SOCIAL WORK AND MANAGED CARE:

As mandated Medicaid managed care is implemented in New York, social services, an essential component of care, is absent from most of the settings which will serve recipients. Social services designed and managed by masters level professional social workers are not now required by State and Federal law and regulation. The need for social services is discussed in this document with a recommendation for necessary regulatory and/or legislative change to ensure the availability of social services

The purpose of social work in health care is threefold: first, to assist individuals, their families and significant others to function when illness, disease or disability results in changes in their physical state, mental state or social roles . Second, to prevent social and emotional problems from interfering with physical and mental health or with needed treatment. The third purpose of social work in health care is to identify gaps in community services and to work with community based agencies and institutions to expand the capacity of the community to provide adequate supports. However, New York State's Medicaid managed care laws and regulations do not mention psychosocial care or social work services as either required or optional services.

Social workers provide, supervise and/or administer services which address the range of social risk problems that patients bring with them to health and mental health settings. Social risk refers to aspects of patient social, psychological and emotional status which increase the chance of illness or interfere with treatment.

Social workers are essential in keeping patients linked to the Medicaid system by keeping them informed of their rights, procedures and changes in policy and by serving as advocates to seek the restoration or maintenance of benefits in the face of bureaucratic errors.

Health care professionals have long been aware of the difficulty of providing medical services to people with significant emotional and social problems which interfere with treatment or in themselves, create medical problems. Over the past seventy five years, social work services have developed in organized health care settings to provide the psychosocial care people require around their health care needs. A sinficant proportion of the more than 70,000 masters and bachelor level prepared social workers in New York State are employed in health care settings. They are found in hospitals, and also in community health centers, diagnostic and treatment centers home care, rehabilitation, long term care and hospice settings. Because of the economics of managed care and a lack of adequate state regulation, Medicaid patients and others covered by managed health care plans are deprived of necessary social services. Besides the social, emotional and health costs to patients, the payers for health care are overspending because of inappropriate and over and under utilization by patients of health care resources. It is essential to add social services as a required health care benefit for all managed care plans.
 

As mandated Medicaid managed care is implemented in New York, social services, an essential component of care, is absent from most of the settings which will serve recipients. Social services designed and managed by masters level professional social workers are not now required. The need for social services is discussed in this document with a recommendation for necessary regulatory and/or legislative change to ensure the availability of social services. Referring to social workers in a letter, Dr. Barbara DeBuono wrote: "Extensive investigation and dialogue has not identified another class of health care professional with the skills and knowledge to oversee staff addressing the psychosocial aspects of the care of these patients." (From a letter by Commissioner of Health, Dr. Barbara DeBuno to Director of The Governor's Office of Regulatory Reform, Robert King, April 1996.)

New York State is at the threshold of a dramatic change in the organization and financing of health care which will accelerate over the next two years with the mandatory enrollment in managed care plans of 2.1 million low income children and adults who are covered by Medicaid. As of March 1998, there were 384,425 or 27.38% of 1,403,865 eligibles in New York City enrolled in 30 managed care plans and 238,504 or 32.4% of 736,239 eligibles in upstate New York enrolled in 40 managed care plans.

New York State's decision to mandate enrollment in managed care for most Medicaid beneficiaries runs parallel to trends in New York's commercial health insurance market. Employers have moved rapidly to offer managed health and mental health benefits to their employees. In 1998, more than 60% of privately insured New Yorkers were covered by some form of managed care. The adoption of managed care strategies by public and private payers, combined with advances in medical treatment, technology and drugs, is rapidly shifting the locus of care from the inpatient, acute care hospital to the doctor's office and outpatient clinic. Under capitation or discounted preferred provider payment systems, the payer, the plan and the provider all have an incentive to help keep members well and to provide efficient and effective care when they become ill. The expectation is that hospitalization will be minimized in favor of care in the community.

While managed care promises easier access, better coordination and a higher quality of care for Medicaid patients and medically underserved communities, there is a growing body of evidence that the health care system and managed care plans have not yet established the primary health care infrastructure to provide appropriate, cost effective care to large numbers of poor New Yorkers. There is an acknowledged shortage of primary care providers available to serve Medicaid patients and low income communities. It is believed a Medicaid managed care system cannot be fully implemented unless nurse practitioners, physician assistants and residents in training are allowed to be primary care providers.

The shift to capitation places the responsibility for more efficient and effective health care on all those involved in making the system work. The purchaser of services, in this case the State government, must become a prudent buyer. As prudent buyer, the State contracts with managed care organizations (MCO's) to arrange for quality care at a fixed price. Finally, the provider is made responsible for delivering the service within the price and quality guidelines. A significant proportion of patients enrolled with a primary care provider arrive with psychosocial symptomatology which complicates care and increases costs. Some community health centers and hospital based primary and ambulatory care clinics have tackled these issues by providing social services directly to their patients, as needed, through staff social workers and social work assistants. The primary care providers and managers recognize their value. Thus, as Medicaid mandatory managed care is implemented, primary care practices, both clinic based and office based, will need to plan for the provision of social services and an efficient system for determining referrals to the service.
 

The purpose of social work in health care is threefold: first, to assist individuals, their families and significant others to function when illness, disease or disability results in changes in their physical state, mental state or social roles . Second, to prevent social and emotional problems from interfering with physical and mental health or with needed treatment. The third purpose of social work in health care is to identify gaps in community services and to work with community based agencies and institutions to expand the capacity of the community to provide adequate supports. However, New York State's Medicaid managed care laws and regulations do not mention psychosocial care or social work services as either required or optional services.
 

MRS. J.

Mrs. J. was a 45 year old woman who was found to have a diagnosis of advanced breast cancer. She required considerable treatment including radical surgery and plastic surgery. As a person without insurance the patient was referred to the social worker by the physicians to assist the patient in obtaining Medicaid. In the course of the application process the social worker was unable to reconcile either the information provided or the affect of the patient. She was more frightened of revealing information than of the seriousness of her disease. Mrs. J. had become "imprisoned" by her husband's threatening behavior.

The social worker counseled Mrs. J. and, in the process, learned of a long history of marital abuse and violence. Mrs. J. feared for her life. While separated from her husband she knew he was searching for her and would attempt to kill her if he located her. She was hiding her real identity, social security number, and other pertinent facts.

The social worker gained her confidence by taking Mrs. J. seriously and , with great difficulty, helped her to obtain many facets of a new identity including a new social security number. This required care in transferring her account, since as a gainfully employed writer, Mrs. J. had accumulated a substantial account at social security.

With the new numbers, and other legally changed data, Medicaid was obtained. Mrs. J. lost her insurance when she entered the underground economy to avoid her husband's efforts to locate her. The social worker also consulted with the District Attorney's office regarding Mrs. J.'s husband. He verified Mr. J. was a dangerous felon. During that process, the social worker arranged for the hospital to use special funds to guarantee her surgery and treatment. Her medical condition stabilized, the social worker obtained Medicaid for her and after 2 years she received Medicare and social security.

In earlier contacts with the health care system no efforts were made to refer Mrs. J. for psychosocial evaluation. Early social work contact and intervention with Mrs. J. to address a serious psychosocial problem could have avoided the personal and financial cost to Mrs. J., the health care system and to Medicaid that was incurred as a result of her advanced illness.

Mr. B.

Mr. B. was a 56 year old chronically ill diabetic who received public assistance and Medicaid. He used a primary care physician at an urban community health center to manage his health care. Mr. B. had minimal employment skills and no family. Due to a bureaucratic error both his public assistance and Medicaid were abruptly terminated, without notice. Over a period of three months, with no source of income, his electricity and gas went unpaid and were shut off. Without Medicaid, he stopped seeing his doctor and taking his medication. As his health deteriorated, Mr. B. became unable to negotiate a resumption of his benefits. He made repeated visits to nearby emergency rooms in order to obtain medical care and medication. He eventually developed diabetic ketoacidosis and was hospitalized for one month in order to stabilize his medication regimen and ensure compliance with it.

Mr. B. was clearly eligible for Medicaid and the hospital based social worker intervened to investigate the cause of his benefits termination. She requested a fair hearing for Mr. B. and was able to get his benefits restored on an emergency basis. The social worker also advocated with Mr. B's landlord to hold his apartment during the hospitalization with rent to be paid retroactively.

Mr. B's case is an example of health and social problems that arise as a result of "churning" - a process by which public assistance and Medicaid benefits are turned on and off due to changes in client eligibility, vigorous efforts to verify eligibility that are fraught with high error rates or simple bureaucratic error. In addition, illness itself prevents some patients from advocating for a restoration of Medicaid benefits that they are entitled to. Churning is a major problem for the patient, for providers and for the payer/managed care plan from both a cost and wellness perspective. With the uncoupling of public assistance from Medicaid and the increased risk of benefit loss due to problems in complying with work and other requirements, more patients are likely to require social work intervention in order to keep or restore their benefits.

Baby G.

Baby G. is a newborn who was hospitalized for pneumonia three times within a three month period last winter. Baby G. was discharged by the primary care pediatrician each time as symptoms were alleviated. During the third hospitalization, a referral was made to the hospital-based social worker who found that for over a year the mother's landlord had failed to repair broken windows in the family's apartment, which created hazardous health conditions. After several attempts, the social worker contacted the landlord and requested that repairs be made threatening legal action. Repairs were made immediately, legal aid was not required, and Baby G.'s episodes of pneumonia ended, preventing further hospitalizations.

In this case, knowledge of the family's social and environmental problems and early intervention in a primary care out patient practice would prevent the use of expensive hospital and emergency room care.
 

Social work services were, until recently, available to patients and their families in hospitals and their clinics. Although the regulations setting the standards for social services remain, the Health Department no longer enforces them. As a result, the quality and availability of social services have decreased. The administration of social work services has been elminiated in many hospitals. This has occurred as a means of coping with the changes in New York State's reimbursement system and the advent of managed care.

Changes and reductions in hospital-based social work services were accelerated after 1993 when Governor Pataki sought to remove or change a number of patient care protections in the New York State Hospital Code. One such protection was the requirement that hospitals in urban communities have organized departments of social services directed by a professional social worker with a master's degree. Social work professional organizations, unions, other health professions, and many consumer organizations, advocated with the State Hospital Review and Planning Council and the New York State Legislature to stop the removal of this regulation from the hospital code.

The New York Health Code still requires social work departments, but hospital social work departments in all parts of New York have been dismantled and professional social work staffing has been reduced and in some cases eliminated. Functions performed or supervised by professional social workers are increasingly performed, if at all, by personnel with no educational preparation or limited experience in assessing and intervening in psychosocial problems and in linking patients to appropriate community resources.
 

Hospital social work departments throughout New York State have experienced reductions of 10-50% during the last three years. Staffing changes are inevitable when the hospital census and bed capacity are reduced. There are excellent examples of primary care social work practice at some urban hospitals and community health centers, yet many new primary care practices and offices are being established by hospitals and private physician groups in low income communities without social workers as members of the team and without systemic links to social services.

More than one third of the hospitals in New York's urban communities have eliminated the director of social work services - and have redeployed remaining social workers to work under the supervision of nurses, generically trained case managers and administrators. While considered a more efficient use of personnel by some, this restructuring removes important structures that maintained quality of care standards. Line social workers now lack professional oversight and supervision of social work services, centralized community resources, entitlement and information centers, and centralized discharge planning support.

Essential community providers, (e.g. federally funded community health centers) and many established MCO's that have served the Medicaid population do not uniformly include social work services as part of their primary care services or benefit packages. In community health centers, social work services that are available are frequently supported through special grants and contracts.
 

Social workers provide, supervise and/or administer services which address the range of social, emotional and environmental problems that patients bring with them to health and mental health settings. Social workers are the appropriate health professionals to assess the nature and severity of psychosocial problems that interfere with medical treatment or recovery. Social workers provide crisis or short term mental health interventions for patients and their families, they identify, refer and/or coordinate other services that are needed and, manage and monitor the plan of services. Social workers are trained to understand human behavior and the impact of illness or social dysfunction on patient and family relationships, and to identify and support the coping mechanisms that allow patients to heal and/or to prevent and solve problems.

Mobilizing the resources of family and friends, as well as economic and community support prevents deterioration making it possible for patients and families to achieve the best level of health. Strengthening the capacity of the individual and family to function and maintain social roles increases individual, family and community well being and reduces the need for expensive medical care

Professional education prepares social workers to understand and negotiate systems and procure community resources. Skilled management of psychosocial problems faced by patients and their families and skilled coordination or development 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. For example, in the case of a patient who will need acute care, skilled pre-admission screening and skilled discharge planning by professional social workers not only provides quality services to patients and their families, it also can reduce costly hospital stays by days or weeks. If primary care is to be the dominant mode of accessing health care, then professional social workers will be needed in primary care doctor's offices or clinics and managed care plans will need to ensure that social services are made available to their enrollees.

Studies of emergency room use demonstrate that 60% of cases have a psychosocial component. Under managed care, it is likely these problems will be brought frequently to a primary care physician's office. Physicians have reported for many years that a significant proportion of patient office visits (30-40%) are based on somatization.

PATIENT PSYCHOSOCIAL NEED AND SOCIAL RISK FACTORS

Social risk refers to aspects of patient social, psychological and emotional status which increase the chance of illness or interfere with treatment. Insufficient income to maintain nutrition is one example. Significant psychosocial problems are often disguised and are manifested as somatic complaints. Family violence including spousal abuse and child abuse are often difficult to assess and require a team approach including social work. Substance abuse, inadequate housing, lack of understanding of drug treatment, the presence of conditions exacerbating asthma and others place patients at risk. Because of these and other conditions, social services are essential as a part of primary care.

Managed care provider systems vary in size and patient capacity as well as in the characteristics of their patient populations. The need for social services will vary and staffing ratios will depend on the prevalence of social risk factors found in the patient population. Social services have not automatically followed the patient out of the acute care hospital to the primary care practice, regardless of need or social risk, nor are they identified as a discrete service in managed care benefit packages. In fact, standards for psychosocial care and social work services in primary care provider sites and medical care organizations are absent from New York State managed care law and regulations. Managed care contracts with providers - physicians, community health centers and hospitals - for the care of Medicaid patients do not require separate social work services or a documented plan for patients to receive social work services based on need or risk status. At the same time, community based social service programs, such as settlement houses and family and children service agencies, face reduced government and private support. Many private agencies are unable to maintain their level of counseling and advocacy services to community members.

High social risk / high utilizers of medical care:

Many of these patients are exempt from managed care, but because they churn in and out of the system, and show up in a variety of settings including hospital emergency rooms, they increase overall Medicaid costs system wide. This category includes people who are homeless, those who use the emergency room as the site of their primary care, who are HIV positive, substance abusers, the chronically mentally ill who are not enrolled in any ongoing treatment programs, people in rural areas with no transportation, and those chronically ill without regular treatment.

As managed care takes hold, this group of patients would benefit from intensive social work services which integrate them into the system, increase their compliance with medical regimens, and prevent inappropriate utilization. A model for this group of Medicaid recipients is the intensive case management system.

High social risk / and low utilizers of medical care:

Low utilization of the health care system is not always a positive. For example, failure to follow up after episodic emergency room visits ultimately can drive up the cost of health care. This group may be similar to the previous one in demographics and may also contain the members of the working poor who are high social risk but are unaccutomed to using the health care delivery system for anything other than emergency care.

This group of patients will benefit from social work services that help them use the health care system appropriately, educate them to use it effectively, and provides or obtains social supports to make it possible for them to use it at all.

Low social risk / high utilizers of medical care:

This group of patients is considered low social risk because their basic needs for shelter and food are met. However, they represent a cohort that has chronic conditions and require continuous follow up by the medical system. For example, they may include a large population of children in urban areas who have asthma, an illness that clearly can be ameliorated and controlled by correcting environmental conditions which trigger asthma. Similarly, they may be individuals who overutilize the health care system because they are not well educated regarding the relationship between nutrition and health or, they don't have alternative support systems. They may be diabetics who need close scrutiny to prevent the long term sequelae of diabetes such as heart disease, stroke and kidney failure.

This is a group of patients who are an accutomed target for to social work intervention and for whom social work has, for many years, been a provider of care. Social workers, in conjunction with their nursing colleagues, can effect behavioral changes in this cohort that may reduce consumption of medical dollars.
 

Because the mix of patients with social risk will vary among managed care settings, service plans and staffing patterns should develop out of local conditions. Time is needed to review presenting problems and social health issues in order to develop an effective social service. Consider, for example, the impact of the discovery of a large number of child abuse cases. Social workers will be needed to work with primary care providers, local non-profit social agencies and appropriate state and city departments as well as with the family. Coordinating these efforts and maintaining the involvement of the family in the health care system are essential. From this understanding and a review of actual experience, the professional social worker and provider organization can arrive at an appropriate staffing pattern.

Differences in settings, size of primary care staff and patient population make it difficult to describe a staffing pattern and cost for social services in managed care. However, a range can be estimated. The average primary care physician provider is expected to handle 4,200 patient visits per year, an average of 4 visits per patient. This would then support a panel of approximately 1,000 patients. At a capitation rate of $130 per month per patient, the managed care practice would receive $130,000 per month or $1,560,000 per year for that physician's panel. Assume the managed care group consisted of ten (10) primary care providers; the managed care payments would be $15,600,000 per year.

If the hypothetical provider organization were to begin to provide social services with a professional social worker and an assistant, the cost would be approximately $80,000 per year. This is an estimated amount since salaries and benefits vary throughout New York State. Using the $80,000 amount, the cost would be increased by .513%. The cost per enrollee per month would be $.66. If the need for social services required called for a larger staff the amounts change. In the previous example, a staff of four would increase the cost to $160,000 per year and would result in a monthly per patient cost of $1.32.

The value of social services to the managed care organization as well as patients is found in the increased efficiency in serving the enrollees. For example, an issue for Medicaid patients is their eligibility status. Maintaining eligibility in the face of recertifications, changes in income, etc. frequently results in the short term changes in eligibility and benefits. This "churning" in the Medicaid system will be very harmful for patients under care and could be very detrimental for maintaining a revenue source for MCO's and providers. Social workers are essential in keeping patients linked to the Medicaid system by keeping them informed of their rights, procedures and changes in policy and by serving as advocates to seek the restoration or maintenance of benefits in the face of bureaucratic errors.

Over the last 30 years, social work services have become incorporated in and integral to inpatient medical and psychiatric services, hospital based primary care and specialty care, community health and mental health clinics, alcohol and substance abuse treatment programs, school health clinics, home care agencies and nursing homes. The majority of social workers nationwide and in New York State practice in health and mental health settings as direct providers and/or administrators of social work services, mental health care and case management or work full or part time as independent mental health practitioners. Many others provide community social services to families and children, youth, the homeless and the elderly, where clients bring problems in accessing and negotiating managed care systems.

In New York State there are an estimated 70,000 masters and bachelor level prepared social workers. 35,000 masters level social workers are currently certified by the State of New York and 22,000 of these professionals are members of the National Association of Social Workers. Social workers are members and leaders of 1199, the Health and Hospital Workers union, as well as AFSCME( DC37, Local 768), PEF, CSEA and other unions representing public sector social workers. New York State's 11 graduate schools of social work (Adelphi University, Columbia University, Fordham University, Hunter College, New York University, Roberts Weslyan College; State University at Albany; State University at Buffalo; State University at Stony Brook; Syracuse University and Yeshiva University) all offer educational programs and field training, that prepare Master's degree students for health and mental health practice. In addition, 29 colleges and universities in New York State offer social work baccalaureate degrees.

There are several models for providing social work services to Medicaid managed care enrollees. Managed care organizations will contract directly with providers, whether they be hospital primary care practices, community health center practices, other Article 28 clinics or private physician offices. Arrangements for social services in these various practices could be made as follows:

1. The hospital primary care practice, community health center, clinic or physician practice employs professional social workers directly as members of the health care team. This is a provider based model.

2. The managed care plan could employ social workers themselves, screen enrollees for psycho social problems and provide social work and case management services to enrollees. This is a Managed Care Organization Centered model.

3. The provider contracts with a community social service agency to provide services for patients identified at psycho social risk by primary care gatekeepers.

4. The provider contracts with a professional social work group practice to deliver social services and mental health care to primary care patients.

To ensure that standards for psychosocial care are included in Medicaid managed care contracts and that social work services are available to Medicaid enrollees, the New York State Department of Health must add social work services as a defined benefit in the Medicaid managed care benefit package.

Health care professionals have long been aware of the difficulty of providing medical services to people with significant emotional and social problems which interfere with treatment or in themselves, create medical problems. Over the past seventy five years, social work services have developed in organized health care settings to provide the psychosocial care people require around their health care needs. These services have centered in hospitals, but are also found in community health centers, diagnostic and treatment centers and other ambulatory settings. Because of the economics of managed care and a lack of adequate state regulation, Medicaid patients and others covered by managed health care plans are deprived of necessary social services. Besides the social, emotional and health costs to patients, the payers for health care are overspending because of inappropriate and over and under utilization of health care resources. It is essential to add social services as a required health care benefit for all managed care plans.
 

Dr. Barbara Brenner, DSc, Gerald Beallor, MSW with Dr. Terry Mizrahi, PhD,

Stuart Kaufer, MSW

Acknowledgments:
 

Prepared with the valuable assistance of Dr. Howard Berliner, Dr. Janet Perloff,

William Hogan