Not a day goes by in my professional life that the part of me that is a consumer of rehabilitation services doesn't trip and stumble over my role as a hospital system executive. My mind travels with my somewhat bent body toward home every evening with thoughts that are confusing, contradictory and, sometimes, even smack of hypocrisy.
In my incarnation as a consumer of rehabilitation healthcare services and an advocate for the rights of people with disabilities, I ask myself, how can we even think of altering the way in which we have been providing intense rehabilitation to those who have suffered trauma and illness? It was so much better 10 to 20 years ago. Insurance companies actually paid the bills. Rarely did they complain. And they did believe in the need for social work, recreation therapy, assistive technology, driver education. They permitted the medical and clinical staffs to make the decisions. They were our allies in providing the best healthcare to our patients.
Unfortunately, most insurers today see rehabilitation medicine as a "boutique" service. Our hospital might as well be located on Rodeo Drive. When insurers think of us, the words "value added" don't leap to mind. The personal, economic and societal benefits of medical rehabilitation were self-evident two decades ago, but today providers are expected to marshal direct, tangible and overwhelming evidence in defense of these services.
But that is only half the battle, for few of those who call the shots wish to take the time to listen and to understand that the quality of life after discharge is most important-even to their profit and loss statements. They ignore the direct relationship between the two, preferring short-term gain to long-term profitability and remaining oblivious to the simple truth that a happier patient is a healthier person.
We at National Rehabilitation Hospital know of instances in which high-level quadriplegics have been told to make do with manual wheelchairs. On paper this "cost containment" measure saves a few hundred dollars. But what of the social cost to the individuals, deprived of their independence, and to the family members unnecessarily and unwillingly thrust into the role of ever-present caregiver? Do those who decree manual chairs stop to calculate the tens of thousands of dollars they may well spend on quadriplegics who develop ulcers on their backsides because the chairs were inadequate for their needs?
At our hospital, we encounter many cases in which insurance companies have taken to leasing rather than granting ownership of absolutely needed pieces of equipment to the disabled in our care. It makes us wonder if perhaps some case managers have been following the scientific research about disability rather more closely than those of us who toil in the field. Perchance, unbeknown to us, all these subscribers we assumed were permanently disabled will soon be miraculously "cured" and the equipment the insurance companies have been leasing to them will be returned to the dealer for top retail dollar.
Just as I work myself into high dudgeon thinking about these and other indignities that have been visited on the disabled, my duties as an executive intrude. And at such moments I feel hypocritical. For I pretend to forget about my role as an advocate for the disabled. I tell myself we must do whatever it takes to keep our hospital system open, increase revenues and lower expenses.
Need to cut a program here and there to protect the bottom line and ensure our financial viability? Done. Reduce healthcare benefits to hundreds of our employees, transferring them from indemnity insurance to managed care, so that we can save millions of dollars? Done as well. Let's just hope and pray that all of them are impervious to trauma and illness.
How, then, do I-do we-find a way out of this swamp of contradictions? It goes against the grain for me, a mainline conservative, to call on the government to rescue those who badly need our services. Yet that is the direction in which we are moving as the popular revolt against managed care spreads and the major political parties vie for the title of Defender of Patient Rights.
But it is not so much legislation that needs to be changed or a new government bureaucracy that needs to be created. It is far more important that attitudes and expectations be transformed. Our society needs to achieve consensus on one key point: The minimum acceptable standard of healthcare has slipped over the past two decades, and the bar must be raised. The backlash against managed care contains the seeds of this new consensus.
For providers and consumers of rehabilitation healthcare, the challenge is even greater. We need to convince the public, political leaders, the business community and the press-and through them, the insurance companies-that rehabilitation is not Rodeo Drive. It is Main Street, U.S.A. For millions of citizens, our services are among the most critical they can receive.
On a micro level, our success or failure in providing individuals with the means to return to independent living often spells the difference between a life meaningfully lived and a life wasted. On a macro level, our success or failure translates into millions of dollars in long-term healthcare costs and economic productivity saved or squandered.
The new consensus will not emerge through spontaneous combustion. Nor will victory go to the bashful. Only unremitting pressure will bring results. The disabled communities need to be unified and fully engaged in this battle. They must join with us and we with them.
Edward Eckenhff is president and chief executive officer of the National Rehabilitation Hospital in Washington. A version of this article appeared in the magazine of the American Medical Rehabilitation Providers Association.