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Managed care and the evolving role of the clinical social worker in mental health.



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 health services Managed care The benefits covered under a health contract  in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  (Crespi, 1997; Cummings, 1995, cited in Chambliss, Pinto pinto

Spotted horse, also called paint, piebald, skewbald, and other terms to describe variations in colour and markings. The American Indian ponies of the western U.S. were often pintos. Most pure-breed associations refuse to register horses with pinto colouring.
, & 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 according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 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 pre·de·ter·mine  
v. pre·de·ter·mined, pre·de·ter·min·ing, pre·de·ter·mines

v.tr.
1. To determine, decide, or establish in advance:
 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 NASW National Association of Science Writers
NASW National Association of Social Workers (Washington, DC)
NASW National Association of Social Workers
NASW National Association for Social Work (UK) 
, 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 scru·ti·nize  
tr.v. scru·ti·nized, scru·ti·niz·ing, scru·ti·niz·es
To examine or observe with great care; inspect critically.



scru
 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 resource allocation Managed care The constellation of activities and decisions which form the basis for prioritizing health care needs  and maximize efficiency and quality of care (Croze croze  
n.
A groove inside the end of a barrel or cask into which the head is set.



[French creux, from Old French crues, groove, from Vulgar Latin *crosus,
, 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 fur·ther·ance  
n.
The act of furthering, advancing, or helping forward: "Pakistan does not aspire to any . . . role in furtherance of the strategies of other powers" Ismail Patel.
 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).

Managed care has limited the use of the most costly services--inpatient psychiatric care--in preference for less-expensive outpatient treatment (Geller, 1996). When inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital  is necessary, periods of hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.

2. the term of confinement in a hospital.
 are shortened, and these stays are authorized only for individuals deemed a danger to themselves or others (Giles, 1993; Schamess, 1996). Managed care providers encourage services that rely on a combination of brief and intensive outpatient therapy and long-term, low-cost maintenance and support, using brief rehospitalizations sparingly spar·ing  
adj.
1. Given to or marked by prudence and restraint in the use of material resources.

2. Deficient or limited in quantity, fullness, or extent.

3. Forbearing; lenient.
 when patients relapse (Bedell, Hunter, & Corrigan, 1997; Schamess).

Another strategy to reduce expenditures has been the use of external review procedures, such as utilization management Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan.  or review, to regulate patients' access to care. Utilization management is a set of techniques used by or on behalf of the provider of health benefits to manage mental health care costs by influencing patient care decision making through a case-by-case assessment of care before its provision (Institute of Medicine, 1989, cited in Alperin & Phillips, 1997). Under this approach, managed care providers must authorize treatment before it is rendered if reimbursement Reimbursement

Payment made to someone for out-of-pocket expenses has incurred.
 for services is to occur. Once treatment is authorized, individuals in the managed care organization determine which professionals the patient may see, what type of treatment he or she may receive, how frequently the patient may be seen, and for how long. This process removes control over many treatment decisions from the practitioner and places it in the hands of managed care decision makers, giving officials from managed health care companies the authority to make many decisions that mental health practitioners and consumers used to make (Edward, 1997).

These changes occurring at the system level of mental health care delivery have transformed substantially the roles of mental health practitioners. Managed health care companies have begun to use the clinical social worker in a much more active role for the treatment of individuals suffering from mental illness. Managed care organizations are beginning to see clinical social workers as preferred providers of nonmedical treatment, in large part because they are less-expensive sources of services compared with clinical psychologists This list includes notable Clinical Psychologists and contributors to Clinical psychology, some of whom may not have thought of themselves primarily as Clinical psychologists but are included here because of their important contributions to the discipline.  and psychiatrists (Schamess, 1996). All of the changes taking place with the increased involvement of managed health care will have vast implications for the role of practitioners in the mental health care field, and, in particular, the clinical social worker.

Key Issues

Brief History

As recently as 1960, before the onset of managed mental health care, the roles of psychiatrists, psychologists, and clinical social workers tended to be distinct. Psychiatrists had the overall responsibility of patient care, conducted psychotherapy psychotherapy, treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. , prescribed medication, and supervised hospital care. Clinical psychologists conducted testing and provided group therapy and other therapeutic modalities Modalities
The factors and circumstances that cause a patient's symptoms to improve or worsen, including weather, time of day, effects of food, and similar factors.
 in institutions and hospitals. Clinical social workers performed comprehensive psychosocial psychosocial /psy·cho·so·cial/ (si?ko-so´shul) pertaining to or involving both psychic and social aspects.

psy·cho·so·cial
adj.
Involving aspects of both social and psychological behavior.
 assessments, counseled regarding family issues, and created discharge plans for patients in social services social services
Noun, pl

welfare services provided by local authorities or a state agency for people with particular social needs

social services nplservicios mpl sociales 
 agencies. At that time, the mental health field was far from overcrowded o·ver·crowd  
v. o·ver·crowd·ed, o·ver·crowd·ing, o·ver·crowds

v.tr.
To cause to be excessively crowded: a system of consolidation that only overcrowded the classrooms.
 (Fink fink   Slang
n.
1. A contemptible person.

2. An informer.

3. A hired strikebreaker.

intr.v. finked, fink·ing, finks
1. To inform against another person.
, 1996).

By the mid- 1970s the number of clinical social workers providing mental health treatment in the United States had grown, almost equaling the number of psychiatrists. Both professions had almost twice the number of clinical psychologists. In the subsequent 15 years, clinical social workers and clinical psychologists tripled their numbers, while the number of psychiatrists grew by less than 40 percent (Goleman, 1985; Manderscheid & Barnett, 1987, cited in Committee on Therapy, Group for the Advancement of Psychiatry, 1992). With the increased number of nonpsychiatric practitioners, along with the introduction of psychotropic psychotropic /psy·cho·tro·pic/ (si?ko-tro´pik) exerting an effect on the mind; capable of modifying mental activity; said especially of drugs.

psy·cho·tro·pic
adj.
 medication, the role of the psychiatrist shifted. As psychopharmacology psychopharmacology (sī'kōfär'məkŏl`əjē), in its broadest sense, the study of all pharmacological agents that affect mental and emotional functions. , biology, genetics, and hard science influenced psychiatry, psychiatrists began to withdraw from psychotherapy. Psychiatric practice instead shifted its primary focus to patients in need of psychopharmacological psy·cho·phar·ma·col·o·gy  
n.
The branch of pharmacology that deals with the study of the actions, effects, and development of psychoactive drugs.



psy
 agents, with psychiatrists prescribing and monitoring medication use and administering medical procedures su ch as electroconvulsive therapy electroconvulsive therapy in psychiatry, treatment of mood disorders by means of electricity; the broader term "shock therapy" also includes the use of chemical agents.  (ECT ECT electroconvulsive therapy.

ECT
abbr.
electroconvulsive therapy


ECT
Electroconvulsive therapy sometimes is used to treat depression or mania when pharmaceutical treatment fails.
) (Committee on Therapy; Hartman, 1994).

With psychiatrists' shift in emphasis, clinical social workers and clinical psychologists assumed more responsibility in mental health treatment, and psychotherapy, in particular. The proliferation proliferation /pro·lif·er·a·tion/ (pro-lif?er-a´shun) the reproduction or multiplication of similar forms, especially of cells.prolif´erativeprolif´erous

pro·lif·er·a·tion
n.
 of managed care companies during the 1980s furthered the increased involvement of clinical social workers and clinical psychologists. Because of improved training and the less-expensive nature of their services, clinical social workers and clinical psychologists were more involved in providing psychotherapy to patients suffering from mental illness. (Committee on Therapy, Group for the Advancement of Psychiatry, 1992; Geller, 1996; Hartman, 1994).

Role Conflict and Competition

Managed health care companies have continued this trend of expanding the roles and responsibilities of nonmedical providers--primarily clinical social workers and clinical psychologists--while narrowing the scope of psychiatric practice (Lazarus, 1996). Managed health care companies see clinical social workers in particular as an economical, substitutable source of labor for both clinical psychologists and psychiatrists in the treatment of patients suffering from mental illness. Presently, clinical social workers provide a wide array of services to clients with mental illness in a variety of settings and at all functional levels of practice. Clinical social workers practice in institutions, hospitals, school systems, clinics, correctional facilities, and private practices. They function in positions of direct service, supervision, management, policy development, research, community organization, and education and training. Clinical social workers frequently perform assessments and arrange and develop services . In these roles they serve as gatekeepers and treatment providers (Gibelman & Schervish, 1996; Shera, 1996). For some time, clinical social workers have performed the largest portion of psychotherapeutic psy·cho·ther·a·py  
n. pl. psy·cho·ther·a·pies
The treatment of mental and emotional disorders through the use of psychological techniques designed to encourage communication of conflicts and insight into problems, with the goal being
 work done in the United States (Hartman, 1994). Clinical social workers provide as much as 65 percent of all psychotherapy and mental health services (Gibelman & Schervish, 1997).

Payers have begun to ask, "What type of therapist is the most cost-effective?" and "What is the advantage of paying one profession higher fees than another for rendering the same service?" when an objective review of empirical studies Empirical studies in social sciences are when the research ends are based on evidence and not just theory. This is done to comply with the scientific method that asserts the objective discovery of knowledge based on verifiable facts of evidence.  shows that there is no absolute proof that one profession can perform psychotherapy better than another. Such research leads managed care companies to conclude that many of the cheaper sources of labor in the mental health field, such as clinical social workers, are as effective in administering treatment to patients suffering from mental illness as other more-expensive practitioners (Austad, 1996).

Until 1985 consumers had a variety of options among mental health clinicians. Patients could choose among practitioners; however, many insurance companies would only reimburse re·im·burse  
tr.v. re·im·bursed, re·im·burs·ing, re·im·burs·es
1. To repay (money spent); refund.

2. To pay back or compensate (another party) for money spent or losses incurred.
 psychologists and psychiatrists for services provided, effectively limiting patients' choice. With the advent of managed health care, further limitation of patients' choice of providers occurred (Herron, 1997; Munson, 1996). Today, choice is often limited, except for the very wealthy, who have more options in their choice of providers because they can afford the most-expensive insurance benefits packages or pay for treatment out-of-pocket (Munson, 1996). Most mental health consumers no longer have the option to go to the provider of their choice and still receive health care insurance coverage. Instead, they are limited to a panel of providers chosen by their insurance company (Gibelman & Schervish, 1996; Munson, 1996). Because of this shift in control of whom mental health care consumers may see for treatment, many practitioners are se eing decreases in client referrals, while other practitioners' practices are thriving.

With managed care's influence, psychiatrists are being replaced by nonmedical practitioners in many domains of mental health treatment in which they once predominated. Psychiatrists are being forced into new practice arrangements and roles, such as consultants for multidisciplinary groups. Psychiatrists are also increasingly being limited to dealing with patients with the most severe mental disorders mental disorders: see bipolar disorder; paranoia; psychiatry; psychosis; schizophrenia. , which tend to involve the use of medication and need for prescription privilege (Goleman, 1985; Lazarus, 1996). Past responsibilities of long-term therapy and treatment aimed at overcoming problems that diminish patients' quality of life have given way to treatment of such cases as serious psychotic psychotic /psy·chot·ic/ (si-kot´ik)
1. pertaining to, characterized by, or caused by psychosis.

2. a person exhibiting psychosis.


psy·chot·ic
adj.
 disorders, with threat to life and risk of decompensation decompensation /de·com·pen·sa·tion/ (de?kom-pen-sa´shun)
1. inability of the heart to maintain adequate circulation, marked by dyspnea, venous engorgement, and edema.

2.
 deemed the main reasons for their involvement (Committee on Therapy, 1992).

The new trend of using clinical social workers in place of clinical psychologists and psychiatrists by managed care companies has touched off territorial disputes
The terms country, state, and nation can have various meanings. Therefore, diverse lists of these entities are possible. Wikipedia offers the following lists:
 among practitioners in the mental health field (Lazarus, 1996). As the mental health professions compete for the same health care dollars, each profession guards its turf, protecting itself by defining responsibilities it is uniquely qualified to perform, and, at the same time, vying vy·ing  
v.
Present participle of vie.

vying vie
 for the right to expand services (Austad, 1996). For example, as the number of clinical social workers has grown in the area of psychotherapeutic treatment, clinical psychologists have lobbied for prescription and full hospital privileges, which historically have been reserved for psychiatrists. Clinical psychologists reason that they could serve as a less-expensive replacement for psychiatrists, or even provide both psychotherapeutic and psychopharmacological treatment to patients (Austad; Fink, 1996). As managed care companies pass psychologists over for less-expensiv e clinical social workers, the lack of differentiation among mental health professionals by managed care companies undoubtedly frustrates clinical psychologists.

Solo versus Group Practice

With managed care's influence, outpatient treatment, and private practice, in particular, has become a viable and increasingly important role for clinical social workers. Although mental health clinics and other institutions provide the greatest opportunity for clinical social workers, a growing number are now carrying out services in a primary setting of solo or group private practice (Gibelman & Schervish, 1996). In 1995, 19.7 percent of NASW members cited private solo and group as their primary practice, and 45.5 percent as their secondary practice setting (Gibelman & Schervish, 1997). Findings indicate that the proportion of clinical social workers entering and practicing as private practitioners continues to grow (Gibelman & Schervish, 1996).

The biggest stimulus in the use of clinical social workers in private practice came with the states' licensing of clinical social workers. Increased licensure of clinical social workers gave clinical social workers credibility as providers of mental health treatment, allowing the movement of numbers of clinical social workers into private practice. As clinical social workers have gained legal recognition and entitlement to third-party reimbursement, the income-generating potential of independent practice has grown (Gibelman & Schervish, 1996).

The future treatment of patients in solo private practice may be in jeopardy, as managed care companies force clinical social workers and other mental health care providers to join group practices. In group practices, clinical social workers, in combination with other mental health practitioners, provide individual and group therapy, family interventions, and a variety of other services, all through one office (Shera, 1996). These groups provide "one-stop shopping," as well as greater access to less-expensive professionals, such as master's-level clinical social workers. Managed care companies find that group practices are more efficient and cost-effective in the management of a population of patients (Johnson, 1995; Munson, 1995).

As managed care companies continue to reduce reimbursement dollars, changes in multidisciplinary team structures are inevitable, with even more reliance on master's-level service providers. Practitioner distinctions already have begun to diminish in favor of more team-oriented models, with the boundaries between the uniqueness of the individual disciplines beginning to blur (Eubanks, Goldberg, & Fox, 1996). Psychiatrists often head the team, coordinating services in conjunction with psychotherapists and other mental health care providers on the treatment team. However, it is not unusual for a clinical psychologist or even a clinical social worker to lead the team, with the psychiatrist relegated to the role of psychopharmacology consultant rather than an active team member (Fink, 1996).

Mode of Treatment

In addition to changing the role of mental health practitioners and the structure of treatment teams, managed care has forced the clinical social work profession, and the mental health field in general, to examine how its members provide care. Managed care companies are exploring new ways they can provide the most effective services to more people under increasing resource constraints (Shera, 1996). The transition from feefor-service to managed mental health care services has created an entirely new culture for mental health care providers and consumers (Geller, 1996). Practitioners must accommodate their treatment to the preferences of managed care. Otherwise, they risk a decrease in referrals, which could ultimately lead to loss of status and income (Hoyt, 1991, cited in Austad, 1996).

Managed health care companies have exerted influence on the ways that mental health practitioners conceptualize con·cep·tu·al·ize  
v. con·cep·tu·al·ized, con·cep·tu·al·iz·ing, con·cep·tu·al·iz·es

v.tr.
To form a concept or concepts of, and especially to interpret in a conceptual way:
 their practice, forcing treaters to modify therapeutic interventions and practice protocols significantly (Shera, 1996). Brief therapy now appears to be the preferred mode of intervention (Gibelman & Schervish, 1996). Longterm psychotherapy has been virtually eliminated for all but private-pay patients. Managed care companies find that studies of short- and longterm therapy suggest that brief approaches are as good as or better than long-term treatment, except in special cases (Lazarus, 1996). The majority of interventions distinguishing themselves in comparative outcome studies are based on behavioral or cognitive-behavioral theories. These treatments tend to be goal- and present-oriented, behaviorally specific, symptom-directive, advice giving, educational, collaborative, and aimed toward the resolution or amelioration a·me·lio·ra·tion  
n.
1. The act or an instance of ameliorating.

2. The state of being ameliorated; improvement.

Noun 1.
 of symptoms in relatively brief periods (Johnson, 1995).

The shift in preference to brief modes of therapy by managed care organizations has changed expectations for therapists. Theoretical orientation of practitioners has become of great interest as managed care companies look for practitioners who use brief treatment methods (Giles, 1993). In response, clinical social workers are trying to align themselves with insurers' goals and preferred modes of treatment, now taking a more-focused, goal-directed, and short-term approach (Austad, 1996). In 1992 NASW found that 37 percent of its surveyed membership had already changed their treatment approach because of managed care's preferences (Rose & Keigher, 1996).

The practitioners most significantly affected by managed care's shift in preferred mode of treatment have been those who provide the extensive and intensive treatments of psychoanalysis psychoanalysis, name given by Sigmund Freud to a system of interpretation and therapeutic treatment of psychological disorders. Psychoanalysis began after Freud studied (1885–86) with the French neurologist J. M.  and psychodynamic psychotherapy Psychodynamic psychotherapy is a form of depth psychology, the primary focus of which is to reveal the unconscious content of a client's psyche in an effort to alleviate psychic tension. , predominantly clinical psychologists (Alperin & Phillips, 1997). Their emphasis on Freudian psychotherapies, which generally have a very long duration of outpatient care and discouraging results in the outcome literature, have been criticized heavily (Giles, 1993). Emerging models of psychotherapy endorsed by managed care organizations assume that the psychotherapeutic process occurs in pieces over time. In these models, psychotherapy functions as an active working relationship between the patient and the therapist, whereby the goal is defined as change rather than cure. Managed care companies' focus on resolving patients' acute symptoms, rather than ridding them of their mental health conditions, has led to the gradual disappearance of the use of the psychodynamic Psychodynamic
A therapy technique that assumes improper or unwanted behavior is caused by unconscious, internal conflicts and focuses on gaining insight into these motivations.

Mentioned in: Group Therapy, Suicide
 model as the dominant framew ork in the treatment of individuals suffering from mental illness (Fink, 1996).

Recently, group treatments have received attention as a cost-effective means of treatment (Folkers & Steefal, 1991, cited in Rosenberg & Wright, 1997). A group format allows a number of patients struggling with similar life issues to come together and benefit by interacting with one another and a therapist, the group leader (Austad, 1996). Managed care companies support group designs, relying on numerous studies that demonstrate the efficacy of short-term therapeutic groups using behavioral and cognitive--behavioral approaches. Managed care organizations find group treatment inexpensive relative to other treatment methods, because one practitioner can treat many clients at once, significantly reducing billable hours of treatment incurred. The potential of group treatment to alleviate the psychological problems of large numbers of people at relatively low cost makes group therapy an attractive option for managed care companies (Rosenberg & Wright).

Despite the utility gains, however, managed care companies do not rely on group treatments as widely as might be expected, primarily because of patients' resistance to group treatment. Some patients find the idea of group treatment difficult to accept because they have a hard time understanding how they will benefit. Many patients prefer individual treatment sessions, where they have the therapist's undivided UNDIVIDED. That which is held by the same title by two or more persons, whether their rights are equal, as to value or quantity, or unequal.
     2. Tenants in common, joint-tenants, and partners, hold an undivided right in their respective properties, until
 attention. These patients may be embarrassed about their problems and reject the notion of others besides their therapist providing input. The logistics of setting up short-term groups, along with current therapist practice patterns, present additional impediments to managed care's use of group therapy (Rosenberg & Wright, 1997). Nevertheless, the immediate cost-effectiveness of groups, coupled with documented positive outcomes, has made the modality modality /mo·dal·i·ty/ (mo-dal´i-te)
1. a method of application of, or the employment of, any therapeutic agent, especially a physical agent.

2.
 particularly appealing in mental health delivery systems and provides a compelling argument for their use (MacKenzie, 1995).

Outcome Measurement and Management

In addition to changes in practitioner roles and mode of treatment, another major trend emerging under managed mental health care is an emphasis on performance and outcome measures. Outcomes management serves several important functions in the mental health field, including evaluating and refining treatments, identifying the most-effective treatments, providing clear descriptions of therapeutic procedures, and enhancing the credibility of psychotherapy. The current marketplace of mental health care increasingly demands greater accountability of its practitioners (Pekarih, 1993, cited in Pratt, Berman, & Hurt, 1998).

Increasing numbers of third-party payers, including federal and state governments, will not fund mental health services without detailed performance outcome data using standardized measures. Therefore, the need to measure patient improvement in treatment and demonstrate efficacy of treatment interventions is greater than ever (Kelly, 1997). Outcome measurement and management is aimed at obtaining evidence of such results. Such evaluative measures provide payers with a quantitative basis to differentiate among providers and types of treatment. Supplying the most cost-effective treatment possible is the primary goal of managed care companies, and by providing empirically validated treatment methods, managed care companies hope to get the most from their expenditures (Jackson, 1996).

Outcome measurement and management not only benefit third-party payers, but also the patients themselves. Outcome measurement and management provide a written record that allows patients to evaluate their own care with a tangible and quantitative product. At the same time, managed care companies, practitioners, and mental health professionals in general, can learn which types of treatment tend to be the most effective for different patient populations. In addition, outcome data can provide credibility for the effectiveness of mental health treatment, thus eliminating any perceptions of arbitrariness (Kelly, 1997).

It is becoming increasingly necessary for mental health professionals to incorporate outcome measurement and ongoing assessment of treatment as part of the normal process of doing business (Pratt et al., 1998). Practitioners who fail to record outcome measurements and demonstrate treatment effectiveness are at a great disadvantage in negotiating with payers compared with those who can. Managed care organizations prefer providers who can demonstrate that their services are cost-effective and will more likely support a practitioner and a treatment intervention that proves results with data. Clinical social workers are at an advantage because they, along with representing a less-expensive source of labor, have been involved in practice effectiveness research for some time (Jackson, 1996).

Case Management

Changes occurring in the mental health field with managed care have increased the importance of the clinical case manager. Typically, the clinical case manager--usually a licensed clinical psychologist or clinical social worker--is the person responsible for the management of patients' treatment. The clinical case manager oversees the patient's benefits, coordinates the efforts of the various entities involved in patients' care, and provides a single point of professional contact for a patient. The clinical case manager stands at the point of interface between the provider--facility and the managed care company. He or she works with the mental health care practitioners to ensure optimum use of the patient's available health care benefits in accordance with the parameters set forth by the individual's insurance policy. Case management and community treatment play an important role in managing mental health care services (Bedell et al., 1997; Birne-Stone, Cypres, & Winderbaum, 1997).

Because clinical social workers have almost exclusively concentrated in this area for some time, many managed care companies hire clinical social workers to fulfill the role of case manager (Jackson, 1996). Clinical psychologists have not embraced case management as part of their routine clinical practice like clinical social workers, making clinical social workers the primary resource for providing case management responsibilities, an important role and a great opportunity in the managed care era (Bedell et al., 1997).

Projections

Managed health care organizations have influenced the delivery of services in the mental health field considerably and will undoubtedly continue to do so (Jackson, 1996; Eubanks et al., 1996). Whether the developments instituted by managed care companies are greeted with pleasure, indifference, or hostility, general agreement exists that the treatment of patients suffering from mental illness will be irrevocably changed as managed care continues to alter drastically the delivery, definition, and outcome of treatment that patients receive (Bozutto, 1992, cited in Alperin & Phillips, 1997). In the future, indicators (Iglehart, 1994) suggest that

* nonpsychiatric practitioners will emerge as the dominant providers of treatment

* use of the traditional fee-for-service health care structure will decrease

* integrated service delivery systems will become the predominant treatment model

* brief modes of therapy will become the preferred method of treatment

* use of outcome measurement and management will continue to grow.

According to Giles (1993), managed care companies will expect nonmedical practitioners, such as clinical social workers to provide the bulk of outpatient care in the mental health care field. Clinical social workers are cost-effective, fully qualified providers of mental health care services in the eyes of managed care companies (NASW, 2000).

Distinctions between master's-level and doctoral-level providers will become more evident as master's-level practitioners assume primary responsibility for direct mental health services, and doctoral-level providers assume more administrative, supervisory, and research-oriented roles (Cummings, 1995, cited in Crespi, 1997; Belar, 1995, cited in Crespi, 1997). The rapid increase in managed care's influence, accompanied by the reduction of referrals to more-expensive specialists, suggests that demand for clinical psychologists will continue to diminish (Frank & Johnstone, 1996). As managed health care organizations restrict consumer choice of providers, many mental health professionals, such as clinical psychologists, may have difficulty joining reimbursement plans (Gibelman & Schervish, 1997; Stroup & Dorwart, 1996).

Despite the shift away from doctoral-level providers and the narrowing role of the medical practitioner in the treatment regime of managed care companies, psychiatrists will likely have an essential and continuing role in the mental health care system (Fink, 1996). According to Giles (1993), managed mental health care still needs medical practitioners for their knowledge of psychopharmacology and experience in prescribing medications. Scientific literature has demonstrated that psychotropic medications List of medications which are used to treat psychiatric conditions on the market in the United States. A
  • Abilify - antipsychotic used to treat schizophrenia, bipolar disorder, and agitation
 are an effective and essential treatment component for most psychiatric illnesses, and psychiatrists, being physicians, are currently the only ones who can prescribe these drugs with the knowledge to do so effectively (Goleman, 1985; Phillips, 1997).

The distance between the domains of psychotherapists and psychopharmacologists will continue to widen, however, as psychiatrists undoubtedly will continue to be the most-expensive mental health professionals. Psychotherapy has already become a predominantly nonmedical activity, and there is every indication that this trend will continue until the medically trained therapist becomes rare (Committee on Therapy, 1992). Some practitioners (for example, psychiatric nurses) who are not psychiatrists can circumvent cir·cum·vent  
tr.v. cir·cum·vent·ed, cir·cum·vent·ing, cir·cum·vents
1. To surround (an enemy, for example); enclose or entrap.

2. To go around; bypass: circumvented the city.
 the barrier to their prescribing drugs through an alliance with a psychiatrist. This practice is likely to increase in frequency, further narrowing the role of the psychiatrist and widening the gap between the medical and nonmedical mental health practitioner (Goleman, 1985). In the future, psychiatrists will more likely focus on treatment planning In radiotherapy, Treatment Planning is the process in which a team consisting of radiation oncologists, medical radiation physicists and dosimetrists plan the appropriate external beam radiotherapy treatment technique for a patient with cancer. Typically, medical imaging (i.e. , supervision, and evaluation, coordinating treatment and providing consultation services. Psychiatrists may still directly treat individuals with the most seve re mental illnesses who often do not respond to psychotherapy, such as patients suffering from schizophrenia. Their primary responsibility with these and other patients will be providing medication and administering procedures that require medical training, such as ECT (Giles, 1993).

Another likely development with the influence of managed health care is the rarity of the solo practitioner (Crespi, 1997). Individual practitioners and small group practices will likely remain, but will probably represent a much smaller proportion of psychotherapists (Committee on Therapy, 1992). With commentators predicting a demise in solo private practice, practitioners will either have to affiliate with managed mental health care groups or forego clients with insurance in favor of those able to afford private payment (Gibelman & Schervish, 1996). The psychotherapist psy·cho·ther·a·pist
n.
An individual, such as a psychiatrist, psychologist, psychiatric nurse, or psychiatric social worker, who practices psychotherapy.
 who decides to operate outside of the managed care system faces not only a degree of professional isolation, but also limitations in referrals and remuneration (Committee on Therapy).

The managed care initiatives sweeping the nation have profoundly affected the ways that clinical social workers and other mental health practitioners deliver services to people suffering from mental illness (Shera, 1996). As these changes continue, clinicians working in a managed care environment will more often practice time-limited psychotherapeutic interventions and, in all but the rarest cases, the practice of unregimented intensive psychotherapy and psychoanalysis will take place outside of the confines con·fine  
v. con·fined, con·fin·ing, con·fines

v.tr.
1. To keep within bounds; restrict: Please confine your remarks to the issues at hand. See Synonyms at limit.
 of the managed care arena. For the majority of mental health care consumers, therapeutic work will focus on precipitating stressors and acute exacerbation that may be treated within the reimbursable re·im·burse  
tr.v. re·im·bursed, re·im·burs·ing, re·im·burs·es
1. To repay (money spent); refund.

2. To pay back or compensate (another party) for money spent or losses incurred.
 framework (Committee on Therapy, 1992; Crespi, 1997).

Finally, with managed care's increasing influence, use of outcome measurement and management will continue. Quantifiable data will play a larger role in treatment decisions. Funding sources of mental health care services will increasingly seek quantitative methods to measure the quality and efficiency of different interventions to guide their purchasing decisions (Jackson, 1996). As managed care companies look for hard data to determine the most effective professionals and treatments, mental health care providers will have to quantitatively demonstrate effectiveness of interventions and treatment through evidence of patient improvement (Gibelman & Schervish, 1996). Thus, the ability to implement and participate in outcomes measurement processes is vital for any practitioner who wishes to operate in the managed care environment.

Conclusion

Despite widespread criticism and various efforts at reform, managed care companies continue to expand (Hoyt, 1995, cited in Chambliss et al., 1997). Clinical social workers currently involved in the mental health field, as well as incoming social work students interested in mental health, must take heed Verb 1. take heed - listen and pay attention; "Listen to your father"; "We must hear the expert before we make a decision"
listen, hear

focus, pore, rivet, center, centre, concentrate - direct one's attention on something; "Please focus on your studies and
 of the rapid developments in the field. Although the changes resulting from the influence of managed care present many challenges, they also create many opportunities for mental health care providers, and for clinical social workers in particular. To take advantage of these opportunities, clinical social workers, and the institutions educating them, must be prepared (Geller, 1996).

Many clinicians currently practicing, as well as current and incoming graduate students, lack information on the breadth of these developments (Crespi, 1997). Clinical social workers must actively seek out continuing education continuing education: see adult education.
continuing education
 or adult education

Any form of learning provided for adults. In the U.S. the University of Wisconsin was the first academic institution to offer such programs (1904).
 courses, conferences, and journal articles discussing developments in the field related to managed mental health care to be better informed. In addition, schools of social work must update their curricula for incoming students to reflect the realities of changes in managed care. Graduate schools must educate future social workers regarding developments, providing students with the information and skills necessary to survive in this evolving culture (Shera, 1996).

Many social work programs are discovering that traditional curricula are no longer adequate to prepare students for practice in the era of managed care. Managed care's emphasis on the provision of mental health services at contained costs requires specialized practice skills, particularly rapid assessment, brief treatment, and the ability to document treatment outcomes. Social work educators must incorporate these elements into their programs (Brooks & Riley, 1996; Schamess, 1996). Social work schools not only should provide training of specialized clinical interventions, but also should focus on the broader range of skills needed for this new era of mental health care services. Some field instructors have reported spending more time teaching the administrative skills required for managed care practice. One school of social work even added a class that deals strictly with managed care issues (Brooks & Riley).

As managed care continues to expand and evolve, social work educators need to continue to evaluate its effect on the training of current and potential clinical social workers. Educators in the field, along with graduate school instructors and administrators, must make the necessary changes to provide clinical social workers with the ability to adapt to the changing environment. Collaboration with managed care is necessary for professional survival (Eubanks et al., 1996). Clinical social workers have an enormous role in the treatment of people suffering from mental illness and have a real opportunity to play a major role in managed mental health care (Shera, 1996). Clinical social workers must rise to the challenge.

Original manuscript received February 20, 1998

Final revision received June 4, 1999

Accepted August 18, 1999

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n.
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adj.
1. Of or relating to struggle within a nation, organization, or group.

2. Mutually destructive; ruinous or fatal to both sides.

3. Characterized by bloodshed or carnage.
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Jeffrey A. Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
, MSW (MicroSoft Word) See Microsoft Word. , ACSW ACSW Academy of Certified Social Workers
ACSW Australasian Computer Science Week
ACSW Advisory Council on the Status of Women
ACSW Alberta College of Social Workers
ACSW Advanced Crew-Served Weapon (US DoD)
ACSW Actuaries’ Club of the Southwest
, was a client services manager, Washtenaw County Community Mental Health Adult Services, 3981 Varsity Drive, Ann Arbor Ann Arbor, city (1990 pop. 109,592), seat of Washtenaw co., S Mich., on the Huron River; inc. 1851. It is a research and educational center, with a large number of government and industrial research and development firms, many in high-technology fields such as , MI 48108. The author expresses his appreciation to Associate Professor Larry M Gant, University of Michigan (body, education) University of Michigan - A large cosmopolitan university in the Midwest USA. Over 50000 students are enrolled at the University of Michigan's three campuses. The students come from 50 states and over 100 foreign countries.  School of Social Work, for his guidance and encouragement; to Associate Professor Candyce S. Berger, University of Michigan School of Social Work, for her insights and suggestions; and to his brother Paul D. Cohen, for his editing expertise.
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