Social Work Practice in Community-Based Health Care

Marcia Egan, Goldie Kadushin

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781136427237
• Edition: 1
• Topic: Medicina
• Subtopic: Teoria, pratica e riferimenti medici

Make sure your practice skills are up-to-date with the changes brought on by managed careAs a result of escalating costs, the focus of health care in the United States has shifted from inpatient, hospital-based care to outpatient care in the community. Social Work Practice in Community-Based Health Care is a comprehensive guide to the knowledge and skills needed to provide effective and efficient practice within a managed-care context that's focused on a diversified, aging consumer population and high-risk health conditions. This unique book examines the essential elements of community health practice, including logic modeling for planning and evaluation, interdisciplinary collaboration, and the use of technology and telemedicine in social work practice. Social Work Practice in Community-Based Health Care presents practical information for social workers in the wake of the insertion of managed care as a "third party" to the relationship between physicians and their patients, and advances in medical care that are transforming previously acute and life-threatening illnesses to chronic conditions. The book offers a critical analysis of available research and model service delivery innovations, applying evidence-based practice to case studies in a style that's easily accessible to practitioners, administrators, supervisors, and social work students. The book also includes glossaries at the end of each chapter and appendices that analyze online resources and address cultural background assessment questions.Topics discussed in Social Work Practice in Community-Based Health Care include:

• the revolution in funding and delivery
• evolving trends and healthcare needs of the consumer population
• a conceptual framework for culturally competent practice
• the nature of social work in ambulatory health
• a brief history of healthcare social work
• emerging practice settings
• the use of new communication technologies in practice
• methods for evaluating direct practice
• ethical considerations
• current community-based programs for culturally diverse and at-risk populations
• and much more

Social Work Practice in Community-Based Health Care is an important resource for social work practitioners, academics, and students.

PART I:

THE CONTEXT OF COMMUNITY-BASED HEALTH CARE

Chapter 1

The Revolution in Health Care Funding and Delivery

• What prompted the revolution in health care funding?

• What is the history of health care funding in the United States?

• What is “managed care”?

• What are the ethical considerations related to health care funding?

• How does managed care influence community-based social work health care practice?

INTRODUCTION

The recent paradigm shift in health care transformed the locus (where), the structure (how), and the focus (to whom) of health care delivery (Dziegielewski & Holliman, 2001; Gorin, 2003). The revolution in health care funding contributing to the paradigm shift was largely driven by the continual rising health care costs over the last two decades of the twentieth century. Several factors interacted to contribute to those increasing costs, including

• the increasing number of older adults;

• the development and use of costly technological health care treatments;

• an excess of empty hospital beds prompting hospitals to shift costs to existing patients;

• the unregulated nature of the health care and insurance industries.

Health care systems were fragmented and redundant, with gaps in needed services. That is, multiple providers delivered similar services to often-overlapping consumer populations while, also, not attending to unmet existing and/or emerging consumer needs for health care.

The annual cost of health care in the United States increased exponentially in the latter part of the twentieth century; projections are for continuing increases in the twenty-first century. By 1990, national health care expenditures approached $700 billion a year (Berkman, 1996). Between 1990 and 2000 the cost of health care in the United States nearly doubled, from $696 billion to $1,309 billion a year (Centers for Medicaid and Medicare Services, 2001, 2003). Estimates for annual health care costs are projected to be upward of $16 trillion by 2030 (Dziegielewski & Holliman, 2001). Strunk and Ginsburg (2004) and Gorin (2003) suggest that the main driver in the continuously increasing cost of health care is the advancement and usage of medical technology, a good deal of which is very expensive and which fosters new spending.

This chapter explores the history of rising costs and the attempts that were made to control those costs that led to the transformation of health care, the history of managing the delivery of health care in the United States, and the types and dynamics of managed health care systems. Each of these is discussed in the context of the impact of the paradigm shift in health care on social work practice in ambulatory health care, with special attention to the resulting ethical dilemmas.

CONTROLLING ESCALATING COSTS OF HEALTH CARE

Escalating costs and health insurer reports of large financial losses coupled with widespread hospital closures and empty beds prompted a series of reforms initiated in the early 1980s to control health care expenditures (Caputi & Heiss, 1984; Jensen, Morrisey, Gaffney, & Liston, 1997; Rosenberg, 1998; Shortell, Gillies, & Devers, 1995). Concerns to control hospital care costs specifically resulted in the development and implementation of the diagnosis related groups (DRGs) policies and regulations. The DRGs were based on the precept that reducing the duration of a patient's length of stay (LOS) in the hospital would reduce the cost of his or her hospitalization. Thus, the DRGs pursued cost containment for hospital care by limiting coverage to predetermined, fixed payments and to a predetermined duration of hospitalization for a given medical condition and diagnosis. The DRGs transformed hospital care funding procedures from the traditional physician-centered “fee for services rendered” reimbursement system to preset standardized payments (Caputi & Heiss, 1984). Switching accountability and coverage for hospital care from the physician to the hospital created a financial incentive for hospitals to limit the duration of inpatient care (Reamer, 1997).

However, the implementation of DRGs had two consequences beyond just reducing the LOS. The first consequence was the expeditious discharge of patients—patients who often had continuing postdischarge multiple health care needs. While attempting to control hospital costs, these regulations increased the need for health care that then had to be provided in the community. The second consequence was to effectively transfer the locus—where the majority of health is to be provided—from the hospital to the community.

Some evidence suggests that because patients were discharged “quicker and sicker,” readmission rates and emergency room use increased, thus increasing the cost of health care (Dziegielewski, 1998). In fact, though controlling the annual rates of increase in the cost of health care, the DRGs were not successful in controlling total health care expenditures (Berkman, 1996). For instance, between 1984 and 1992, there was a 20 percent reduction in inpatient hospital days, an 11 percent reduction in the total number of hospital admissions, and a decrease in the annual rate of increase in health care costs (Shortell, Gillies, & Devers, 1995). However, total expenditures continued to increase; the total expenditure for health care in 1985 ($429 billion) more than doubled by 1995 ($989 billion) (Dziegielewski & Holliman, 2001).

Though total health care expenditures continued to rise under the DRGs, efforts to control the cost of health care persisted. By the mid-1990s, “managed care” systems were being implemented to extend cost control mechanisms beyond the hospital. Insurance providers, employers who offered insurance benefits to employees, and the government endeavored to constrain mounting health care expenditures and increase efficiency across the continuum of health care from inpatient to outpatient settings (Jenson, Morrisey, Gaffney, & Liston, 1997; Schneider, Hyer, & Luptak, 2000). Motivated by the increasing cost of health care and by a disarray of nationwide health care plans and reforms, managed care organizations developed to vertically and horizontally integrate services and funding coverage within competitive business- and market-based programs.

The dominance of managed care health care systems by the end of the 1990s, in the private sector and in Medicare and Medicaid, was evident. Though corporatized private management of health services had been slowly developing during the latter part of the twentieth century, by the end of the 1990s over four-fifths of patients were managed by twelve powerful managed care systems (Davidson, Davidson, & Keigher, 1999; Dziegielewski, 1998). A further indication of the rapid expansion of managed care organizations is the reported data that by the mid-1990s, nearly three-quarters (73 percent) of all outpatient visits billed to third party payers were under managed care systems (Berkman, 1996). More recently, data from 2001 suggest that 90 percent of workers with employer-sponsored health insurance are in some type of managed care system (Jensen & Morrisey, 2004). The expansion of managed care in health care coverage was not exclusive to private insurers. The number of Medicaid beneficiaries enrolled in some form of managed care increased from about 2 million in 1990 to nearly 12 million, or one-third of all beneficiaries, in 1995. By 2000, 40 percent of Medicaid recipients, of whom nearly all were women of childbearing age and children, were enrolled in a managed care plan (Weissman, Witzburg, Linov, & Campbell, 1999). It is expected that the proportion of children receiving Medicaid health benefits under managed care arrangements will continue to increase. However, because enrolling chronically ill or disabled children, whose health care is costly, is not advantageous to managed care organizations, these at-risk children may join the growing ranks of the uninsured (Deal & Shiono, 1998; Pear, 1999).

The growth and domination of managed care in health care in such a short span of time seems like an extremely rapid revolution. However, managed care has been around for some time, as a brief discussion of its history in the United States demonstrates.

A Brief History of Managing Health Care Delivery and Funding in the United States

Various types of systems to manage health care have existed in the United States since the early twentieth century. The roots of contemporary managed care programs may be traced to (1) early benevolent societies providing prepaid health care for immigrants and the poor and (2) benefit plans for the employees of large industries, such as lumber, railroads, and mining companies (Friedman, 1996). As an example of the former, the Benedictine Sisters in Minnesota, who organized and provided health care for the purchase of a health care “ticket,” were early providers and managers of hospital and outpatient health care for the poor (Boo, 1991). In early employer/company-based health care programs, employees paid for benefits, and the company owned the hospitals and directly employed physicians. Examples of this era of managed health care are the Kaiser Permanente Health System (a California-based health system) and the Ford family-funded health care program of Detroit General Hospital, which provided physician-centered managed health care for employees and for the poor, respectively (Friedman, 1996). The first physician-hospital organization that paid capitation fees to physicians for providing health care to “members” (who paid $25 annually) was the Community Cooperative Hospital of Elk City, Oklahoma. The Cooperative, a prepaid program, was created and directed by a physician called Michael Shadid in 1931 in response to his frustration with the poor quality of health care and income-driven unnecessary surgeries (Shadid, 1959). The thread of benevolence is evident in these early efforts to offer and manage health care, unlike the overt business motivations of managed care systems currently (Starr, 1982, 1994).

Until the latter part of the twentieth century, organized and “managed” health care approaches were sporadic and idiosyncratic. Health maintenance organizations (HMOs) were developed initially by the employer-owners of large companies as “benefits” to workers. One such organization, the now familiar Kaiser Permanente Health System, was used by the lumber industries in Washington and California to recruit and retain employees (Cowles, 2003; Friedman, 1996). Since the mid-1970s, when public law legalized HMOs and expanded the definition of prepaid health care to include physicians in independent practice associations (Health Maintenance Organization Act of 1973, P.L. 93–222; Gorin, 2003), the number of HMOs in a variety of forms grew exponentially (Starr, 1994). A decade later, federal legislation, in an attempt to foster preventive and comprehensive care systems, created fiscal incentives for establishing for-profit managed care organizations to facilitate enrollment by Medicare and Medicaid recipients (Tax Equity and Fiscal Responsibility Act of 1982, P.L. 97–248). Multiple mergers and acquisitions resulted in the integration of systems into only a dozen mega–managed care organizations. By the mid-1990s, 85 percent of Americans who had health insurance were in some form of managed care (Davidson, Davidson, & Keigher, 1999).

To summarize, specific individuals and/or local/regional enterprises led the early ventures into the “managing” of health care. More recently, developments in managed health care resulted from a desire to compete more aggressively in the marketplace, to enhance profitability, and/or to control a specific market share, preferentially across the nation.

THE CHANGING STRUCTURE OF HEALTH CARE DELIVERY

The term “managed care” is not a single homogeneous construct, as managed care systems are complex and diverse. In general, managed care is a system for integrating health care delivery systems by approving the care rendered and also by following the patients throughout their care. Managed care is implemented through a variety of techniques that influence the provision of health care, health care consumers, and providers, and put in place administrative control of health care access, cost, and quality. In essence, managed care plans integrate the utilization (i.e., use of services), provision, and funding of health care (Dziegielewski & Holliman, 2001). Several techniques are used by managed care to control cost (Berkman, 1996; Dinerman, 1997; Redmond, 2001; Shortell & Hull, 1996). These include

• preauthorizing eligibility to receive specific care (i.e., precerting);

• predetermining the extent of care covered and provider fees;

• monitoring the type and extent of care provided;

• emphasizing health care delivery in outpatient, rather than inpatient, settings.

Although managed care plans are not uniform in how these techniques are specifically combined in the coverage plans, their overall objectives are clear and directly linked to cost control: to ensure that health care is provided with the most cost-effective treatments and interventions, said treatments and interventions are demonstrably effective, and all providers are accountable for the care that they render.

Theoretically, managed care seeks to assure adequate, quality health care with emphasis on prevention, while containing the cost of health care. Prevention of serious, and costly, illnesses, such as cancer and heart disease, is obviously important for the reduction of health care costs. It is informally, but widely, agreed that, in practice, managed care's top priority may not be quality comprehensive preventive health care, even though prevention strategies provided at the patient level of care are shown to be empirically effective (Amonkar, Madhavan, Rosenbluth, Odedina, & Simon, 2000).

Capitation, Efficiency, and Accountability

Managed care systems accomplish control of costs by endorsing those treatments that are the least costly and proven to be effective, by capitation payments to providers, and by making providers accountable for patient outcomes. These mechanisms control both what health providers do and patient utilization and, taken together, change the structure of how health care is delivered by inserting managed care systems into the process of delivering care at the level of providers and consumers.

Capitation is the hinge that holds the system of managed care together by imposing a fixed payment for a specific health care service or treatment. Capitation has some distinct advantages to health care providers and potential disadvantages to both patients and providers. One of the advantages to providers is that capitation assures them an expectable revenue stream. The fact that capitation is not adjustable when a patient's care requirements exceed the capitation fee is a disadvantage to providers and to patients (Schneider, Hyer, & Luptak, 2000).

Managed care organizations hold the provider accountable for both the effectiveness and efficiency of care, and for patient outcomes. Obviously, for a given patient, assuring that the services provided are not duplicative, overlapping, and/or conflicting is in the patient's best interests. Conversely, constraining care to the limits of a patient's managed care plan when that patient is in need of greater or more expensive care is not in the consumer's best interests. Before the dominance of managed care in health, and its insertion into the physician-patient relationship, the physician was the sole determiner of the type and duration of patient care. In contrast, managed care systems emphasize planning and implementation of health care services by interdisciplinary providers. Accordingly, interdisciplinary teamwork and decision making is gaining in importance. Nonetheless, the role of physic...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• ABOUT THE AUTHORS
• CONTENTS
• Preface
• PART I: THE CONTEXT OF COMMUNITY-BASED HEALTH CARE
• PART II: CULTURALLY RESPONSIVE PRACTICE IN AMBULATORY HEALTH CARE
• APPENDIXES
• References
• Index