The "R-word"
Unlike my previous blog titled "The "F-word: Function(al)", I'm easing in to telling you what my "R-word" is. That's because some people consider this word a profanity. It isn't on the list of the "usual suspects" in the English language; but plenty of Americans consider it obscene, especially in the context of health and human services. Some articles, advertisements and talk show hosts taking a stand against various ideas for U.S. health care reform count on the R-word's "shock value" to convince the audience of the danger of the reform plan(s) being discussed. Nevertheless, we OTs should consider how avoiding the R-word seriously undermines our efforts to do our very holistic best for our clients.
OK, here goes nothing: the R-word is "Rationing". As much as we Americans hate to admit it, the health and human services in our "free market" are parceled out according to various standards of need (usually a euphemism for "ability to pay"). Insurance is a rationing mechanism: policy language determines what the payment shares will be. Professional practice acts, licensures, and the various rules about referral mechanisms and professional hierarchies (e.g. which disciplines can "open" a case) affect who gets what when (or if). The various codes that determine reimbursement (e.g. DRGs, RUGs, CPT, etc.), and other categorizing mechanisms, are attempts to create objective and "fair" responses to the fact that resources aren't infinite, so we need to use the resources as wisely as possible. The increasing emphasis on Evidence-Based Practice (EBP) is another tool for minimizing the effects of human emotions on difficult resource-allocation decisions, while simultaneously optimizing the "person-resource match".
All this dancing around the R-word gets us nowhere, especially with the renewed attention to "health care reform" in the U.S. In 5 Misconceptions About Health Care, Shannon Brownlee and Ezekiel Emanuel stated,
"...[A]ccording to the Congressional Budget Office (CBO), there appears to be no connection between how much...payers spend on patients in different parts of the country and the quality of the care the patients receive."
Quality is directly related to optimizing the "person-resource match." Of course, one of the many variables affecting "best match" is timing. We aren't always involved with people when the best matches are possible. But cobbling together sub-optimal or poorly timed person-resource matches just to avoid facing the truth that we can't be all things to all people does everyone a dis-service. For an OT to say that s/he doesn't have anything to offer "at this time" is not admitting incompetence or even failure. For one thing, "at this time" leaves the door open for changes in circumstances in which the same OT could make an objective difference for the client. It could also mean that a different OT - or even a different discipline altogether - with his/her own set of experience, perspective and resources, would be a better match for the client.
When a client seems to have plateaued, and/or I'm out of ideas on how to stimulate progress, I haven't been shy about discussing options with the client, referral source and/or payer that amount to "firing" me. Believe me, that approach has paid dividends in terms of new referrals, as well as in getting "off the map" support for my ideas from people who have come to trust my judgment. I've had payers wave off my offer to provide details of my rationale for what seems to be a "wild hair" idea, and just OK it. One even said, "You've pulled rabbits out of hats before; I'll sell tickets to this one." I'm not the only "magician" OT; but I tend to have an easier time than most in getting support for working the magic of occupation on behalf of my clients, because I respect, rather than demonize or fear, the R-word, and approach the system accordingly.
Yet many OTs seem to pretend the R-word doesn't exist, rather than demonstrating how our understanding of occupation can make it work better. For example, the firestorm of responses to "Avoiding Therapy Dependency" highlighted this aversion to the R-word (though the author didn't use it). The respondents couldn't see how to use OTs' unique understanding of occupation to focus attention on what we can do to optimize the matches between our clients and resources. Cost-effective person-resource matching is what rationing is; and as such is not inherently bad. Why would we want anything but best-matches for our clients?
I urge all OT practitioners to think differently about the R-word and how their OT services can be seen as being among the wisest use of resources in any given situation.