Managed care and social work practice: a call for action
Jeanette R. Davidson, Ph.D ACSW, Associate Professor, Columbia University School of Social Work
Social workers participating with managed care organizations (MCO's) face proactive dilemmas on a daily basis
particularly when they witness firsthand the many problems encountered by clients within the system. To be fair,
managed care champions a number of laudable goals including: clear contracting with clients; demonstrated
efficacy in work with clients; fiscal prudence with available resources and use of short term treatment approaches
where appropriate.
However, fundemental differences in mission between traditional social work and the business of managed care
are at the root of many of the practitioners' concerns. Managed care companies are intent primarily with reducing
the costs of care and maximizing profits. This they accomplish by limiting and denying services for clients. In
contrast, social workers tend to be needs driven and inclusive in focus. Shapiro (1995) describes the attempt to
combine professional social work values and corporate cultural values in managed care as a "marriage of
adversarial priorities."
When working with MCO's, practitioners identify as particularly problematic: Quality of Care Issues
Quality is generally hurt when programs and services are cut. Practitioners then see a reduction in prevention efforts
and severe limits to treatment for clients that are quite untenable -- dying cancer patients have been refused coverage
for the level of palliative hospital care they need; adult survivors of childhood sexual abuse may be deemed to be
years past the necessity for care; and clients struggling with chemical addictions regularly do not qualify for
maintenance and relapse prevention treatment. When MCO personnel, with financial incentives to deny care, have
the power to define "medical necessity", it is rather like the foxes being asked to oversee the needs of the chickens!
The strategies utilized to ration services impact quality of care. These include: developing consumer "unfriendliness";
using unpopular providers; restricting choice of providers or requiring change from a trusted provider; insisting upon
medication as a condition for treatment; and creating an atmosphere that judges and shames the client by requiring
periodic treatment review (Miller, 1994).
Ethical Issues
When clinical judgements indicate the need for client services and these are denied or inappropriately restricted by
MCO personnel, this constitutes an ethical problem. Many clients find out when they seek treatment that their allotted
mental health visits may actually be fewer than indicated in their benefit package and are at the discretion of an MCO
gatekeeper.
While seeking to control the variables in the service delivery, MCOs have not established adequate provisions for
consumer appeals, for transportation needs to ensure access to care, for long term chronic illnesses and for cultural
and ethnic diversity. The ethical ramifications of these shortcomings are yet to be realized.
Another clinical concern relates to the demise of confidentiality in the clinical relationship. MCOs routinely require
practitioners to reveal sensitive and highly personal information about clients, ostensibly for purposes of evaluating
"medical necessity" and "best practice guidelines". This ethical problem is often compounded by managed care's
reliance on vulnerable information systems (Davidson & Davidson 1995; 1996).
Professional Status Issues
MCOs, now more than ever, dictate proactive guidelines and approaches to be utilized with clients. Often, however,
the accent is on "managing", not "care". Clearly the status of the profession is jeopardized when social workers'
knowledge, clinical judgement and ethical standards can be overruled by MCO policy.
Even now, many able clinicians have left the profession or are refusing to work with managed care panels because
they abhor the professional compromises that certain MCOs demand. Social work education is impacted, too, with
the possibility of some kinds of training becoming obsolete "not because clients would not benefit, but because
industry will not pay" (Shapiro, 1995) and with many field placement arrangements between agencies and schools
of social work in jeopardy because of managed care constraints.
A Call For Increased Action
Many practitioners have been (and continue to be) "out of the loop" of influence in the evolution of managed mental
health care. MCO personnel make enforceable decisions both at the macro level (e.g., policies and regulations) and
the micro level (e.g., determinations about coverage for individual clients) which in many instances leave practitioners
with diminished power to treat clients. Social workers must find a way to become much more proactive in shaping
thechanging mental health environment. Some recommendations are:
Tim Davidson, Ph.D, Director of Mental Health Services, Putnam County, New York.
Dava Weinstein, MSW, Chair, Independent Practice & Managed Care Task Force, NYC NASW
(May 1997)