By: Jan Ligon
Summer 1997, Vol. 4, No. 3
Spelling Out Managed Care
by Jan Ligon, Ph.D., LCSW, ACSW
The emergence of managed care and its growing influence on the delivery of health care services will affect all social workers, including students and recent graduates. Managed care means change in the way social work services are delivered and it is important for social workers to stay informed as the concept of managed care continues to evolve. What does managed care spell now?
Managed care means managed costs. Employers must control the cost of health care, and managed care is one attempt to do that. About 60% of Americans are now under some form of managed care.
Assessment has always been an important aspect of social work practice, and it is a critical skill in managed care. Assessments must be prompt, accurate, and communicated in a manner specified by the managed care organization. It is common for managed care to use a medical model requiring that there is a medical necessity for services to be provided.
Needs of the client are matched by the managed care firm to a broad range of services within the firm' network of providers. A continuum of care in services may include inpatient, outpatient, home-based, and other services.
Access to services is usually provided through a toll-free telephone number which is available around-the-clock. Prompt response and immediate linking to services can reduce costs.
Gatekeeping refers to the approval process required by managed care firms in order to obtain initial services as well as to continue services beyond the initial amount approved.
Ethical concerns are prevalent in managed care and can lead to dilemmas around conflicts between the demands of managed care and the needs and rights of clients. For example, clients have the right to confidentiality, but managed care requires a great deal of information, which may be stored on computers and not fully protected. Another dilemma occurs when the social worker feels that the client is still in need of services, but the managed care firm will not approve the request; social workers may decide to treat clients without reimbursement in some cases.
Demand management refers to patient education, training programs, early detection, and self-care programs, which are targeted to empower the consumer and reduce the need for unnecessary or inappropriate services.
Capitation refers to a growing method used by managed care firms, which uses a fixed rate of payment for services to a defined group of recipients. For example, a managed care firm would pay a mental health provider a flat amount of dollars per covered person to provide an agreed upon array of services to the people in the defined group. The benefit to the purchaser of services is that the cost is fixed; the downside to the consumer is that the provider benefits by delivering the least amount of services possible.
Accreditation, licensure, and certification of both providers and facilities is a significant concern of managed care firms. Social workers need to acquire and maintain the highest levels of licensure and certification obtainable, and programs and facilities must be accredited in order to be providers to managed care firms.
Research and evaluation of the outcomes of treatment and services is essential to survive as a managed care provider over time. While behavioral health services are behind in this area, managed care demands “best practice” interventions and documentation of the outcomes of services. Social workers and students need to be knowledgeable about effective treatments and the methods and approaches used to measure and evaluate interventions and programs.
Evolving describes the current state of managed care. During this period of rapid change, it is important for students and recent graduates to stay very current on new developments in managed care through professional publications, the Internet, and other resources.
MANAGED CARE has expanded at a very rapid pace and is likely to continue to grow for the foreseeable future. It is also important to note that new and different forms within managed care are also developing. There is no single approach to managed care, and plans range from being very generous to being very limited in benefits. It is also difficult to define managed care in terms of good or bad. There are aspects of managed care that can be extremely beneficial to consumers of services, but there are also horror stories about poor outcomes within these plans. It is most important for social work students and new graduates to stay current and informed in this rapidly growing and changing entity.
Jan Ligon, PhD, LCSW, ACSW, is Assistant Professor at the University of South Carolina College of Social Work in Columbia and is an Editorial Advisory Board member of The New Social Worker.