Advocacy in Health Care
(November/December 2003)
By Penny Jeffa Schwartz, DSW, Program Coordinator, Department of Social Work Services, Mount Sinai Medical Center
The health care system has always been a challenge for clients to navigate. In today’s world of managed care, PPO’s and the rest of the alphabet soup that comprises the health care system as well as the problems of decreasing resources and reimbursements, privatization of health care institutions, AIDS, cancer and fears of bioterrorism, finding one’s way through the maze is more daunting than ever. So, how do clients find their way? The sad truth is that many do not and others succeed only after many failed attempts. Social work advocacy is often essential to the clients’ abilities to negotiate their health care. This professional social work function starts with facilitating clients’ ability to obtain and maintain health insurance. For without health insurance there is no access to health care in our marketplace-based system of health care delivery.
At Mount Sinai Medical Center, this advocacy starts at the Resource, Entitlement
& Advocacy Program (R.E.A.P.) of the Department of Social Work Services.
R.E.A.P. is charged with assisting clients in obtaining and maintaining health
care access by assisting with the application and renewal processes for such
benefits as Medicaid, Child Health Plus, Family Health Plus, Medicare, TANF,
Social Security, Supplemental Security Income, etc. Additionally, as managed
care has expanded in both the public and commercial sectors of health insurance,
REAP has assumed the responsibility for assisting ing denials of care, advocating
for “out of network” care, as well as such basics as helping clients
to understand how their health insurance works and how to get the most out of
a system designed to limit usage of health care services. At REAP the entitlement
counselors perform a differential entitlement assessment in which client data
is collected, analyzed and compared to all programs for which the client might
be eligible. The advantages and disadvantages of each of these programs are
explained to the clients who then decide to which program(s) they wish to apply.
The REAP counselor then assists the clients with obtaining the necessary documentation
to complete a viable application as well as completing all the requisite forms.
REAP then submits the application on behalf of the client (where client representation
is permitted by the various agencies), we track the application, challenge any
deferrals or denials, and follow the situation until an acceptance is obtained.
In cases where clients might have attempted this complex set of maneuvers on
their own, we may need to represent the clients at a “Fair Hearing”
in order to get an adverse decision reversed. REAP is successful in obtaining
a favorable decision on a submitted application in about 99% of the time.
Perhaps a case example would illustrate the role of social work advocacy in
health care. A few years ago, a woman writer was referred to REAP by the Breast
Health Resource Center. This woman had a breast mass the size of a grapefruit
and was in dire need of surgery, radiation and chemotherapy. However, she had
no health insurance and was not wealthy enough to pay for all these services
privately. The REAP counselor met with the patient. In that initial interview,
they agreed to apply for Medicaid benefits. The client returned the next day
with documents. While reviewing these papers, the counselor noted that there
were major discrepancies that would have resulted in a denial of the Medicaid
application. When the counselor addressed this, the client simply shrugged and
was willing to abandon the process. The situation was then brought to my attention,
as the director of REAP. Using every clinical skill in my repertoire, I tried
to get the client to clarify her situation. She continued to refuse. The client
left. We were very worried about this woman and the serious consequences that
would result if she did not get medical care as soon as possible. I called the
woman at home and ardently urged her to come in and speak with me again. During
that next meeting, I asked what could be more compelling than an advanced breast
cancer that would kill her if she did not get immediate medical care. This woman
then proceeded to relate one of the most horrific cases of domestic violence
I had ever heard in over 20 years of practice. It became patently clear that
her fear of her ex-husband was more frightening then a death due to cancer.
This client told me that, apart from the district attorney, this was the first
time that a health care professional listened to her story with understanding
of her plight.
Through massive advocacy efforts with social security, Medicaid and the hospital,
we were able to get her social security number changed to her “assumed”
identity and helped her apply for SSI for the first six months after which the
social security disability application would be effective. We applied for Medicaid
until the SSI was approved (a process that could take three months). Her situation
was dire and medically emergent. She could not afford to wait for all the bureaucracies
to finalize their changes and approvals. REAP then advocated with the hospital
to admit this woman, perform the surgeries necessary, and start the radiation
and chemotherapy even before the Medicaid approval. The hospital agreed to do
this based on our assessment that she would be found fully eligible. For the
first time in over fifteen years, this woman could get appropriate health care,
could come out from the “underground economy” and live with a “new
identity” that could not be traced by her abusive ex-husband. She began
to write again only now the images were filled with light and hope even though
she had a terminal illness. In a way, her cancer had helped her achieve the
freedom that had been denied by her fears of her abusive husband. Without advocacy,
that would not have been possible, nor would she have had the five years of
freedom and life before her cancer recurred and eventually claimed her life.
Social work advocacy and entitlements assistance benefit both clients and the
health care institutions that support these efforts. For the hospital, entitlement
services and advocacy help reduce uncompensated care, help get more timely payments
because patients enter the system with health insurance, and promote a positive
image of the health care institution in the community as a caring and accessible
place. For the client, the benefits of social work advocacy and interventions
may well mean the difference between life and death as in the previous example.
In less dramatic situations, health care social work advocacy enables clients
to gain access to needed health care, to maintain that access by maintaining
their insurance and help them to understand how to utilize their health care
benefits in a context of empathy and clinical skill that is best exemplified
by our profession.