Managed Care and the Evolving Role of the Clinical Social Worker in Mental Health
Cohen, Jeffrey A., Social Work
During the past 15 years, managed care has become a central philosophy and organizing theme for the delivery of mental health care services (Gibelman & Schervish, 1996; Hartman, 1994). With managed carets increased control, the mental health care delivery system has undergone massive changes. These changes are reshaping professional practice and radically altering the provision of mental health services in the United States (Crespi, 1997; Cummings, 1995, cited in Chambliss, Pinto, & McGuigan, 1997). Managed care has already altered standard system delivery models in mental health, replacing the traditional model of individual practitioners providing fee-for-service medical care with a variety of groups contracting to provide services to organized groups of citizens (Committee on Therapy, Group for the Advancement of Psychiatry, 1992).
Shapiro (1995) defined managed care as "any kind of health care services which are paid for, all or in part, by a third party, including any government entity, and for which the locus of any part of clinical decision-making is other than between the practitioner and the client or patient" (p. 441). According to Iglehart (1994), managed care systems integrate the financing and delivery of appropriate medical care by
* contracting with selected practitioners and hospitals that furnish a comprehensive set of health care services to enrolled members, usually for a predetermined monthly premium
* using quality controls that contracting providers agree to accept
* creating financial incentives for patients to use preferred providers and facilities
* assuming some of the financial risk for practitioners, altering their role from serving as agent for patients' welfare to balancing patients' needs against the need for cost control.
More than 200 managed care companies serve approximately one-half of the U.S. population. It is anticipated that within the next two or three years this figure will approach the entire population (Bozutto, 1992, cited in Alperin & Phillips, 1997).
With its involvement in the mental health field, managed care strives to provide efficient quality care at a lower cost than that offered in the fee-for-service professional community (NASW, 2000). Support of managed care companies is largely a reaction to escalating costs in the health care field. Americans in 1995 were spending 12 percent to 14 percent of their income on health care, with costs increasing about 11 percent to 12 percent each year. Health care costs in the United States have been rising at alarming rates, because of the aging population, changing disease patterns, increasing costs of health care technology, and focus on treatment of disease rather than prevention. Mental health care costs are no exception (Crane, 1995; Crespi, 1997). To address the rising expenses of treatment, profit-driven managed care companies have assumed increasing control. They scrutinize the nature and scope of mental health treatment, looking for ways to cut costs (Edward, 1997). Managed care companies have attempted to achieve cost savings by instituting financial, administrative, organizational, and monitoring constructs that minimize resource allocation and maximize efficiency and quality of care (Croze, 1995, cited in Geller, 1996).
Managed care companies have looked to control costs by shifting from a manipulation of patients' benefits to cost control through the proper management of care. In furtherance of these goals, managed care has implemented gatekeeping devices to determine when patients have a real need for treatment. As a result of these changes, managed health care companies have limited authorization of expenditures to only those services that the gatekeepers deem necessary and appropriate, to be delivered in the least-restrictive and least-intrusive treatment setting, and only by designated qualified practitioners. Despite these changes, advocates of managed mental health care believe that patients can still receive proper care, at the proper time, in the proper setting, by the proper type of provider, and with considerable cost savings compared with unmanaged care (Schamess, 1996). …