs, rehabilitation too often has focused on reimbursement issues, failing to address the needs of individuals with disability. This may be because rehabilitation continues to be poorly understood at both the federal and state levels. Whatever the cause, rehabilitation will succeed only when it focuses on health policy for individuals with disability, not narrower, self-serving insurers. Shortly after going to Capitol Hill in 1991, I was impressed by the “Women and Children First” legislative proposal of the American Academy of Pediatrics. In this nascent period of health care reform, the AAP put forth an incremental bill that, for a relatively small amount of money, provided comprehensive health benefits for women and children. What was remarkable about this bill was that although pediatricians would benefit by this legislation, it was not viewed with jaundiced eyes by
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members of Congress. Because the AAP had a long, ongoing, intense commitment to advocating on behalf of children on Capitol Hill, its political message was viewed as part of a social message that had a higher valence. Rehabilitation must assume this same position on behalf of adults and children with disability. TO do this, we must develop a cogent policy initiative.
Principle 5: The nature of political change: right time, right place, right leadership, right information. In politics, as in the rest of life, timing is everything. The best prepared legislation will flounder if it is not supported by effective political management and effective information dissemination and if the time for the view and values expressed in the legislation is not optimal. It is widely unappreciated among the public but is generally accepted in legislative circles that passage of legislation requires many years. Successful members of Congress and of state legislatures recognize that commitment and passion for a topic is critical to create the energy needed to repetitively introduce bills over multiple sessions. For example, while I was working with Senator Bingaman, he introduced a series of legislative initiatives that were ahead of the time. In 1992 he introduced an amendment to a bill in the Labor Committee that would have created a global budget for health care spending. Senator Kennedy, the Chair of the Labor Committee at that point, roundly dismissed this concept. Interestingly, two years later this same concept appeared in Senator Kennedy’s mark (the Committee Chair’s version of a bill) for the Clinton Health Bill. Similarly, in the same session of Congress, Senator Bingaman introduced the first managed competition legislation in the Senate, the Health Insurance Cooperative Act. Again, this met fierce resistance, especially from Democrats on the Labor Committee. Again, two years later, purchasing cooperatives were a fundamental part of the Labor Committee markup of the Clinton bill. Indeed, the final passage of the bill rested on the ability to forge a compromise on the size of purchasing cooperatives and whether purchasing cooperatives included Multiple Employee Welfare System programs (MEWAs).
Principle 6: The enduring nature of reform enhances the importance of professional groups and the ability to influence the process. Upon arriving on Capitol Hill, I was immediately impressed by the high value placed on health professionals’ views. Although there was a tendency to dismiss health professionals’ constant complaints about reimbursement, there was a fundamental respect for their thoughts on issues relating to the development of health care delivery systems, graduate medical education, etc. A consequence of this is that almost every member is interested and willing to hear the ideas of health professionals when these ideas are presented with an emphasis on the needs of patients or consumers. When these are presented in a more self-serving reimbursement-oriented manner, there is less interest and tolerance with the message. This does not mean that messages that benefit a profession cannot be conveyed successfully to Congress. In the 104th Congress, a provision of the Welfare Reform Act affected child day care centers. Advocates of this proposal deluged members of Congress with cutout doll figures colored with crayons by children. The comprehensiveness, pervasiveness, and salience of this message assured that their message was heard and, in fact, incorporated into legislation. Obviously, rehabilitation providers speaking with genuine concern and interest in the welfare of individuals with disability also carry a potent message. Too often, however, the image of rehabilitation providers, even when they are known on the Hill, is of groups viciously fighting for their piece of the pie while denying other parallel interests their share.
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Principle 7: Critical to the process of effective lobbying is a clear core identity and enabling vision that allow a profession to effectively pilot the political process.
The successof groups such as the AAP or chiropractors in conveying their message to legislators reflects their clear core purpose and core values that remain fixed while their strategies and practices change in a competitive market. Recently, Collins and Porras’j wrote a cogent review of the importance of an enduring vision in determining the long-term successof businesses.To adapt to rapid changes, almost every business needs to have a clearly defined senseof purpose. This senseof purpose can be defined as a vision that declares what the company can become and determines what can be changed and what must be preserved. The vision complements a core ideology that combines a company’s core values and core purpose. Although there is clear common purpose for professionals in rehabilitation, in our political activities we are too often focused on our need to educate politicians on what we provide, ignoring our clear core values and our shared vision of improving the lives of individuals with disabilities. Successful political action of groups such as ACRM requires a long-term commitment, extraordinarily innovative vision, and a clear core value that focuses on the development of innovative and effective health delivery systems for individuals with disability. Although I have taken great pains to describe how my experience allowed me to develop the concepts and principles that I have presented, there is nothing intrinsically complex about these issues. I imagine many of you could have generated a similar set of principles without the experiences I have been fortunate to enjoy. Indeed, my comments may simply reflect observations of the obvious. Even if that is the case, I hope that this opportunity will serve as a forum to help us focus on the next epic of health care reform. Clearly, there will be reform of Medicaid, and likely of Medicare, in the 105th Congress. The Clinton Administration, the Prospective Payment Assessment Commission (ProPac), and the Physician Payment Review Commission (PPRC) all have recommended that systems be
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implemented to address the current gaming of the subacute and rehabilitation systems by the transfer of patients from acute hospitals to rehabilitation and subacute units?.’ This likely reform provides our profession with the opportunity to begin developing innovative, effective models of rehabilitation based on single episodes of payment. As an association, we are capable of coming together and working with foundations and the Health Care Financing Administration to develop these types of models. Among our members are individuals with substantial expertise in developing both the financial and clinical delivery systemsnecessaryto test new and effective models of providing rehabilitation care. Rather than letting laissez-faire market dynamics drive rehabilitation into unfriendly constellations, we should attempt to determine our fate by actively recognizing the principles governing political action and the opportunities we have to leverage this process. Acknowledgment: I thank Dr. Timothy Elliott for the comments he provided on an earlier draft of this manuscript. References 1. Stevens R. In sickness and in wealth: American hospitals in the twentieth century. New York: Basic Books, Inc., 1989. 2. Pope AM, Tarlov AR, editors. Disability in America: toward a national agenda for prevention. Washington (DC): National Academy Press, 1991. 3. Shortell SM, Gillies RM, Anderson DA, Erikson KM, Mitchell JB. Remaking healthcare in America. San Francisco: Jossey-Bass Publishers, 1996. 4. Frank RG, Sullivan MJ, DeLeon PH. Health care reform in the states. American Psychologist 1994;49:855-67. 5. Medicaid: An overview. Health and Human Services Health Care
FinancingAdministration.Washington(DC): GovernmentPrinting Office, 1995. 6. Collins JC, Porras JI. Building your company’s vision. Harvard Business Review 1996; September/October:65-77. 7. Annual report to Congress 1996. Physician Payment Review Commission. Washington, (DC): Government Printing Office, 1996. 8. Report and recommendations to the Congress. Prospective Payment Assessment Commission. March, 1996. Washington (DC): Govemment Printing Office, 1996.