Managed Care Forum Sparks
Controversy Over Program Shortcomings
(June/July 1992)

The May 4th Managed Care Forum presented by the Chapter's Health Care Policy Network highlighted recent developments in coordinated care for Medicaid recipients. Keynote speaker, Dr. Bruce Vladeck, President of the United Hospital Fund, pointed out that there is no agreed upon definition of managed care, although it is a very rapidly growing form of health care delivery. Although forms of managed care have been in existence since World War II, such as Kaiser-Permanente, HIP and similar plans in Washington DC and Peugeot Sound, they are associated today with newer efforts to promote cost savings through controlled utilization. Gerald Beallor, in commenting on the presentations from the point of view of social work, noted that some, such as the Editorial writers of the New York Times have come to see managed care as the answer to our national health care ills. He made it clear that the many news articles in the same paper pointed out some of the negative impacts of many managed care plans on unwary enrollees.

Valerie Bogart, Senior Attorney of the Legal Services for the Elderly, presented a devastating analysis of the New York State legislation and plan which mandates managed care for Medicaid recipients. She raised substantial issues of access and coverage, particularly for those with special needs because of their age, disability, or mental status. Her remarks amplified on the testimony she developed for her agency which was presented at a recent New York City hearing. The testimony is available from the Legal Services for the Elderly.

A more positive picture of the potentials of managed care for Medicaid recipients. Enrollment is voluntary and there has now been five years of experience with the plan. Safeguards for patient care are provided through the central office of the plan which contracts with existing community health care centers for care of Medicaid patients on a capitation basis. However, even in an admirable program such as the Bronx Health Care Plan, directed by Maura Bluestone, there are serious gaps, particularly in providing for mental health needs and the care of those with alcoholism and substance abuse. These remain serious issues in managed care and reflect the inadequacies of existing primary care settings, particularly those serving low-income and poor people.

Nevertheless, as Robert Gumbs, Executive Director of the NYC Health Systems Agency made clear, the State legislation mandates managed care and leaves no choice for the counties and large cities of New York State. He demonstrated the growth of need and the crisis in providing health care services in New York City. The lack of access has led to the growth of Medicaid mills and the expensive and extensive overutilization of emergency room care. Governor Cuomo and many state and city officials are convinced that the managed care program will make a positive difference. One of the unexplained issues remains the shortage of primary care physicians and where these will come from for the new network of primary care centers proposed by the Health and Hospitals Corporation and announced by Mayor Dinkins as his "Communicare" plan.

Gerald Beallor, who testified at the City hearing on behalf of NASW raised these and related issues. His testimony is available from the Chapter. At the forum, Mr. Beallor noted that social workers in hospitals and clinics in New York City are very aware of the shortcomings of primary care offered by physicians with little sensitivity to emotional and social problems. Social workers in these settings have developed practice skills in locating vulnerable patients and providing mental health and referral services to broaden the services available to individuals and families. While there is nothing in the new managed care plan to ensure better services, there is the opportunity for social workers to influence the development of existing and planned primary care services by lending their expertise about social health care and the use of primary care teams. In employee assistance plans and union membership plans, social workers have played a major role in providing a broad range of services as well as direct mental health services. Nationally, social workers are found in other managed care plans including Medicaid.

Some of those at the forum raised the issue of the underlying inadequacy of Medicaid and Medicare and the entire patchwork of payment plans, the lack of health care coverage for millions of Americans and the emergence of a deeper split between health care for the wealthy and health care for the poor. Should we, as social workers, support and assist in the development of managed care for Medicaid patients, or should we be seeking passage of the NASW sponsored single payor National health Insurance plan, or the Russo bill which is similar? The leadership of the Health Care Policy Network recommends pursuit of both goals. Dr. Terry Mizrahi has announced that the HCPN will develop a managed care task force and will also be sponsoring a Chapter meeting on national health care policy which will include some opportunity to analyze the Canadian experience.

Esther Chachkes, Chair of the Forum, ended the meeting, which had attracted several hundred members, with appreciation for the support and participation of both Dr. Barbara Silverstone, President of the Chapter, and Dr. Elaine Walsh, President-elect. They and the Board of Directors of the Chapter have made health care issues a priority for next year's programming.