The role of the rehabilitation physician in the postacute continuum

Compared to just 10 years ago, the US health care terrain looks much different today. In 1985, hospitals were the hub of a bustling delivery system that focused on acute care services and undervalued primary or preventive care. Health insurance benefits created incentives for consumers to use hospitals where their care was fully reimbursed, and discouraged office visits for which there were hefty copayments. Today, admissions into acute care hospitals are screened by none other than those same primary care physicians. These gatekeepers often have more authority over patient services and referrals than do the specialists and the hospitals. Financial incentives have made a 180 degrees shift, now motivating consumers to use outpatient care and office visits to satisfy the majority of their health care needs. Moreover, there are currently health care providers actively delivering a wide range of treatments and services that were not available or "covered" a decade ago. The migration of treatment out of hospitals into the vast frontier of postacute care has revolutionized our thinking about how patients receive treatment, in what locations, and by whom. This article describes the trends in financing and in clinical innovation that have contributed to the expansion of postacute alternatives. The factors that most clearly contribute to new opportunities facing rehabilitation physicians in postacute care are discussed, as are the added competencies required of those who choose to take a leadership role in the postacute delivery system. A case study of one model "managed care system" where the rehabilitation specialists are driving the care is presented. The future for rehabilitation specialists who are positioned to participate in setting the standards for high-quality postacute and chronic care in a future marketplace dominated by managed care is discussed.