From January 2001 NASW NEWS
Copyright ©2001, National Association of Social Workers, Inc.

Managed Care Is Faulted

New York City Chapter Issues Damning Report

The report makes specific recommendations about questioning decisions.

By Corinna Vallianatos, NEWS Staff

The New York City Chapter of NASW in December released "Warning: Managed Care May Be Hazardous To Your Health," an analysis of more than 300 managed health and mental health care incidents collected from consumers, health professionals and advocates in New York.

Compiled by the chapter's Managed Care Critical Incident Project, the report details six problem areas:

• Health care decisions are not made by patients and providers.
• Appeals related to inappropriate health care decisions are delayed and restricted.
• Home care services are refused.
• Access to emergency care is denied.
• Barriers to care are increasing.
• Continuity of care is disrupted.

The report also provides examples of some of the more egregious managed care industry failings:

• A Medicare HMO threatened to take a 94-year old's wheelchair.
• A woman having a life-threatening asthma attack was taken to a hospital in her HMO plan instead of the neighborhood hospital.
• A person with AIDS was denied approval by his managed care organization (MCO) of medications he had previously been on.

"In theory, managed care promises coordinated and comprehensive health and mental health services that are both affordable and accessible," the report states. "The benefits of preventive screenings and positive health promotion are not disputed. However, health care under the present managed care system suffers from a significant lack of cooperation between all parties involved. The report documents the price consumers and providers pay when cooperation is diminished by bureaucratic red tape common to the for-profit managed health care industry."

And the red tape takes many guises. "Warning: Managed Care May Be Hazardous To Your Health" holds forth a bevy of examples of enrollment problems, such as misleading MCO marketing or confusing benefit packages; disenrollment problems, such as delinquent forms; and access-to-care problems, such as unanswered phones, long waits for appointments and denial of specialty care.

The report also details quality-of-care issues, such as limited coverage of prescription drugs; consumer reimbursement issues, such as stalled reimbursement; and care-related issues for health care professionals, such as breaches in confidentiality, rejection of determined treatment routes or arbitrary changes in provider panels.

The report provides specific recommendations on increasing consumers' and providers' awareness about the right to question MCO decisions. According to Dava Weinstein, New York City Chapter staff, people receiving mental health care challenged MCO decisions at a third the rate of people receiving other health care.

These recommendations include: intensive public education of the law to consumers, health professionals and advocates; and state departments of health and insurance to further develop means for enforcing existing New York State managed care laws. This system would: hold MCOs responsible for informing patients, providers and the public of their rights and responsibilities according to the law; hold MCOs responsible for an immediate-response system when patients require immediate care; and hold MCOs responsible for accurate marketing information.

The recommendations, the report says, are necessary to ensure a publicly accountable health care system.

Back to NASW NEWS Contents