Humane Managed Care?

Is humane care the hallmark of service provision in the managed care revolution? This question dominates conversation among human services professionals as well as consumers. It is a conversation grounded in experience and propelled by the need to grapple with dramatic changes in the provision of care. It is one of the most important questions we must address to remain true to our commitment to healing, protection, and nurturance. We have assembled this volume as an ongoing part of the conversation as it has taken place in a variety of contexts among and by practitioners, managed care providers, educators, and students. The information and perspectives are provided to encourage active participation in the conversation for all who work in or are preparing to work in the human services.

The quality of mental health and health care depends on our unabated efforts to answer questions repeatedly raised about managed care. We need to know what has happened in the conversion of the caregiving relationships previously offered by physicians, social workers, nurses, and psychologists into care that is largely influenced by the dominant term "managed." What outcomes have resulted from the forceful takeover of health and mental health care? Have the long-practiced traditions of humane services provision also been honored and retained as intrinsic to managed care services? As resources have been redistributed, has there been greater access to care within new continua of services? Has better-quality care based on increased accountability been achieved? Have we realized the vision that if preventive care becomes the foundation for health and mental health it will be the most effective means for cost reduction in the long term? Or has the essence and tradition of humane services provision been sacrificed through management systems that embody corporate principles, systems, language, and values. Is humane managed care an oxymoron?

As educators and professionals, we take seriously our responsibility, embodied in our codes of ethics, to uphold the provision of humane services. In a system in which service is designed to be efficient in the short term and profit driven, are we holding on to, incorporating, and advancing principles, ethics, and best practices that are truly humane? Professionals across the human services are grappling with a practice context for which most were never prepared. Major assumptions about humane and effective ways to practice have been called into question as professionals struggle to be "providers" in agencies and institutions where they were trained to be healers, scientists, helpers, and advocates. The consumer language of the marketplace has eclipsed the familiar relational language of therapy. Does the concept of managed care and all related terminology limit the vision and potential for care? The fiscal bottom line is now the standard set by gatekeepers, the interpreters of managed care. It ensures accountability for scarce resources. In lieu of a national health care policy, the marketplace has instituted competition as a mechanism that promises quality care through quality control. Has managed care advanced the quality of care, and is it by definition also humane?

What recalibration has occurred since the management of care has become the dominant way of providing equitable service to the majority of people? Can corporate means and language be transcended and transfigured by the people who are caregivers, the professionals who do not define themselves simply as providers? Can the human beings who offer knowledge, skills, and resources through relationships that require time, respect, and decency turn a managed care provider system into healing and nurturing experiences that meet common human needs, rather than a system offering care that recipients may experience as a semblance of packaged consumer products?

The vigor of management systems has taken hold with the declared intent of improving the performance of service providers. Accountability and demonstration of effective practice are promoted as procedures that ensure quality care. In this new era, complex information systems transport people’s lives across unprotected zones to augment efficiency and accountability while potentially violating the established confidence of caretaking relationships. Ethical issues and concerns are mushrooming. Legal and ethical complaints are being brought before courts, accreditation bodies, and state and federal regulatory bodies in an effort to define "humane managed care." And although the new system of accountability and management has solved some of our health care system’s problems, it also has created new problems that need to be addressed.

Many contend that managed care does not serve everyone and that it serves unevenly. It has become increasingly evident that humane care in the managed care system is conditional, depending on diagnosis, payer categories, service unit allowances, and available networks that are well resourced. Cost shifting, one of the most notable strategies managed care has used to reduce costs, can disadvantage those who are not fortunate enough to have a support network of family or friends who can provide care when institutions will not. However, the shift from overly expensive inpatient services to outpatient and community-based care can work only if we invest in these new service systems. The promise of comprehensive community-based systems of care must be effectively implemented in the current environment of cost containment and profit making. There is a serious contradiction between comprehensive service delivery, which has been the central commitment of many professionals, and the provider system’s primary commitment to "sufficient" service and profitability. Conflicts of interest are inherent as the philosophy of service and care clashes with the philosophy of profit.

Health, mental health, and child care have become "industries," and like other industries are transformed by takeovers and mergers. As conglomerates increase, individual choice becomes more limited. The managed care market system has a track record of reducing costs and saving money over the open-ended fee-for-service approach at a time when health care costs were threatening to spiral out of control. Economically, the potential exists to make a broader range of services available.

In this new order of "providing care" so much depends on whether the "market" will deliver care that men, women, children, and families need and can afford. With government protection receding, market forces may not be moderated fairly for the vulnerable populations—children, elderly men and women, and people who are chronically ill or disabled. In response to reduced benefits structures, limitations have been challenged through legislation promoted to protect individuals from the abuses of the health care market.

Can we all hope that as profit-based managed care systems are being fashioned in the marketplace they will be modified by professionals and consumers? Is it and will it continue to be their advocacy that defines rights and entitlement and ensures that new service continua will be developed in place of more expensive institutional care? Will poor people, disenfranchised nondominant cultural and racial groups, and people with chronic illness or developmental disabilities be able to obtain services in the marketplace? Who will make the decisions about rationing Medicaid resources in the year 2010?

We also are very concerned about the preparation of the upcoming generation of professionals who will not only provide service but will also advocate for humane service provision. Where and how will these professionals be trained when supports for professional training through internships, supervision, and continuing education are being drastically reduced or eliminated? Training programs for "behavioral health care" providers abound, sponsored by newly formed consultant groups and insurers. However, the narrow focus on behavioral health limits professional development. The tradition of shared responsibility for training has been lost in the frenzy of cost cutting accomplished by paring student internships that have been valuable resources and catalysts for learning in health and mental health settings. This dramatic change will transform fieldwork training and the preparation of future practitioners.

In this volume we address these fundamental questions. It has been rewarding for us to see various conversations over the past three years come together to present the complexity we have encountered in trying to answer the questions posed. We have valued the many opportunities that have provoked and stretched our thinking. Two forums that have informed this work are of special note. The first was a special issue of the Smith Studies—The Human and Corporate Faces of Managed Care—that was published in June 1996 and included presentations that had been delivered the previous summer in seminars and lectures at the Smith School for Social Work. The second forum was "The First Managed Behavioral Health Care Invitational Conference for New England Graduate Social Work Faculty," held at Boston University School of Social Work in October 1997. This conference was the first of its kind, with 13 schools participating. Support from the Robert Wood Johnson Foundation, the National Institute of Mental Health, obtained by Dean Wilma Peebles-Wilkins, Boston University, in her capacity as chair of the New England Association of Deans and Directors of Schools of Social Work, and with additional support from the Alcohol and Drug Institute at Boston University, brought together leading administrators, policy analysts, and educators to consider the implications of managed care for social work curricula and research. Our inquiry as social work educators was fueled by a host of questions that articulate concern for humane managed care. The keynote presentations from that faculty development conference are included here. New colleagues were also discovered at the conference, and they have become important contributors to this volume.

Geography of This Volume

We are pleased to bring together an unusual collection of scholarly articles and research, as well as case studies from the field. We have gathered a breadth of perspectives provided by a range of health professionals—social workers, psychiatrists, and psychologists as well as administrators, policy analysts, case managers, professional educators, and researchers. The challenge of and for "humane" managed care is presented here as both a public and a private issue affecting health care, mental health care, and related services that support children and families at risk. Those most centrally involved—those responsible for providing care—have presented their experiences and perspectives based on long tenure in human services. State mental health systems, local hospital care, mental health clinics, health maintenance organizations, and network systems of care are described and examined. In the tradition of field studies that bring cases forward for examination, clinicians’ and clients’ stories are told as "notes from the field." Administrators provide detailed strategic plans that convert fee-for-service and government-funded services to managed care contracts.

Policy issues are considered from the perspectives of health, mental health, and services for children and families. The economics of care, "managed, mismanaged, or unmanaged," is juxtaposed with political decisions that maintain the disadvantaged population in the social system. Educators and researchers also offer meta-analyses, adding another perspective that describes and examines complex outcomes ranging from the type and quality of care given to the state of and future directions for professional social work education.

Part one of this volume sets the stage through policy and program analyses. Part two provides a major case study of one state’s "privatization" of its mental health services, beginning with the commissioner’s management journal describing the shift to private managed care. In contrast, a longtime professional caregiver who is also an experienced administrator at a psychiatric hospital describes how he and his facility experienced the implementation of the commissioner’s strategic re-engineering of mental health. Complementing these two different perspectives are two major research studies that report on the services delivery reconfiguration and utilization outcomes that have resulted. Reports of casualties of this change, including loss of life, are excerpted from a state legislative report. Such tragic outcomes are a sobering postscript to this case study. Overall, the varied and complex documentation of different outcomes provides a unique opportunity for assessing the cost and benefits of privatization in terms of its effects on humane managed care and on mental health services in one state.

Parts three and four present agency and practice perspectives as well as focused discussions of the challenges facing professional social work. Productive evolutions of service are reviewed, with emphasis on accountability, quality assurance, equitable distribution and cost shifting, as well as community-board management. In stark contrast, disturbing practice with adolescents with serious disturbances and with people with mental illness in major hospital and community settings is illustrated with case examples that document practitioners’ worst fears. These case studies show how the bottom-line mentality of gatekeepers and administrators combined with employment practices that sacrifice experience and competence in favor of the least-expensive practitioners result in the "dumbing down" of the professions. Best practice, based on skill, knowledge, and the implementation of assessment-based intervention plans, is lost when the corporate value of cost reduction ranks first in determining who will provide services and how they will be provided. It is very difficult to make sense of increased suffering when there is clear potential for help, as well as knowledge and skill that could have been used for healing.

Practice perspectives demonstrate clinicians’ resourcefulness and show how humane care still happens. Short-term work, clinical case management, and psychodynamic approaches are explored within the managed care context. One chapter, "Losing Innocents," can be taken as a metaphor for the experience of many managed care practitioners. The author’s practice experience raises, both specifically and generally, the most troubling questions concerning the extraordinary challenges faced by those who are very sick and disabled. People who are alone and seriously ill fail to receive care because they are unable to actively shape the managed care they receive as well as need. From these case studies an alarming picture of inhumane care emerges where cost reduction results in care rationing that will not save money in the long term because of the very nature of chronic conditions that will worsen without care, requiring more-involved services at another time. These questions are replayed in the chapter "Notes from a Sinking Ship," a case study of a mental health center’s practices of cutting costs to ensure institutional survival but seriously impairing the care of clients with chronic mental illness. In the end, the center may still be lost, along with its tradition of helping a population in great need—an institutional casualty of the managed care revolution.

Part four presents perspectives from the National Association for Social Workers, the Clinical Social Work Federation, and a national study of hospital social work, focusing on the challenges for social work and our allied professions. Obstacles and barriers, such as the deprofessionalization of social work and the takeover of social work roles, are discussed, as are strategies to optimize opportunities for services provision. Important clarifiers of the most salient issues that require new knowledge and approaches make clear how the context of care continues to change substantially. Leaders of professional organizations chronicle the move toward unionization, lobbying, and support for managed care alternatives. The critical path for preserving choice and the fight to maintain the right to elect psychotherapy is charted. Advocacy efforts are detailed for clients and professionals, with collective action and unionization promoted as ways of influencing the corporate giants that now control health and mental health care. Authors also study ethical and legal issues specific to managed care practice and abuse. Special attention is given to confidentiality, professional autonomy, and the reality of managing cost frequently taking precedence over managing care.

The landscape of new opportunities is surveyed in part five, which examines primary care, social work’s role in working with state Medicaid contractors, multidisciplinary work in community clinics, clinical case management, and professional affiliation groups. These options describe the frontier for social work practice. With each option, new challenges and opportunities are evident for graduate and continuing education that will enable social workers to move forward toward carving out new ways of providing service.

The challenges for professional education are introduced in part six as sobering realities that are "forcing social work to make choices." Wide-ranging concerns about managed care have acted as catalysts for social work educators who are committed to providing the new "right" direction for curriculum development. With fieldwork training in serious jeopardy, it is important that we all more closely examine what is happening in practice. This also is a time to consider innovative training initiatives, recognizing that collaborative options to support fieldwork can markedly advance learning. Options range from attention to short-term models of treatment to introducing students to postmodern approaches that expand the ways we use helping relationships. Part six is important as an initial effort to chart the future direction of social work education.

Finally, part seven offers direction and resources for the important work of researching managed care. Research is designed to answer questions and to provide information so better decisions can be made about how to use health and child care resources. The two contributions here ably introduce options, possibilities, and directions that research should take. The state of managed care research is broadly reviewed, indicating the value of current studies and the potential of large-scale projects now in progress to answer many of the questions we have asked. Building on the available knowledge and expertise and asking critical questions, these researchers provide direction and resources for future studies.

We believe practitioners, policymakers, managed care providers, educators, researchers, and students should evaluate the human and corporate faces of managed care depicted in this volume. It is our hope that the volume will be a valuable resource in assisting many to address and answer questions posed by the revolution in services delivery. Humane managed care depends on informed professionals who are prepared to grapple with issues involving the relationship between care and fiscal responsibility. This involves grappling with corporate language, systems, and values, as well as the ideology that pushes the frontier of health and mental health care toward preventive community-based care. As professional social workers we are rooted in a tradition of activism that grew to maturity through our work in the Industrial Revolution. In the new market revolution that has enveloped health care and now services for children and families to the extent that they are considered industries, we encounter familiar challenges to social justice and humane practice. We hope that you will examine managed care through the perspectives and experiences of the collected authors in this volume and join with them and other concerned professionals in working for humane managed care.

Acknowledgments

This project has gone through many phases, and we are grateful to the people who have contributed along the way. Our particular thanks to all of the authors. We want to acknowledge those who have given extra time to updating their original work and to those who have written especially for this volume. It has been a pleasure to work with such a committed and able group of professionals. We value the vitality of their thinking and their ongoing work in this area.

We are particularly pleased to have collaborated with Jane Browning, Paula Delo, Christina Davis, and the production staff at NASW. They are a great team, and we have valued their investment in this project. Their vision, enthusiasm, encouragement, and patient attention to details are greatly appreciated. Thanks also to Linda Beebe, who initially shared the vision of Smith’s collaboration with NASW to advance social work knowledge of managed care by combining our recent publications in this area.

On the home front, we are indebted to Marjorie Postal, our research analyst at the Smith College School for Social Work, who has been indispensable in coordinating and processing manuscripts. The sheer volume of details has been daunting, and we appreciate her patience, expertise, good humor, and skill. We also want to recognize the expert team who assisted in the production of the special issue of Smith Studies from which this volume grew: Joyce Leamy, Louise Krieger, Idene Rodriguez Martin, and Samantha Armour.

We appreciate permission for reprints from the following publishers: American Psychiatric Press, Inc., for work from Psychiatric Services Journal; Harwood Academic Publishers for work from Crisis Intervention and Time Limited Treatment; Haworth Press for work from the Journal of Psychoanalytic Social Work, Social Work in Administration, and Social Work in Health Care; Manticore Publishers for work from Families in Society; Mosby-Year Book, Inc., for the use of material from the Harvard Review of Psychiatry; NASW Press for reprints from Health & Social Work and Social Work; Open Minds; the People-to-People Health Foundation for work from Health Affairs. The Annie E. Casey Foundation also supported an excellent report (Managed Care: Challenges for Children and Family Services, edited by Leslie Scallet, Cindy Brach, and Elizabeth Steele) under the direction of Patrick McCarthy on managed care for children and family services, and that report was the source of the policy chapters in that area.

The support of the New England Association of Deans and Directors of Schools of Social Work in developing the first faculty development conference on managed care provided an important venue for dialogue and learning. We are grateful to the Robert Wood Johnson Foundation, the National Institute of Mental Health, and the Alcohol and Drug Institute at the Boston University School of Social Work for providing support for that conference.

For interest, support, and lively debate, we thank our colleagues and students at Smith College School for Social Work. We are looking forward to continued collaboration and collective action for humane care, however it is managed.

Our clinical mentors, who have taught us about the meaning and value of relationship-based care that addresses the unique feelings and needs that clients bring to clinical encounters, have more than earned our deep appreciation. They taught us about a framework for humane care that has informed all of our work on this volume.

A special vote of thanks goes to our families for generously providing us with good quality managed care as we stretched the envelope to put this volume together. We are committed to working for humane managed care for you and for your children.

Gerald Schamess, MSS
Professor of Social Work
Anita Lightburn, MSS, MEd, EdD
Dean and Elizabeth Marting Truehaft Professor
Smith College School for Social Work
Northampton, MA