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Managed Care: Changing the Landscape in Social Work Education and Practice
Raymond R. Webb, Jr.

Mr. Webb was the keynote speaker for the University of Pittsburgh School of Social Work's 60th Anniversary Symposium: Preparing Social Workers to Practice in a Managed Care Environment. September 1998.

Thank you so much. I am delighted to be with you today. The older I get the more this school has meant to me. The tremendous opportunities that my graduation from our school has given me in my career would never had happened had I not been part of our school. It is a great time for us. It is a time of challenge. It is reflected in something that I heard some time ago. I recall reading that what we must do in this ever changing environment is to see our world wearing bifocals. It is essential that we see as clearly as possible that which is in front of us and equally important that we be able to see what lies ahead of us. Seeing our world through bifocals... we must look at the issues with which we are dealing and understand that change can be difficult and can create anxieties, but adaptation is essential.

I don't want to take much time today talking about reforms or what is happening as far as trends. Many of you are living those trends today. I would like to state the fact that health care reform is happening incrementally. The same can be said for welfare reform. This so called "devolution" or the passing of responsibility from the federal government to state government and then onto the counties is abundantly clear. This devolution has tremendous implications for all of us. I believe it is particularly important for those of you who are working at a county level. The roles that you play will shape the policies of the future because those policies are being locally determined. I must say that I am worried that our federal and state governments no longer feel a responsibility for many of their most vulnerable citizens. But, through privatization or passing responsibilities down to local governments, they are, in fact, abrogating their own responsibilities.

Privatization is clearly exemplified by the fact that the managed care industry has successfully captured the private health care business. We now must understand that the growth markets for managed care companies are Medicaid and Medicare. Isn't it interesting that we have permitted the insurance industry to take over both the insuring and delivery of healthcare? I think it is amazing when one considers that no industry in this country has discriminated more against persons with mental illness and/or addictive disease, yet we are now asking them to manage those services.

"It is essential that we define our own destiny and not permit others to define it for us."

We must understand that the most vulnerable of our population - the aging, the disabled, and the poor - are now clearly in the throes of managed care. Although the issue of access to healthcare is one the selling points of managed care, and many of us would agree access to medical care and the fee-for-service system left much to be desired, it is important to recognize that access is not the principal driving force in moving to a managed care system. Both access and enhancing quality are critically important, but ladies and gentleman, what is driving the system is cost containment. If you lose sight of that, believe me, it will be a problem for you.

The changes I am alluding to will not be limited to the management of fiscal and behavioral health care. Clearly, many of the underlying principles why we have moved to a managed care system will become part of the management of an entire range of human services. Will it look the same? No. There will be variations in how human services are insured and paid for. As an example, instead of talking about medical necessity, perhaps we will talk about social necessity. What is critical for social workers is that they be part of defining what these criteria will be.

The managed care companies now have major planning components that are looking at how they can make a profit in a variety of new markets outside of healthcare management. Very obviously, companies that are for profit must have their stockholders as their principal responsibility. What we are seeing as these companies grow and expand is enhanced compe

"Seeing our world through bifocals...we must look at the issues with which we are dealing and understand that change can be difficult and can create anxieties, but adaptation is essential."
tition within the healthcare markets. It is clear to me that agencies that have always been considered essential community providers or 'safety net' providers will find it necessary to compete in the market against for-profit companies. We see this occurring in Pennsylvania in both mental health and in drug and alcohol services.

I am firmly convinced that we can deal with all of the issues I have raised if we are smart about it. There is no question in my mind that, once the profit margins go down, the for-profit managed care companies will move to other markets and activities. The key issue is whether or not we can survive in the interim and, yes, even seize the opportunity to become more effective and efficient providers.

Today, I want to look at social work in the managed care environment from three perspectives. I want to discuss it from a clinical standpoint; from the perspective of management, administration, and supervision; and finally, talk about social workers as advocates. During the course of my discussion I will attempt to identify some of the implications for social work education in each of the three areas.

Social Workers as Clinicians:

I find it fascinating as I talk to managed care executives across this country that they speak with pride that they have hired significant numbers of social workers in their companies. What does that say? I believe it clearly says that social workers are of significant value, that we are respected, and, more importantly, it puts our profession in a position to influence the development and implementation of the policies which direct managed care activities.

There is no question that clinicians are impacted significantly by the changes that are occurring. The way we have practiced over the years is clearly being challenged. The fee-for-service system is no longer going to be a major player. New practice standards, guidelines, and clinical protocols are being developed and are being insisted upon if one wishes to continue to practice. We will be required to change our practice to short term, time-limited, focused, solution-based treatment modalities. These new approaches will be required by both the public and private payers.

Many of us have worked diligently with people on an individual basis. It is clear and the research is demonstrating more and more that group treatment for many situations can be just as effective. Thus, managed care companies are forcing the use of more groups and, at the same time, are requiring shorter and shorter numbers of sessions.

What are the implications for training? I reflect back on my own experience at our school, because I had the opportunity to both learn about psychiatric casework and

"There is no question in my mind that, once the profit margins go down, the for-profit companies will move to other markets and activities. The key issue is whether or not we can survive in the interim..."
group work. What is critically important is that those in education understand the significance of the changes which are occurring in practice and provide the appropriate curriculum. Focus must not just be on treatment modalities, but must also be on justifying the practitioners' interventions and outcomes. Clear documentation of all interventions will be essential. We must take advantage of these sophisticated technologies that are available and are being developed that will, in fact, free social workers to be more creative. The integration of funding will create the opportunity for social workers to be able to look at a child or family and treat them in a comprehensive way.

I believe we have to understand that we must move away from utilization review of our activities to a process of utilization management by ourselves. It is essential that as clinical social workers we manage our own utilization through the development of treatment plans and through the maximization of resources available to us. I do not want someone to manage me. I want to manage myself. I know I can do a better job than they ever could, but somehow we lose sight of that fact and permit others to impose requirements upon us because we fail to participate in the process of developing those requirements. We can do better.

As I noted before, clinical social workers will be judged by outcome. There is so much discussion today about outcome measurements, but little has evolved. I would hope that our school could get out front in defining these outcomes.

As I talk to clinicians across this commonwealth, I find that one of the skills that they are finding essential is that of being a good negotiator. I found a recent article in the Journal of Social Work to be most helpful regarding the need for social workers to develop negotiating skills. In addition to the need to document your interventions and to define outcomes, it is important that clinicians be able to successfully negotiate with the needed course of treatment with payers. Clinicians will be paid for what is authorized, not necessarily that which the client needs. I would hope that our school is involving the managed care industry in the classroom. Members of the faculty should be bringing people into the classroom who understand what is happening in the health and social service environments and should use these same folks to help establish the curriculum. Students have the right to have available to them "state of the art" information. The school has the responsibility to provide this information.

Social Workers as Managers, Administrators and Planners:

It is my experience that middle managers within agencies are having a very difficult time making the necessary adaptations. These individuals, as has always been the case, are caught between what administration wants and what they perceive as the needs and desires of the staff. Without question, middle managers are the group of individuals who will have to make more significant adaptations than any other group. Middle managers must understand that their roles and responsibilities of yesterday may not be their roles and responsibilities for the future, and they must be willing to make the required changes.

I have had the opportunity to work with a number of agencies in southeast Pennsylvania where managed care has significantly penetrated both the public and private behavioral healthcare markets. I find it interesting that these agencies are not cutting their staff but are increasing them, particularly in support staff carrying out billing functions. Some agencies are hiring credentialed social workers, and social workers are playing an increasing role in utilization management activities. In the past many of these agencies have been program funded, and, therefore, have not paid significant attention to cost. Strong fiscal departments are critical. They must not only be able to determine the actual cost in the delivery of a service, but also to understand that cost is not always driving the system-the price the people will pay for that service is the critical issue. Schools of social work must, through continuing education programs, help middle managers and administrators understand the changing market conditions and

"If an organization doesn't see itself as a part of the continuum of services and continues to be directed by attempts to be all things to all people, it will fail."
provide them with the tools to success. Continuing education will play a significant role in helping managers and planners to understand that their agencies can no longer function totally autonomously. If an organization doesn't see itself as a part of the continuum of service and continues to be directed by attempts to be all things to all people, it will fail. It is absolutely essential that organizations see themselves in partnership arrangements with other organizations that collectively may represent a full continuum of care. In this regard then, administrators must take a close look at their organizations. A high quality continuum of care can be provided to their clients.

Every organization is driven by the need to perpetuate itself and to survive, but agencies must play it smart if they are to survive in the current environment. It agencies are not willing to critically look at their service components, their organizational structure, and their mission, they are not playing it smart.

Administrators have a tremendous responsibility in terms of providing the organizational leadership for their agency. Good leadership is no longer enough-excellent leadership is required. That leadership must include providing opportunities for the staff to develop and to provide all levels of staff with the opportunity to succeed in whatever responsibilities they are assigned. It is equally important that boards of directors clearly understand the changing environment, understand what constitutes their market areas, understand the competitive nature of the environment, and provide the structure necessary to make decisions quickly, but thoroughly.

Five years ago our Association published a managed care readiness survey. I find it interesting that those agencies that took the document and implemented it through a committee of their staff, consisting of the maintenance personnel up to their chief of psychiatry, seem to be doing well. The survey provided an opportunity for everyone to participate in assessing how the organization will move forward.

The last thing I would like to suggest is that administrators and managers, as well as boards of directors, must understand that they have to approach collaborative relationships on the basis of win-win: in my estimation, the concept of win-lose does not exist. If you are not driven by win-win, I can assure you that it will be lose-lose.

The win-win situation takes into consideration the need to understand truly how to spell the word partnership. It doesn't really matter who you are or who the payer is. What is essential is that we work toward a partnership arrangement that recognizes mutual value. I cannot think of a clearer example of win-win than the bill to license professional counselors and marriage and family therapists we now have before us in the Pennsylvania legislature. At the same time, social workers are attempting to secure a clinical practice bill. Is it not possible for these two groups to come together and make it a win-win situation? If not, guess what's going to happen? Both will lose.

At this point I can't help add that social workers have not had a significant impact on the legislative process because as a group we fail to participate in the legislative process. As a group we do not support our political action committees as do our colleagues and the other helping professions.

Social Workers as Advocates:

I fully realize you are all advocates in your own way, within your own systems, for your clients and through your professional associations and agencies. I simply do not believe that we have been quite as effective at advocating for our own profession as we probably should be.

Basic physics tells us that it takes a great deal of energy to move folks, institutions, systems, etc. out of a static base into a state of disequilibrium. Although it takes a great deal of energy to get a system moving, once you do, it requires far less energy to keep it moving. Thus, it is important to understand that we have a healthcare system and a welfare system in disequilibrium at this point in time. This system is out of balance and, as all systems attempt to do, they strive to achieve equilibrium once again. This simply means that it requires less effort when these systems are out of balance to influence positive directions before equilibrium is reestablished. Now is the time to have the kind of impact that we have always indicated a desire to have, but it can only happen in one way and that is if we fully participate in the process of creating change.

Influencing the system can be realized when a social worker actively volunteers to be on planning committees at the local level. Right now in Allegheny County a great deal of planning is going on in terms of the mental health and drug and alcohol systems under managed care. How many of us have indicated a willingness to participate in those planning processes? Perhaps had we extended ourselves, the commissioners in surr

"We must understand that the most vulnerable of our population - the aging, the disabled, and the poor - are now clearly in the throes of managed care."
ounding counties might not have partnered with a for-profit behavioral healthcare entity, but would have seriously considered, as has Allegheny County, partnering with the provider community to manage the mental health and drug and alcohol services. We hold in our hands the future of the behavioral service system. In the final analysis, I am firmly convinced that the partnership between funding organizations and the providers will succeed and endure.

Throughout my comments, I have tried to respond to the role of education. I am reminded of something I read not long ago that talked about today's times. Today, more and more information is available, and we are moving at faster and faster paces. We are besieged with uncertainties about the future and are affected by variables that lie outside of our control. Realizing this, it is essential that education provide every opportunity to make curriculum changes reflective of the changing times. I probably spend 40 percent of my time dealing with issues of managed care and particularly in the Medicaid program. Thus, I fully understand the volume of material that crosses my desk and is available off the internet. It is understandable that educational institutions may be experiencing a time lag. Again, I believe it is essential that people who are experiencing the changes be involved in the educational process. The students that have graduated from this school and are working in this field may, in fact, be the best educators in this rapidly changing environment.

I can't over-emphasize the importance of field instruction, particularly for clinicians. As I have previously indicated, treatment modalities and clinical requirements are changing rapidly, and I find that many agencies are keeping abreast of those changes. Thus, the field instructor is having direct, hands-on experience in facilitating the adaptations and, as such, can provide first hand knowledge to students.

I previously alluded to the need for the school to be involved in evaluative research, particularly in the area of outcome measurement and state-of-the-art treatment procedures. I also believe we need to develop the ability to better market our services and their values. Agencies clearly must be much more aggressive in defining their roles and responsibilities and to develop marketing plans that put them out front and make them important to any managed care network that may be developed.

It is essential that we define our own destiny and not permit others to define it for us. I thank you for inviting me to this program. I sincerely wish you the best.

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