chp 1

Contexts and Health Care

• Introduction to Standards in Occupational Therapy

  • Chapter explores relevant ACOTE Standards

  • B.6.1: Describe contexts of health care, education, community, and social systems in relation to occupational therapy practice.

  • B.6.2: Identify the impact of policy issues and socio-economic factors on occupational therapy practice.

  • B.7.1: Identify influence of contextual factors on management and delivery of occupational therapy services.

  • B.7.2: Identify systems and structures that create legislation and regulations affecting occupational therapy practice.

Key Vocabulary

• Entitlement: Legislation guaranteeing rights to specific benefits for certain groups.

• Medicare: Federal insurance for individuals aged 65+ or with certain disabilities.

• Medicaid: Joint federal-state program providing health insurance to qualifying individuals.

• Habilitative Services: Services aimed at helping individuals develop or maintain skills for daily living.

• Telehealth: Use of telecommunications to deliver health care over distance.

Case Study: Ruth's Scenario

• Subject: Ruth, an 80-year-old woman residing in Chicago, recently experienced health issues.

  • Lives with her daughter and son-in-law.

  • Recently involved in a car accident resulting in injuries.

  • Concerned about health insurance and care options for her grandson.

• Role of Occupational Therapy: Understanding the regulations affecting access to services for Ruth amid her recovery.

• Historical Contextual Points:

  • The intertwining of health experiences with legacies of legislation, policy issues, geography, and demographics.

  • Insight into how these factors impact practitioner work environments, reimbursement, and access to services.

Entitlement Legislation Overview

• Entitlement laws guarantee specific benefits for groups (Freedman, 2012).

  • Examples include:

  • Social Security

  • Medicare

  • Medicaid

  • CHIP

  • IDEA

  • ACA (Affordable Care Act)

  • ADA (Americans with Disabilities Act)

• Social Security Act

  • Established in 1935 during the Great Depression.

  • Provided essential support programs for the impoverished.

  • Set a precedent for future healthcare reforms and influenced the development of private insurance.

• Legislative Compromises:

  • Varied political perspectives influenced the types of health benefits available (Rothman, 2005).

• Iron Triangle of Health Policy:

  • Cost, Access, and Quality interact; improving one often detracts from another (Mehta & Jha, 2012).

Medicare

• Historical Context:

  • Debate on national health insurance began pre-Social Security Act.

  • Medicare emerged from efforts of Truman and Johnson's administrations.

  • Initially targeted individuals 65+ (1965).

• Coverage Expansion:

  • Underwent several reforms from 1965 to 2010, significantly affecting occupational therapy services.

  • 1972: Coverage extended to individuals under 65 with disabilities.

  • 1981 Budget Cuts: Reduced coverage recognition for occupational therapy in homes.

• Current Medicare Structure:

  • Part A: Covers inpatient hospital services, home health, hospice.

  • Part B: Covers outpatient services, exams, therapies, preventive care.

  • Part C (Medicare Advantage): Offers private insurance options.

  • Part D: Outpatient prescription drug coverage.

  • Certain long-term services not included (dentistry, hearing aids).

• Impact on Occupational Therapy:

  • Medicare’s policies severally impact service provision and access to patients.

Medicaid

• Legislation Origin:

  • Established alongside Medicare in 1965.

  • A federal-state partnership with states establishing their own rules.

• Eligibility:

  • Must cover specific low-income groups; many benefit from both Medicaid and Medicare.

• Mandatory Coverage Areas:

  • Inpatient and outpatient services, physician visits, lab services, etc.

  • States have flexibility in covering additional services.

• Occupational Therapy in Medicaid:

  • States have discretion; mandatory provision for medically necessary services to children under EPSDT rules (Lohman, 2014).

CHIP (Children’s Health Insurance Program)

• Details:

  • Established in 1997 as part of Medicaid to broaden children’s access to health care.

  • Coverage specifics vary by state.

The Affordable Care Act (ACA)

• Introduction:

  • Signed into law on March 23, 2010, addressing health care access issues.

• Key Provisions:

  • Mandates health insurance coverage for most U.S. individuals, regulations for plans, Medicaid expansion, and health exchanges.

• Statistical Context:

  • In 2012, 17.7% of individuals under 65 were uninsured.

  • 39% uninsured individuals earned < federal poverty level, while a notable percentage exceeded 400%

  • Access to care disparities highlighted: 26% uninsured went without care versus 4% insured (Askin & Moore, 2012).

• Health Outcomes: Evidence shows uninsured individuals face worse health outcomes compared to their insured counterparts (Askin & Moore, 2012).