In an era of managed care, rising costs of rehabilitation, and growing concerns over the quality of care given to those individuals with disabilities, professionals must begin to look at health reforms. These reforms must address these issues as everyone has a responsibility to provide the best care possible for persons with disabilities.

People with disabilities have, on average, higher health care costs and are considered to be a high-risk population. They also experience greater difficulty in gaining access to adequate medical care than persons without disabilities, and many are now faced with insurance policies that attempt to exclude them or reduce the qualifying benefits. Persons with disabilities also face the challenges of finding medical personnel familiar with the health care needs of people with disabilities. There is growing concern that those individuals enrolled in managed care health plans may not have access to needed health services. Actually, some managed care organizations, known as social health maintenance organizations, have been established specifically to manage the care of people with disabilities. In a study conducted by Burns, the number one ranking of issues related to health problems associated with the aging of disabled individuals was the availability of home care, support, and independent living services and the number three issue was the knowledge of problems of aging with a disability by physicians and the health care industry. In issues related to financing primary care services for persons with disabilities, the number one issue was a need for improved financing for home care, while the number three issue was providing training to health care providers on the primary and acute needs of disabled persons. Studies have also shown that individuals with disabilities are more likely develop secondary conditions which do not surface until after the person is discharged from medical rehabilitation. Despite this information, there has been a lack of program development and little research conducted to address these issues.

According to Sandstrom et al., rehabilitation bridges the gap between the health care system and the community and rehabilitation needs to focus on care. Medical rehabilitation provides restorative services to individuals who acquire an impairment from a congenital condition, a traumatic injury, an acute illness, or a chronic health condition that limits the individual's ability to function independently. Organized medical rehabilitation has become a major component in the continuum of health care services. During the period from 1985 to 1994, the number of freestanding rehabilitation hospitals increased 175 percent and the rehabilitation units based in acute care hospitals increased 118 percent. An example of this freestanding rehabilitation center is HealthSouth, an organization which has acquired approximately two-thirds of the freestanding rehabilitation hospitals in this country. There are some fears, however, that this reduction of competition will result in higher rehabilitation costs and possible lower quality. In a effort to control costs, managed health care organizations have worked to decrease expenditures for members who require rehabilitation services. From this, one major concern is the impact of managed care on the quality of care. Outcomes measurement and quality indicators are used more frequently to assess performance of the health care providers and there is hope that these can be used to stimulate competition in the area of quality.

This brings us to the question of how to provide the best possible rehabilitation in an era of cost-effective managed care. Health promotion and disease prevention is becoming the latest trend, and physical therapists have always been very active in wellness, prevention, and health promotion. Home health care has seen explosive growth in the 1990s and a large proportion of the physical therapy profession is represented in home care provision. According to Batavia, there is evidence that managed care organizations are attempting to "funnel" patients who require comprehensive rehabilitation services to providers that offer a less intensive process of rehabilitation, such as skilled nursing facilities. Many of these managed care providers would rather send an individual with a brain or spinal cord injury to a nursing facility that provides some type of rehabilitation services rather than a more expensive comprehensive medical rehabilitation center. According to Selker, attempts to restrict expenditures are reflected in the growth of preventive intervention funding and several health reform plans include long-term benefits for persons of all ages with a disability. These plans will increase the demand for home physical therapy. The Institute of Medicine observed that "even in managed care systems, patient demand for physical therapy is high." However, despite this growth in demand, the supply of physical therapists is diminishing. Hospital vacancy rates are reported at 16% to 17% and shortages of faculty and clinical sites continue to be a major factor constraining supply.

Managed care physician groups are referring patients to cheaper settings of care, such as subacute rehabilitation facilities and transitional care units. A central focus among the more expensive providers of rehabilitation services is cost consciousness in an attempt to become more efficient and productive. Managed care organizations are striving to move patients to the lowest level of care with the lowest cost at the earliest point in time. According to Wheatley, if at all possible, the organizations are "extremely aggressive in attempting to bypass entire levels of care" and that physicians within the managed care groups only consider cases such as traumatic brain injury or spinal cord injury to be appropriate for acute inpatient rehabilitation. These "subacute" care facilities are able to offer lower cost rehabilitation services because they have less intensive technologies and patients generally receive less hours of care than in an acute rehabilitation setting.

Sandstrom et al developed the Community Integration Rehabilitation Model, which has two components: institution-based rehabilitation (IRB) and the community-based rehabilitation continuum (CBRC). The purpose of the IRB is restoration of function and long-term care for individuals with severe disabilities while the primary purposes of the CBRC are restoration of function and the prevention of new disability and secondary disability. This outpatient care is a cost-effective way to provide rehabilitation services for individuals with a strong social support.

Keeping all this in mind, it is important to look at other options for providing physical therapy and rehabilitation at locations which could be more cost-effective yet do not diminish the quality of care provided. Olsen conducted a survey of management and operations at various sports medicine centers and some of the findings are worth mentioning in light of the use of physical therapists and the attempts of managed care organizations to control costs. According to The American College of Sports Medicine (ACSM), "sports medicine encompasses the scientific and medical aspects of exercise and athletics...including prevention and treatment of disease and injuries related to exercise and athletics." However, rehabilitation, acute care, and injury prevention were reported as the primary goals and services of the centers. Services at the centers included musculoskeletal rehabilitation, medical treatment, diagnosis, and fitness testing. Olsen reported that licensed physical therapists were employed at 93% of these centers and certified athletic trainers were employed at 62% of the centers. It was stated that a certified athletic trainer was the credential most frequently held by physical therapists at 42% of the clinics. Sports physical therapy has been a broad specialty practice recognized by the American Physical Therapy Association since 1987, but as of April 1996, only 185 persons were certified sports physical therapy specialists. Nearly all of the centers (98%) billed insurance companies and managed care contracts were present at 73%. Prepaid capitation was a method of payment for managed care services while a discounted fee for service was accepted at 62%. It was also noted that physicians were a source of referrals at 98% of the centers.

What could all this mean for the area of physical therapy and rehabilitation? If sports medicine centers provide prevention and treatment of disease and injuries related to exercise and athletics, and the services provided at the centers included rehabilitation, medical treatment, diagnosis, and fitness testing, why are they typically restricted to treatment and rehabilitation of athletic injuries? Since certified athletic trainers and physical therapists are working together in these sports rehabilitation centers, it appears that athletic trainers could also potentially be hired to work at physical therapy centers. As a certified personal trainer working towards becoming a certified athletic trainer, it is my opinion that if these qualifications are enough to work with the rehabilitation of athletes, then they should also be sufficient to work with persons with disabilities in any setting. If the managed health care organizations are attempting to control costs, it seems logical that they should be interested in paying for preventive rehabilitation at sports centers that hire athletic trainers and personal trainers. Also, in order to work together, both sports medicine centers and fitness centers should lower associated fees and work with the insurance companies to ensure that the quality of care is not compromised. Those of us in the health industry have a commitment to provide services even to those who cannot afford them, and we should make every attempt to do so. This is what one would want should a family member suddenly become disabled.