An Evaluation of Medicaid Managed Care:
Social Work Issues and Recommendations and The Social Work Role in Managed Care
(May 1995)
In January, 1994 the Board of Directors and the Health Care Policy and Practice Network of the New York City Chapter held a think tank for leading social workers in all areas of health and mental health care to share their
experiences about the development of managed care for people enrolled in the Medicaid program. Out of the
discussion, a work group was formed to document the emerging issues and to make recommendations for improving
the way managed care is being implemented. This documentation and recommendations are included in two newly
published position papers:
The following is a summary of these papers. |
AN EVALUATION OF MEDICAID MANAGED CARE:
SOCIAL WORK ISSUES AND RECOMMENDATIONS
NASW is concerned that the rapid growth of managed health and mental health care in New York State is surpassing the ability of consumers and government regulators to assess its quality and appropriateness.
Medicaid managed care and its implementation is of particular concern. On the one hand, managed care offers the opportunity to provide needed primary care services to low income, medically underserved communities - care that is accessible, comprehensive and accountable. On the other hand, a challenge is to ensure that managed care plans provide the full range of Medicaid services available.
ISSUE 1: Medicaid managed care enrollment practices are flawed.
Recommendation: Consumers must be educated about their benefits, privacy, freedom of choice, control of care and rights to disenroll or change provider. Resources must be allocated to social services districts for consumer education.
ISSUE 2: There are access barriers to health care for homeless families and individuals enrolled in Medicaid managed care.
Recommendation: Families and individuals who are homeless or become homeless should be exempt from managed care unless their choice is to enroll. Enrolled clients who become homeless should have the right to receive fee for service care while their housing problems are being resolved.
ISSUE 3: Waiting times for physician appointments are inappropriately long for some Medicaid managed care patients.
Recommendation: Waiting times must be monitored as part of quality assurance activities, and Plans must be required to add enough medical specialty and mental health providers to meet recipient need in a reasonable time period.
ISSUE 4: Medicaid covered services are not uniformly available.
Recommendation: A mechanism is needed to ensure that Medicaid patients receive mental health and other services to which they are entitled without having to disenroll from a plan.
ISSUE 5: The rights of Medicaid managed care patients to receive emergency hospital care must be protected.
Recommendation: Protocols must be developed and mandated that ensure prompt authorization for emergency care, compensate hospitals for the costs of triage and assessment of need, and make alternate care plans available to the patient if emergency room care is refused.
ISSUE 6: Services for special populations may be jeopardized.
Recommendation A: Medicaid managed care plans should be encouraged to incorporate Prenatal Care Assistance Program providers as panel members for prenatal care.
Recommendation B: A mechanism must be found to fund school-based health clinic services provided to students who are enrolled in a Medicaid managed care plan.
ISSUE 7: Access to community mental health services may be compromised.
Recommendation A: Methods must be developed for managed care patients to receive authorization for additional mental health treatment, when needed, without undermining confidentiality through the forced discussions of problems by telephone with representatives of managed care plans.
Recommendation B: Managed care plans must be flexible enough so that health care can be accessed with one provider (ie., managed care company) and mental health care of a client's choice from another (ie., licensed community agency or therapist) and paid for by Medicaid. This "health only" option will support the survival of licensed community based mental health clinics in New York City whose funding source is threatened as more Medicaid recipients enroll in managed health care plans.
Recommendation C: The "health only" option must be considered for patientsoutside State jurisdiction who are diagnosed as mentally ill. These adults and children should be able to enroll in Medicaid managed care for health care and be eligible for mental health care from licensed community based agencies/facilities through fee for service Medicaid.
Recommendation D: Contracts should be encouraged between managed primary care providers and licensed community mental health providers, with both responsible for appropriate utilization.
ISSUE 8: Standards for psychosocial care and social work services in primary care provider sites and medical care organizations are absent from Medicaid managed care law and regulations.
Patients entering the medical care system, whether for primary, acute or remedial care, bring with them social and psychological problems that effect their ability to use medical care, to prevent illness or disability or recover and to maintain their normal level of functioning in family, personal or work relationships. There is a common need among all patients, whether insured privately, by Medicare and by Medicaid, or uninsured, for urgent, routine and/or occasional mental health, social work and case management services throughout the continuum of care - primary, specialty, acute hospitalization, home and nursing home care. However, New York State Medicaid managed care law and regulation does not mention psychosocial care or social work services as a required or optional service.
Social workers are appropriate health professionals to assess the nature and severity of psychosocial problems that interfere with medical treatment or recovery, to provide crisis or short term mental health interventions for patients and their families, to identify, refer and/or coordinate other services that are needed and, to manage and monitor the plan of services.
Social workers are also trained to understand and negotiate systems and procure community resources. Skilled management of psychosocial problems faced by patients and their families and skilled coordination of resources provides continuity between the hospital or health provider and the community, and reduces the need for what may be unnecessary medical care or inappropriate hospitalization or institutionalization.
Recommendation: Standards for psychosocial care and the inclusion of social work services in Medicaid managed care must be adopted by the New York State Department of Social Services, the New York City Office of Medicaid Managed Care and managed care plans.
Social workers with Master's level training are prepared to provide, supervise and/or administer services needed to address the range of social, emotional and environmental problems that patients bring with them to health and mental health settings.
There are two essential social work roles in managed care:
In managed care organizations, social workers perform quality assurance, utilization management, network development and operations management. Social workers bring to these roles the ability to view the patient situation within a person-in- environment context, examining the biopsychosocial dimensions of the patient's needs. Techniques of social work case management are used that provide a theoretical and technical framework for coordinating services including preventive care, medical, mental health and substance abuse services with family and community resources. Social workers are cost effective coordinators of care, balancing patient and organizational needs.
Social workers are fully qualified providers of health and mental health services. They provide psychosocial assessments, care coordination and planning, counseling on adjustment to physical and mental illness, and mental health counseling and treatment for patients and their families in both medical and psychiatric settings.
Social workers help patients adopt skills and behaviors to cope with and/or prevent social and emotional problems. In primary and other medical care settings, they can assess patient need for mental health treatment and make appropriate referrals. Social workers also perform case management and discharge planning in health and mental health settings, and are trained to understand and negotiate with social systems and organizations that provide needed support to patients.
In managed health care settings, the two social work roles can be combined through the use of professional social workers as members of primary care teams in hospital and/or community based clinics or as professional consultants to primary care physicians in their office-based practices. Models of primary care social work practice can be found in hospital clinics and community health centers. These models provide comprehensive medical and psychosocial services within the primary care setting, strengthened coordination and reduced fragmentation of care between medical and community providers, and more appropriate use of medical care, thereby reducing costs.