Suggestions to social workers for surviving in managed care.

Abstract

Health care professionals and consumers have witnessed a revolution in health care delivery during the past decade. Both employers and the government have sought to shift enrollment from traditional fee-for-service or indemnity medical care, into managed care to slow the growth of health care expenditures and promote efficiency in health care delivery. The United States has been transformed from a fee-for-service system to a managed care system with health care plans that and guide patient choices about providers and specific from subtle (patient information) to very direct ways (no reimbursement for uncovered services) (Feder & Moon, 1998; Sofaer, 1998). Nearly 75 percent of the employed population receive their health care in managed care systems (Jensen, Morrisey, Gaffney, & Liston, 1997), and even those in fee-for-service plans frequently have incentives, such as reduced out-of-pocket expenses, to use specific providers. As managed care continues to shift the locus of care from an inpatient to an outpatient setting, the need for hospital social work has decreased (Rosenberg, 1998). Social workers, like other health care professionals, have seen layoffs in inpatient settings and increased employment opportunities in home care and other community care settings (Berger et al., 1996; Rosenberg, 1998; Volland, 1996). Discipline-specific roles have blurred, patient care tasks have been reengineered, and the need for professionals to do certain tasks has been disputed and changed. Although some question the relevance of clinical social work in health care settings (Keigher, 1997; Munson, 1998), we believe that the core social work skills and values are essential to providing quality care for patients in managed care. The need for social work in ambulatory care settings is slowly gaining recognition and acceptance (Levenson, 1998; Netting & Williams, 1995; Simmons, 1994). Cost and time pressures on primary care physicians allow them little time to address important psychosocial and economic problems affecting the overall health of patients. Social workers are well qualified to assess psychosocial needs of high-risk patients and how those needs influence their overall health status (Mellor & Lindeman, 1998). Factors such as insufficient money to purchase medication, feelings of sadness and depression, and difficulties performing activities of daily living, which patients often are reluctant to discuss with their physicians, are readily shared with social workers. In a recent study on the interaction between physicians and social workers in a hospital setting, Abramson and Mizrahi (1996) found some improvements in the communication and interaction between physicians and social workers, and a growing respect among physicians for the assistance provided by social workers in patient care. This growing respect is readily transferred to ambulatory care settings. The challenges for social workers in managed care are twofold. First, we want to retain the core values of the profession--advocacy, self-determination, and client focus--often considered at odds with corporate for-profit health care. Second, we need to develop the business acumen to demonstrate social work's effectiveness in a service industry where demonstrated outcomes predominate. THE BASICS OF MANAGED CARE At the center of managed care is the concept of capitation, which is a payment mechanism used by many HMOs to compensate physicians for services. Under capitation a physician is paid a fixed amount monthly per patient in advance of services being provided. Capitation offers physicians some distinct advantages by providing a steady income stream, paid in advance of services being provided. It also has drawbacks for the physician in that capitation payments are not increased for patients with medical costs that exceed the monthly payment being received. In theory, managed care changes the incentives for both the health care plan and the providers of services. …