HEALTH PROMOTION INTERNATIONAL
© Oxford University Press 2000
Vol. 15, No. 1
Printed in Great Britain
Promoting the health of people with physical
disabilities: a discussion of the financing and
organization of public health services in Australia
RICHARD D. SMITH
Health Economics, School of Health Policy and Practice, University of East Anglia,
Norwich NR4 7TJ, UK
SUMMARY
People with physical disabilities have a high probability of
suffering secondary disabilities and disability-related acute
health problems. Critically, they experience difficulties in
access to health-promoting services. Of importance in reducing barriers to such services is the role of funding systems. There has been little research or comment in the area
of funding, and this paper attempts to redress this imbalance by providing an overview of two specific systemic
barriers in the funding of health promotion for those with
disabilities in Australia: the method of service reimbursement and the disparate nature of funding sources. It is clear
that there needs to be a revision of health care funding
systems to enable an increase in the promotion of health
amongst people with physical disabilities. Two possible
solutions are considered: case-management and the increased
involvement of private industry. The potential benefits of
this are illustrated by reference to reducing unnecessary
rehospitalization. With changes occurring in the Australian
health care system, e.g. the move to case-mix funding and
case-management, there is the potential for people with
disabilities to either lose their access to health promotion
further or to capitalize on these changes to ensure improvements. Either way it is clear that those involved with health
promotion need to urgently address the issues raised in this
paper in a timely fashion, to ensure that beneficial changes
are capitalized upon and the potential for negative impacts
is minimized.
Key words: disability; economics; funding; health promotion
INTRODUCTION
In 1993 the Australian Bureau of Statistics
estimated that 3.2 million Australians (18% of
the total population) had some form of specific
physical disability; defined according to whether
a person had one or more specific pathology,
e.g. loss of sight or hearing, for 6 or more months
(Stuifbergen et al., 1990). Furthermore, the
prevalence of such disabilities is increasing with:
(i) advances in medical technology resulting in
more patients surviving serious accidents and
disease, but with permanent disabilities; and (ii)
the population steadily ageing, thus living longer
with disabilities associated with old age
(Australian Bureau of Statistics, 1993).
People with disabilities are, on average, more
likely than those without disabilities to experience a broad range of health problems, including
urinary and respiratory tract infections, and be
more at risk of, e.g. cardiovascular disease and
stroke (Young and Northup, 1979; DeJong et al.,
1986; Batavia et al., 1989; Marge, 1993; DeJong
and Batavia, 1998). Families also suffer problems
related to the informal care of those with disabilities, including increased stress-related
physical and emotional illness, reduced ability to
care for children and undertake household tasks,
reduced time and energy for work, reduced social
interaction and stigmatization (Kinnear and
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R. D. Smith
Graycar, 1984; Green, 1985; Braithwaite, 1986;
Braithwaite, 1990; Pearlin et al., 1990; Kemper,
1992; Max et al., 1995). Further, those with disabilities, and their families, are often low income
earners, with ~62% having government benefits
as their principal source of income, and 60% of
income units containing a person with disability
having no income earner whatsoever [compared
with 23% of all income units] (Davies and George,
1993). Disabling conditions also simultaneously
reduce the base of active workforce support for
national social benefit systems, whilst increasing
the expenditures of such systems (Commonwealth
Department of Community Services, 1985).
People with disabilities therefore represent
significant health needs and investment in health
care resources, both in terms of the primary disability and secondary complications. Although
the prevention of these conditions is important,
of equal importance is to make living with them
as healthy as possible, as many disabilities are
life-long.
Although health promotion may be significant
in leading to lower levels of premature mortality,
higher quality of life and lower health care costs
for the general population, it has the potential to
be even more significant for those already with a
disability, whose quality of life and independence
rely critically on their ability to maintain their
narrow margin of health (DeJong and Hughes,
1982; Batavia et al., 1988; Stuifbergen et al., 1990;
DeJong and Batavia, 1991). However, barriers
[defined as perceptions regarding the unavailability, inconvenience or difficulty of a particular
health-promoting option, arising from people’s
internal cognitions, from significant others and
from the environment (Stuifbergen et al., 1990).
Barriers of particular importance may be convenience of facilities, transportation and lack of
information (Stuifbergen et al., 1990; Gilderbloom
and Rosentaub, 1990)] preventing access to
health promotion services for the prevention of
further disability, and the promotion of health in
general, are important in determining the quality
of life and health status of those with disabilities,
although it is often not the disability that is the
cause of these barriers, but the external environment. In particular, many of these barriers occur
due to the various funding and organizational
systems of services designed to provide support
for people with disabilities and to finance health
promotion and health care services.
Following consideration of the context of
disability and health promotion, this paper
considers two important systemic barriers to
promoting health for those with disabilities in
Australia: the method of reimbursement and the
disparate nature of funding sources. Two possible
solutions to these problems are then considered:
the broadening of the case-management approach
and capitalizing on private industry initiatives.
CONCEPTUALIZING DISABILITY AND
HEALTH PROMOTION
Although disability is commonly referred to in a
pathological sense, focusing on specific conditions,
it is more appropriately viewed as a process. The
World Health Organization (WHO), e.g. view
people as moving from pathology (characteristics
of the physical body) to impairment (operations
that the person is unable to perform because
of those characteristics) to disability (activities
that the person is unable to do, given the level of
assistance provided in the society they live in,
because of that inability) to handicap (the disadvantages they suffer as a consequence) (World
Health Organization, 1980). Impairment is seen
to be a permanent or transitory psychological,
physiological or anatomical loss of body structure
or function. Disability by contrast is any restriction on performing an activity within the range
considered normal for a human being; it may be
temporary or permanent, progressive or regressive. However, handicap, which is commonly what
is thought of as ‘disabled’ by lay definition, is a
‘social’ disadvantage for an individual resulting
from an impairment or a disability that limits or
prevents the fulfilment of a role that is considered
‘normal for that individual’. Thus, one can be
impaired without being disabled, and disabled
without being handicapped.
Importantly for considering this issue in the
context of health promotion is the distinction
between intrinsic disability (without personal or
equipment assistance) and actual handicap (even
with such assistance). ‘Disability’ is therefore not
considered to be a personal characteristic, but is
instead a gap between personal capability and
environmental demand (thus, e.g. being dependent on some assistance to do daily tasks may be
considered to be a disability, but being without
that assistance would lead to handicap). According to this definition, policy should therefore
focus not only on impairment and disability in
the medical sense, but crucially on the ‘prevention of handicap’, in the sense of the removal
Promoting the health of people with physical disabilities
of the gap between personal capability and
environmental demand (Verbrugge and Jette,
1994). This definition therefore concentrates on
the physical environment as much as on the
individual with the impairment.
Health promotion, in this paper, is thus viewed
in a public health context, whereby the intention
is to maintain and enhance existing levels of
health through the implementation of effective
programs, services and policies (World Health
Organization, 1986; Goodstadt et al., 1987). In
particular, it is seen as a key facet in the development of policy which supports individuals
in this maintenance and enhancement of their
health (Green, 1991). This will include protecting
people against disease/injury, inducing health
behaviour modification (e.g. exercise), informing
and modifying social and professional values and
attitudes (by education), and lobbying for
changes in the social and political environment in
which people live (e.g. by legal means to make
buildings more wheelchair friendly) (Tolley,
1993). The health promotion perspective should
therefore be viewed as encompassing a wide
variety of overlapping and interlinking initiatives
[including health protection, preventive medicine,
health education, public policy, and community
and individual empowerment (Tannahill, 1985;
Holman, 1992)] in order to maintain and enhance
existing levels of health and well-being for people
with disabilities (World Health Organization
Regional Office for Europe, 1985; World Health
Organization, 1986; Goodstadt et al., 1987;
World Health Organization Regional Office for
Europe, 1987).
Important in this wider perspective is the
recognition of the health-promoting role and
responsibility of all health professionals (Kaplan,
1992). This is important to the delivery of health
promotion for people with disabilities as: (i)
the health services that such people receive may
be delivered with a health promoting focus;
(ii) health promotion initiatives targeted at the
general population may include components
specifically aimed at people with disabilities; and
(iii) specific health-promoting projects for people
with disabilities may be devised.
However, the development and extension of
programs for the prevention of further disability,
and the promotion of general health for people
with disabilities, are hindered by the lack of
understanding of the socioeconomic implications
of disability within society and mechanisms to
address this. These issues are of considerable
81
importance, as it is the funding arrangements
which largely determine the scope and amount of
health promotion received by people with
disabilities, how this is distributed and to whom it
is distributed.
Thus, health promotion, in its broader public
health role, is a vital component in maintaining
and improving the health of people with disabilities. Although the discussion in this paper
has wider implications for other population
groups, people with disabilities are clearly an
already disadvantaged group, with the current
system of financing and provision of health promotion and health care inadequately addressing
their needs.
SYSTEMIC BARRIERS TO FUNDING
HEALTH PROMOTION FOR PEOPLE
WITH DISABILITIES
Method of service reimbursement
Predominantly, current methods of reimbursement for services within the Australian health
care sector do not allow for the additional time
required to undertake a service with a person
with a physical disability. In the hospital sector,
the use of prospective payment systems, e.g.
case-mix funding, provides a financial ‘penalty’
for hospitals that treat patients with disabilities
who require more attention than the ‘average’
patient. Such systems, in place in most Australian
states, reimburse hospitals a fixed amount per
patient treated, according to the condition
treated. This figure is calculated, and set, on an
‘average’ cost basis, providing the incentive to
treat at lower than this ‘average’ cost, and thus
secure a surplus. However, this rate is set with no
consideration of the extra resources required for
people with specific additional needs. Thus, the
cost of care becomes a barrier to people with
disabilities receiving even the ‘normal’ level of
care that most Australians would expect (Evans
et al., 1990).
There are similar disincentives within general
practice in Australia. The GP may incorporate
some element of health promotion, e.g. dietary
advice, within the traditional ‘6-min’ consultation.
However, if such advice was likely to take longer
than this, the incentive would be to not provide
such advice, as consultation reimbursement is
fixed. Although certain procedures, e.g. various
forms of screening, do carry a separate financial incentive for the GP to undertake, many
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R. D. Smith
health-promoting interventions do not. This is
particularly so in the case of routine care and
treatment that may be delivered in a healthpromoting way to people with disabilities. Furthermore, primary care consultations, and any
other form of care, can take longer for people
with disabilities than for people without, but again
the fee set to reimburse general practitioners
does not allow for this additional cost. Thus, the
disparity between reimbursement and actual cost
provides a disincentive for health promotion to
be delivered, and possibly even sought, for people
with a physical disability.
In addition to direct service financing, of
significant concern is adequate funding for educational programs, particularly for service providers, to engender a move from health promotion
focused on disability ‘prevention’ toward health
promotion focused on disability ‘management’
(DeJong and Batavia, 1988; Yordi, 1988; Davies,
1992). Whilst there is clearly a need for ‘expert’
knowledge and skills, there is also a need for
‘general’ education of health professionals to
view people with disabilities in a sympathetic and
empathetic light, the lack of which has been
found to be a significant barrier to people with
disabilities receiving adequate care. This is critical in order to ensure that health professionals
have a full understanding of the needs of people
with disabilities, and are therefore able to
respond with the provision of appropriate advice
and services (Capitman, 1986; Yordi, 1988; Kane
et al., 1991; Davies, 1992). The impact of such
improved education could potentially result in
further illness prevention, hospitalization avoidance and minimized length of any hospital stay,
and improved quality of life for people with
disabilities and their families (Davies, 1992).
Disparate funding sources
Funding sources for services, e.g. health care,
social services and education, are distinct and
separate, especially within Australia with its
federal system of government (similar to that in
the USA) providing significant self-governing
responsibilities to individual states. Even within
health care there is financial separation of primary and secondary care, and state and federal
responsibilities, with over 60 distinct and separate funding streams (Paterson, 1996). With such
diversity of budgets, and a financial climate of
cost control, there is little incentive for active cooperation, and much incentive for cost shifting.
This creates an extraordinary complexity in the
funding and provision of health promotion and
health care for people with disabilities, with both
funding and provision coming from a variety of
disparate and separate sources. For instance, one
carer has been quoted as using 26 phone numbers regularly to co-ordinate care for her child
(Australian Institute of Health and Welfare,
1994).
Yet few important outcomes can be achieved
by the health service working in isolation. For
example, in order to minimize the handicap imposed by paraplegia, it is necessary to prevent
medical complications and progressive deformity,
maintain physical fitness, and be trained in the
use of appropriate technical aids. But it is also
necessary to live in a house which is accessible
and useable by someone in a wheelchair, in a
location where there are dropped kerbs, buildings with public access and transport facilities to
allow the person autonomy in the fulfilment
of their personal potential. Promotion of such a
person’s health would not have been successfully
achieved if they were to become marooned in an
inaccessible flat, however good their self-care
and wheelchair skills may be. Thus, for appropriate outcomes to be achieved, it will often be
necessary to combine services of health, social
and local authorities, including education, housing, transport and employment.
POSSIBLE SOLUTIONS
Case-management and co-ordinated funding
One possible means for reorganizing the
financing of services, to account for problems
of financial disincentives and disparate sources of
funding, is case-management. This has been
adopted in a variety of settings, e.g. the Social
Health Maintenance Organizations in the USA
and private sector initiatives (Yordi, 1988;
Henderson et al., 1988; Davies, 1992). Under this
system one individual (or a multidisciplinary
team), designated the ‘case manager’, would have
the responsibility for organizing, co-ordinating
and (if a budget holder) purchasing all the various, multi-sectoral, services which the individual
may require. A variety of models of casemanagement may be considered, from simple
negotiation for care, to being a partial or total
budget holder, to individuals with disabilities
becoming their own case-managers. Within
Australia such an approach of providing services
Promoting the health of people with physical disabilities
in a co-ordinated and collaborative fashion (including private sector institutions and employers
as well as the public sector) has been advocated
for a number of years (National Health Strategy,
1993; Australian Institute of Health and Welfare,
1994), and is currently being trialed with the
Council of Australian Governments (COAG)
‘Co-ordinated Care Trials’ (COAG, 1995;
Duckett et al., 1995; Duckett, 1996).
However, one should note that the appropriateness and efficiency of case-management
has not been established unambiguously. Evidence
suggests that although case-management may be
an effective and efficient organizational mechanism for some clients [principally those with
complex needs (Capitman, 1986; Kemper, 1988;
Weissert and Matthews-Cready, 1989; Kemper,
1990; Kane et al., 1991; Davies, 1992; Davies,
1994)], many clients with low to moderate levels
of disability can gain considerable benefits from
community services provided without casemanagement (Davies et al., 1990; Davies, 1992;
Davies et al., 1993; Davies, 1994). Furthermore,
a range of alternative approaches has been
suggested, many based on aspects of contracting
and other features of ‘managed competition’,
which may or may not include aspects of explicit
case-management (Davies, 1992; Scotton, 1995).
These potential means of reform are clearly
complex, and will require further research with
respect to the population of people with disabilities, but offer the potential for significant gains
over the current process of service organization.
Health promotion, disability and private
industry
Much health-promoting activity is, and could
potentially be, carried out within private industry.
There is growing interest in the use of health
promotion in the workplace, with many large
corporations (e.g. Xerox, AT&T and the
Victorian Railway Company) having their own
medical departments or programs established to
conduct a range of occupational health initiatives
(Galvin, 1986; Tate, 1987). The philosophy
behind this is to promote the employees’ health,
thus increasing productivity and reducing the
company’s health care costs by controlling the
disability period during which the employee is
absent (Morrow, 1985; Rieth et al., 1995).
Employer-based health promotion and disability management emphasize the early identification of risk factors, planned management
83
of physical and disability-related symptoms, a
willingness to modify jobs, and the establishment
of personnel policies that facilitate work return
and job retention rather than ‘defacto and
premature retirement for … disabled workers’
[(Galvin, 1986), p. 218]. Such work-based programs tend to encompass both disability management and health promotion activities, where
‘disability management’ refers to the active
process of minimizing the impact that a disability
has on the person’s ability to function in their
work-based role, and health promotion refers to
the prevention of ‘further’ disability and promotion of good health habits (Tate, 1987). There
will, of course, be considerable overlap between
these concepts.
Disability management, in identifying and
providing suitable interventions is thus an
essential part in: (i) developing the individual’s
own resources through a variety of health
promotion initiatives; and (ii) the removal of
barriers imposed by the work environment.
Health promotion is a critical part of this disability management, as it is designed to prevent
‘further’ illness and disability, e.g. by reducing
risk of injury (Tate, 1987). Such disability management programs often use a ‘case manager’ to
co-ordinate the multiple needs of the employee
with a disability, but also to assess their progress,
their work and home environments and care,
and generally act as that person’s advocate
(Rieth et al., 1995).
Such interest by the private sector could be
capitalized upon by health promotion policy. For
instance, public funds could be used to encourage
individuals to demand, and employers to provide,
health promotion. Second, they could be used to
finance or subsidize particular activities to make
them more accessible (Australian Institute of
Health and Welfare, 1994). Third, private sector
use of case-management could provide a useful
model for the use of case-management in promoting health for people with disabilities by the
public sector.
CONCLUSION
This paper has highlighted two specific systemic
areas where research and policy might be
focused to restructure funding to reduce barriers
in access to appropriate health promotion and
health care for people with disabilities. The
potential benefits may be significant, e.g. in
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R. D. Smith
improving health and reducing costs associated
with unnecessary rehospitalization. Such rehospitalizations may account for 60% of all hospital
costs (Zook et al., 1980), with individuals with
physical disabilities experiencing significantly
higher rates of rehospitalization than the general
population (Turoff, 1975; Meyers et al., 1985;
Braithwaite, 1986; Pearlin et al., 1990). However,
although the majority of causes of such readmission, e.g. urinary-tract infection, decubitus ulcers
and pressure sores are entirely preventable
(Braithwaite, 1986; Teague et al., 1990; Sullivan,
1992; Corrigan and Martin, 1992; American
Congress of Rehabilitation Medicine, 1993),
there needs to be an incentive for the various
agencies involved to engage in preventive measures and closer co-operation. Rehabilitation
services, e.g. have a wide remit in the promotion
of health for people with disabilities, including
prevention of such secondary admissions, and
funding arrangements need to recognize this role
(McLellan, 1992). The hospital sector also requires
an incentive to review admissions to identify
potential preventable admissions, and work directly with the community to address the problem
(Australian Institute of Health and Welfare,
1994). Further, education of health professionals,
and patients, in self-care and health-promoting
behaviour could reduce such readmission. Private
industry also has a role to play in the provision of
health-promoting services. By strategic use of
services offered by employers, delivery of health
promotion in a timely and targeted way should
reduce the use of health services by people with
disabilities, as well as increase their health and
well-being. Of course, many of these issues go
well beyond the needs of people with physical
disabilities, with such initiatives also applying to
many populations other than those with physical
disabilities.
There is a need to find models of the finance and
delivery of care, as well as specific interventions,
that will avert such unnecessary rehospitalization,
as well as respond to the health needs of those
with specific disabilities (particularly as they
get older). Ultimately this requires incentives
for providers of care to consider the longer-term
needs of the disabled. One of the more promising
ways to proceed in the restructuring of health
promotion and care for people with disabilities is
the move toward case-management.
Although restructuring the funding arrangements of any aspect of health promotion and
health care is not a task to be undertaken quickly,
changes and reforms are already taking place.
Within these changes there is both the potential
for people with disabilities to lose or to gain. The
danger is that, in applying health care reform,
health promotion, particularly for those who
already have some form of disability, may seem a
‘soft target’ for funding cuts, or be disadvantaged
as an unseen side effect. However, there is also
the potential to use the current willingness, even
eagerness, to change the structure of funding to
promote the health of people with disabilities.
For instance, the move toward budget-holding
and case-management could be of great benefit.
Whatever the potential, it is vital that research is
undertaken in a timely fashion to capitalize on
the changes taking place to ensure both that
the potential harm to those with disabilities is
minimized, but also that the changes which will
be beneficial are promoted and capitalized
upon.
ACKNOWLEDGEMENTS
The author would like to express his appreciation
to Roy Batterham, Rob Carter and David Dunt
of the Program Evaluation Unit of Melbourne
University for informative discussions and comments, and to two anonymous referees. The
research described in this paper was supported
by the Victorian Health Promotion Foundation,
and was carried out whilst the author was employed at the Health Economics Unit of Monash
University.
Address for correspondence:
Richard D. Smith
Health Economics
School of Health Policy & Practice
University of East Anglia
Norwich NR4 7TJ
UK
E-mail: [email protected]
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