Maintenance of a patient's overall health often requires efforts beyond those of the physician and the patient. Assistance often comes from community-based programs to which physicians may refer their patients. Many of these programs provide services for patients with specific types of illnesses; the roles of such categorical community services are described in the appropriate chapters in this book. Other services or programs are designed to assist patients or their families regardless of illness type. This chapter describes four of these: Social Security programs for disabled people; vocational rehabilitation; family and medical leave; and home health services. This chapter explains eligibility for these services and programs, the nature of the benefits, and the role of physicians in enabling their patients to participate in them.Chapter 8 provides similar information about another noncategorical program, workers’ compensation, which is designed to provide coverage for health care costs and income support to people with work-related diseases.
Social Security Programs for Disabled People
Loss or decrease of a person's ability to earn a living accompanies many illnesses. Beginning with the 1954 amendments to the Social Security Act, income support for medically disabled people has been available in the United States. Further modifications since 1954 have led to the program that exists today. Three fundamental benefits are currently available through the Society Security Administration: disability insurance (DI), Supplemental Security Income (SSI), and Medicare (health insurance for DI recipients). Medicaid is a federally and state-administered health insurance program that is available automatically in many states for people who receive SSI and for mothers of dependent children whose incomes are below the poverty level. Detailed information about each of these services is available from any local Social Security office.
Definition of Medical Disability
The Social Security Act defines disability as the “inability to engage in any substantial gainful activity by reason of a medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.”
Disability Insurance (Title II of the Social Security Act)
Eligibility
To be eligible for DI payments, a disabled worker must have paid into the Social Security program for a minimum period of time before becoming disabled; in addition, there is a requirement for coverage during 5 of the 10 years before the onset of disability. Today, 9 of 10 workers and their employers pay the Social Security tax (Federal Insurance Contributions Act, or “FICA”). For younger workers (up to age 31 years), there are modified requirements to meet insured status.
Disabled dependents of a fully insured worker who is retired, disabled, or deceased may be eligible for DI payments in two situations: a child who became disabled before age 22 years (eligible for DI payments at the time that the child's parent retires, becomes disabled, or dies; payments may begin as early as age 18 years and continue as long as the child's disability lasts) and a widow or widower who is between 50 and 59 years of age and who did
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not work under Social Security but who became medically disabled before or within 7 years of the death of a fully insured spouse.
Benefits
DI payments go to disabled workers before the age of 65 years (after age 65 years, Social Security Retirement Income replaces disability payments) and to eligible children, widows, or widowers as long as they remain disabled. The first monthly DI check is not paid for the first 5 months after the onset of the worker's disability (e.g., a patient who is certified as disabled 6 calendar months after becoming disabled immediately becomes eligible for a check covering the 1 month in excess of the required 5-month wait). SSI (see Supplemental Security Income) is often awarded to people who are found to be “presumptively disabled,” effective the first day of the month that follows the month in which they apply for benefits. Income from DI for a disabled worker is the same amount as the retirement income the worker would receive if he or she were age 65 years.
In 2003, the average monthly payments were $862 to disabled workers and $888 to nondisabled widows and widowers. In that year, 5.8 million disabled workers and 1.6 million spouses and children were receiving DI benefits. The leading causes of disability for disabled workers were mental disorders that do not involve retardation and musculoskeletal conditions. Approximately 10% had circulatory conditions or diseases of the nervous system (1).
In addition to income support, disabled people younger than age 65 years receive Medicare (Social Security Health Insurance) after they have been eligible for disability benefits for 24 months. Patients with end-stage renal disease receive Medicare coverage effective when they begin long-term dialysis.
Process of Disability Determination
There are a number of steps in the process of determining medical disability.
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reports. In some states, doctors also have access to a free teledictation service for dictating their reports.
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TABLE 9.1 Impairments Qualifying a Person with Chronic Obstructive Pulmonary Disease for Medical Disability Under Social Security |
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TABLE 9.2 Impairments Qualifying a Person with Central Nervous System Vascular Accident for Medical Disability Under Social Security |
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If an insured worker has an impairment that does not meet the standard criteria for disability but nevertheless claims inability to do his or her usual job, the DDS obtains additional information to determine the claimant's residual functional capacity to perform past work despite the impairment(s). If the past work was such that the impairment would prevent performing the work, DDS proceeds to a last step to determine if the claimant can do other work. Limitations of age, education, training, and work experience are considered by the DDS team in establishing whether a worker is able to perform “other work.”
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TABLE 9.3 Impairments Qualifying a Person with Convulsive Epilepsy for Medical Disability Under Social Security |
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TABLE 9.4 Impairments Qualifying a Person with Major Dysfunction of a Joint(s) (due to any cause) for Medical Disability Under Social Security |
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Appeals Process
If the initial claim of disability has been denied, the claimant may file for reconsideration within 60 days of receiving a denial notice. The case is then reevaluated by a different DDS team. If the claim is denied at this reconsideration, the claimant has 60 days to file a request for a hearing. Hearings are conducted by administrative law judges. If the claim is again denied, the claimant may make an additional appeal for review by the Appeals Council. After that, the case may be taken to the United States District Court.
A patient's personal physician can be instrumental in ensuring that the patient gets the fullest consideration throughout the disability determination process. If the physician believes there are aspects of the patient's illness that make it more severe than the criteria indicate, the physician should communicate this information in writing, together with support for this opinion, to the Disability Determination office.
Periodic Review and Return to Work Incentives
All claims are reviewed for referral to vocational rehabilitation (see Vocational Rehabilitation) at the time the disability decision is made. In addition, every person with a permanent impairment is re-evaluated every 5 to 7 years. Those expected to improve are reviewed 6 to 8 months after the DI decision is made, and those in whom improvement is possible but less predictable are reviewed about every 3 years. Even if the original impairment is judged not to be severe on review, payments are continued for those who have started a vocational rehabilitation program because of improvement in their medical condition; benefits
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continue until the rehabilitation services are completed or until the person stops receiving these services. The purpose of these processes, and the following conditions, is to encourage disabled people to return to work.
In addition to disabled workers, workers’ children who became disabled before the age of 22 years and disabled widows and widowers can also have a trial work period.
Supplemental Security Income
SSI is a federal program that was introduced in 1974 under Title XVI of the Social Security Act. It is paid for out of general funds rather than Social Security funds, but it is administered by the same state agencies that administer the Disability Determination program. The application process is similar to that described above for Social Security DI. Applications are filed at a local Social Security office, and the same criteria are used to evaluate SSI disability claims as are used for DI claims.
The basic differences between SSI and Social Security benefits are as follows:
In most states, people approved for SSI are also eligible for Medicaid and other social services provided by their state. All people receiving SSI are reviewed once each year to determine whether their income and other resources still make them eligible to receive SSI. Like DI recipients, they are reviewed every 3 to 7 years to establish whether their disability is still present (see Periodic Review and Return to Work Incentives).
The maximal monthly income from SSI in 2005 was $579 for an individual and $869 for a couple. In 2003 there were 6.9 million recipients of SSI on the basis of disability, blindness, and age (older than age 65 years and without Social Security). Most had a mental disorder (1). As described for DI, the report of a patient's physician must be received before income support under SSI can be initiated.
Vocational Rehabilitation
State vocational rehabilitation agencies existed before the federal Disability Determination program was created in 1954. In many states, these agencies administer the Disability Determination program in addition to providing vocational rehabilitation services.
Eligibility
To be eligible for vocational rehabilitation, a person must have an impairment that interferes with his or her capacity to obtain suitable employment, or that is a threat to his or her present career; this does not mean that the person has to meet the criteria for medical disability discussed earlier. The person must have a reasonable chance of being able to engage in a suitable occupation after vocational rehabilitation services are provided. A suitable occupation would include being a homemaker provided that vocational rehabilitation would enable the person to remain in his or her own home instead of requiring institutional care.
Services
The services provided by vocational rehabilitation agencies vary among states. However, they usually include the following:
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Physician's Role
As noted earlier, all people applying for Social Security disability benefits are screened for referral to vocational rehabilitation. For those people, the report of the patient's physician (see Process of Disability Determination) may be used by the vocational rehabilitation agency. For people who are not applying for medical disability, the physician is often asked to provide a general medical report for the vocational rehabilitation agency. An important role of physicians is to encourage patients to apply for vocational rehabilitation and to maintain continued interest in their progress. It has been estimated that every $1,000 spent for vocational rehabilitation increases by $35,000 the lifetime earnings of those who are rehabilitated.
Family and Medical Leave Act
Eligibility
The purpose of the Family and Medical Leave Act (FMLA), passed in 1993, is to grant temporary medical leave to employees under certain circumstances. Employers covered by the Act are (a) any employer who employs 50 or more employees for each working day during each of 20 or more calendar work weeks in the current or preceding calendar year and (b) all public agencies, which are covered without regard to the number of employees. Public as well as private elementary and secondary schools are included in this second category.
Under the FMLA, employers must grant an eligible employee up to a total of 12 work weeks of unpaid leave during any 12-month period for one or more of the following reasons:
Any employee who takes leave under FMLA is entitled, on return from such leave, to be restored to the position he or she held when the leave commenced or to an equivalent position with equivalent pay and benefits. During the leave the employer must maintain the employee's health coverage under any group health plan of the employer; and the leave will not result in the loss of any employment benefit accrued before the leave commenced.
Physician's Role
An employer may require that a request for leave for situations under items 3 and 4 above be supported by certification documented by the health care provider of the eligible employee or of the son, daughter, spouse, or parent of the employee, as appropriate. Sufficient certification, documented on the FMLA form, includes the following information:
The four-page FMLA form and additional details regarding FMLA can be obtained from one's employer or at the website of the Department of Labor (http://www.dol.gov).
Home Health Services
A consequence of illness as distressing to the patient as the loss of the ability to earn an income is the temporary or permanent loss of the ability to remain at home. Most people require acute hospital care one or more times in their adult lives, and a small proportion also require long-term institutional care. The principal objectives of home health services are to minimize the need for admission to
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acute or long-term care facilities and to decrease length of stay and associated costs in these facilities.
National Trends
Home health care is the sector of the health care industry that grew the most in the end of the 20th century (3). Growth in home health initially accelerated after passage of the Omnibus Reconciliation Acts of 1980 and 1981, which increased funding for home health services by Medicare and Medicaid. Between 1980 and 1995, the number of patients served per year grew from about 0.9 million to approximately 3.6 million for Medicare and from about 0.4 million to approximately 1.4 million for Medicaid. More recently, cost-effectiveness initiatives from the managed care industry have further promoted home care as an alternative to hospital care.
Range of Services and Providers
Home health services provided include basic care provided by informal caregivers (family members and friends); home food services available at a nominal cost to the patient (Meals-on-Wheels); care provided by physicians or their associates who make home visits; services provided by the personnel of home health agencies; specimen collection and performance of diagnostic procedures such as radiographs and electrocardiograms by clinical laboratories; and delivery/rental by medical suppliers of infusion equipment, medications, and durable medical equipment such as hospital beds. Even when professional help is involved, most of the responsibility for carrying out care is assumed by the patient or a member of the patient's family; as noted in Chapter 1, it is the assumption of responsibility by patients and their families that most distinguishes ambulatory care from institutional care.
Overall coordination of the home care provided by home health agencies is usually provided by a nurse case manager. A substantial proportion of the care is often carried out by home health aides, analogous to nursing aides on hospital wards, under the supervision of the nurse. In recent years, nurse practitioners, enterostomal therapists, and clinical pharmacy consultants have been added to the staffs of many home health agencies, so that more sophisticated care can be provided. In addition to nursing, home care services may include physical, occupational, and speech therapy; nutritional, behavioral, and social work counseling; and mental health services. Home health agencies provide the professional services of hospice programs (see Chapter 13) in many communities, or may have their own hospice programs. In addition, maternal and child health programs have been developed to respond to the needs created by rapid discharge of mothers and newborns.
In recent years, home health agencies and suppliers have added services that require skilled use of equipment traditionally used only in hospitals. These services include the administration of intravenous therapies, ranging from short-term normal saline and electrolyte infusions to courses of antibiotics, cancer chemotherapy, cardiac medications, and total parenteral nutrition, and the care of ventilator-dependent patients at home. These initiatives have emerged in response to efforts to reduce the length of costly hospitalization for patients who prefer home care to hospital care for parenteral therapy that may have to be administered for 1 week or more. Day-to-day supervision of the overall care of patients receiving in-home parenteral therapy or ventilator support is usually not provided by the company that supplies and monitors the equipment; consequently, this responsibility is assumed by a nurse case manager who knows the physician's comprehensive plan for the patient and is in close contact with the supplier. Table 9.5 lists the types of clinical problems most commonly referred to home health agencies.
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TABLE 9.5 Problems Most Commonly Referred for Home Health Services |
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Criteria for Third-Party Reimbursement
Any patient or patient's family may purchase services from a home health agency. During the past 30 years, much of the cost of home care has been covered by Medicare, Medicaid, other third-party payers, and managed care organizations. The number and types of services authorized are being more tightly controlled today as part of cost-containment efforts. Beginning in 2001, Medicare changed from a cost-based to a prospective payment approach, similar to the diagnosis-related group approach to paying for
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hospital care. These changes have promoted the development of detailed care guidelines and increased focus on instructing patients and family members to carry out care plans. Patients must meet the generic criteria listed in Table 9.6 for services to be reimbursed by Medicare and other third-party payers.
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TABLE 9.6 Criteria for Third-Party Reimbursement for Home Health Services |
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Medicare pays for “intermittent” home care services, defined as no more than 35 hours per week. There must be a documented goal of care that has a finite end point. Because of the Medicare criterion that the patient must have a medical problem requiring skilled care, payment for the services of a home health aide is often denied after the active problem becomes stable, even when the home health aide's services are important in maintaining the patient's health. In some instances, Medicaid funding is available for ongoing personal care services, provided in lieu of nursing home care.
Physician's Role
For home health services that are reimbursed, the patient's physician must approve and sign orders for all services and revisions of services. Medicare requires an extensive report and newly signed orders every 60 days.
The quality of the communication between physicians and home care providers often determines how much the patient will benefit from home health services. When physicians provide clear and complete initial information and both physicians and home care providers can reach each other easily when needed, patients who would otherwise require in-hospital care can receive excellent care in their homes.
The American Academy of Home Care Physicians (http://www.aahcp.org) is an organization of physicians and other home care professionals, founded in the late 1980s, that is dedicated to improving the quality of home care. The organization's newsletter, other publications, and annual meeting focus on the evaluation of and education about home health care ideas and programs.
Specific References
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.