Delegate Assembly passes Managed Care Policy Statement

Delegate Assembly passes Managed Care Policy Statement
(November/December 1993)

The New York City Chapter's draft Managed Care Policy Statement, which was initiated by the Chapter's Health Care Policy Network, was passed, with modifications, by NASW's 1993 Delegate Assembly in August. The following draft document will appear in its final form in Social Work Speaks, a compendium of policy statements, program priorities and resolutions which will be available from NASW's publication office, (800) 227-3590 in January.

POLICY STATEMENT

NASW advocates the following policy strategies on standards, social work role, and advocacy.

Standards

When integrated community health care networks are created or contracts are made with existing ones, the specifications and contracts must respond adequately to the health care needs of the population to be served, as consumers will be constrained from using other health care resources. Standards for managed care plans at a minimum should include the following:

A full range of readily available services including primary care and subspecialties including mental health services and hospitalization

Clearly maintained safeguards for confidentiality, including issues of computer technology

Access to services that meet the needs of families, working people, older people, and people with disabilities (the emergency room will no longer be available for routine care at night or on weekends)

Clearly drawn affiliation agreements with specialty providers, hospital pharmacies, home care agencies, and other services

Appropriate transitions for clients who must change health care plans or who have exhausted their benefits during the course of treatment to facilitate continuity of treatment with the current provider or provide clinically sound transition to another provider

Emergency and urgent care procedures available on a 24-hour basis

Medical record access to caregivers on a 24-hour basis

Social work services basic to primary care and acute care settings in which beneficiaries have access to health and mental health services provided by social workers to receive crises intervention, assessment, prevention, health education, rehabilitation, and continuity of care

Specialized mental health services provided by social workers to include psychotherapy and counseling practice for individuals, families, and groups and substance abuse prevention and treatment

Complaint and appeal mechanisms readily available and easy to use by all participants

Advisory boards that include consumers and that meet regularly and participate in policy and program development decisions.

Social Work Role

Social workers have been involved in all stages of the development of managed care. A number of major managed care organizations identify social workers as their founders. Many others employ social workers in key executive positions, as well as in utilization staff positions and as providers of health and mental health services. As in any host setting, it is imperative that social workers function in their organizational roles within the framework of the values and standards of the social work profession.

Social workers may play three key roles in the managed care treatment environment.

Direct Provider of Services
Social workers are fully qualified providers of health and mental health care services. Social workers are responsible for psychosocial assessments, care coordination and planning, counseling on adjustment to physical and mental illness, and counseling and treatment for individuals, families, and groups. Social workers are trained and licensed or otherwise regulated to provide prevention, assessment, and treatment of emotional and mental disorders, psychosocial dysfunction, disability, and impairment. The person-in-environment treatment perspective of social work provides a stimulus for rapid attainment of effective social functioning.
Social workers are accessible geographically and demographically. Social workers are sometimes the only mental health care providers in the community. Social workers reflect the racial and cultural demographics of U.S. society and have a history of working with culturally and economically diverse populations.
Social work is a recognized and regulated profession. All federal programs that provide mental health care coverage and most private insurers recognize clinical social workers as autonomous providers of mental health services. State regulation and professional credentials provide a measure of consumer protection.
Managed Care Program Staff
In managed care organizations, social workers perform utilization management, network development and management, and operation management. Social workers bring to these roles the ability to view the client situation within the context of the person-in-environment, examining the biopsychosocial dimensions of client needs. They use the fundamentals of social work case management that provide a theoretical and technical framework for coordinating mental health and substance abuse benefits with the resources of the family and the community in the best interest of the client.
As part of this process, social workers have brought a familiarity with and a respect for multidisciplinary and interdisciplinary practice, as well as the ability to help various systems negotiate and work collaboratively.
Health Care Leadership
Social workers develop and implement service delivery models that significantly improve options for care. They present continuum of care options that support optimal functioning of the client in the least restrictive environment, and they promote healthy community functioning.

Advocacy

Because public policy relating to managed care is embedded in federal, state, and local laws, advocacy efforts require a multitiered approach. Social workers should:

Challenge managed care plans to ensure the inclusion of professional social work services.
Promote state and federal legislation that supports basic standards of care that include universality, accessibility, affordability, comprehensive and adequate services, and portability.
Actively work for passage of legislation that mandates professional social work services in managed care plans, including self-insured plans.
Promote legislation that mandates that utilization review be done only by a health care professional licensed in the specialty for which he or she is reviewing.
Challenge closed provider networks that restrict provider participation and consumer access.

Current health policies reflect interpretation of existing laws. To alter the impact of managed care on consumers and on social work, NASW will need to create appropriate structures to actively examine existing policies at all levels of government. This assessment must also consider the feasibility of creating a consensus for new or supplanting legislation, or of amending existing acts, with concomitant dangers of opening a Pandora's box. There are powerful players in the forthcoming debates on these issues and NASW will need to join with others to amplify its strength while remaining clear about its constituencies' needs.

Managed care organizations and providers of services must establish mutually respectful operations to ensure that the client is neither overtreated nor undertreated. Specific standards for managed care organizations and for social workers in solo and group practice contracting with managed care organizations should include:

Provider relations
Practice management
Treatment planning and termination
Confidentiality
Provider responsibilities
Ethical behavior.

First and foremost, NASW expects managed care organizations and all social workers involved as staff or providers to work toward the best interest of the direct consumer of service. Working together, in a client-centered context with the best talents and resources available, we can improve the health care delivery system.

There is no guarantee that any health care delivery system will be free of inequalities and quality problems, but the NASW policy on national health care that calls for universal health care coverage can result in a fair and equitable system. Managed care under a national heath care policy would be governed by a universally adopted set of principles applicable to all.

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