Academic journal article Health and Social Work

NEGOTIATING AND CONTRACTING IN A MANAGED CARE ENVIRONMENT: Considerations for Practitioners

Academic journal article Health and Social Work

NEGOTIATING AND CONTRACTING IN A MANAGED CARE ENVIRONMENT: Considerations for Practitioners

Article excerpt

Managed care, for better or for worse, has become a central philosophy and organizing theme for the delivery of health care services in the United States. Recent professional literature has focused on several concerns with regard to the involvement of social workers in managed care, including the effect of managed care on the availability and quality of mental health services for specific populations (Jackson, 1994; Wetle, 1993), and the effect of managed care on mental health practice (Alperin, 1994; Brown, 1994; "Managed Care Curbs Backed" 1998; Weinstein, 1998), specifically with regard to access to and quality of care. Rationing of certain types of expensive, specialized care already is occurring, and the demands for controls on health care expenses, including mental health care, will continue to affect provision of services. A third concern forms the focus of this discussion: the ability of social workers to negotiate and successfully compete with other mental health professions in gaining access to and participating in provider networks for the delivery of mental health services.

Providing a business model for social workers' participation in the U.S. managed health care system has far-reaching implications. Cost-containment strategies and data-driven utilization management systems have translated to time-limited mental health services. Clinical practitioners have found that fewer clients are covered by fee-for-service insurance and that competition among various mental health care services providers (such as marriage and family therapists, counselors, psychologists, and psychiatrists) is increasing. To succeed in this increasingly competitive environment, practitioners are joining together to form interdisciplinary practice groups that offer a range of services. In doing so, they expect to increase their appeal for managed health care organizations (MCOs) (Cummings, Pallak, & Cummings, 1996; Emenhiser, Walgren King, Jaffe, & Penkert, 1998; Landers, 1994).

The world of integrated service provider networks, managed care providers, and preferred provider systems has grown to the point that clinical social workers need to be skilled not only in their own profession but also in business negotiations; specifically, in contracting for services. Although negotiation skills are part of the repertoire of interventions used with and on behalf of clients, adaptation and application of such skills for use by practitioners on their own behalf are notably absent. We provide a guide to the critical elements involved in contracting for services from the perspective of social work practitioners now working with or who plan to work with MCOs. The skill requirements identified here apply to independent and agency-based practitioners. The elements we identify are adapted from four sources: the literature on managed care, the relevant standards for behavioral health organizations accredited by one of the national accrediting bodies (for example, the Council on Accreditation of Services for Families and Children), formal and informal discussions with social workers engaged in contracting with MCOs, and review of a sample of contracts made available by practitioners on a confidential basis.

Managed care is present in all aspects of health care and affects almost every setting in which social workers practice. Special-needs HMOs are being developed to provide care to people with chronic mental illnesses, HIV and AIDS, and others at high risk. Although treatment in such settings necessarily may be longer term in nature, capitation ceilings, preapproval requirements for treatment, and case review by third parties, among other issues, are quite similar to those faced by practitioners serving lesser-risk populations (Cummings et al., 1996; personal communication with B. Rock, School of Social Service, Fordham University, December 1, 1997).

We acknowledge that managed care is an emotional and highly controversial issue for the social work profession and related helping professions. …

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