The Social Service Health Specialist in tm HMO DOMAN LUM
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Health Maintenance Organizations—in which the subscriber is assured of a physician's care and access to specialized services for a fixed, prepaiet fee—are gaining national attention. On the basis of a study that examined the variations in services and structure, the author discusses the role changes that the HMO is forcing on the health professional.
of the Health Maintenance OrganiW zation Act of 1973 (P.L. 93-222), which President Nixon ITH THE PASSAGE
signed into law on December 30, 1973, the concept of prepaid group practice as an alternative to fee-for-service health care became a viable system for the delivery of health care. The language of the Health Maintenance Organization (HMO) legislation addressed the need to control costs through reorganizing the medical care system, to provide health maintenance and preventive health services, and to redistribute medical resources to insure their accessibility to residents of inner-city and rural areas. What serious impact will be made on these problems remains to be seen, but the HMOs do represent a potential change in the delivery of health care. HEALTH AND SOCIAL WORK, Vol. 1, No. 2, May 1976
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The HMO concept of health care is not a panacea for all ills inherent in health care delivery—restrained expectations are necessary as well. Mechanic cautioned that HMOs should not be oversold. The improvements for which the HMO system has a strong potential are limited to eliminating abuses and inefflciencies in the current organization, to providing greater continuity between preventive and other aspects of care, to moderating patterns of excessive hospital use, and to facilitating a high level of treatment through the use of ancillary assistance and good technical facilities. 1 Wilson stated: Perhaps the HMO's greatest influence will be the comparison of what happens to people who receive care under the HMO system versus those who get it under the fee-for-service system. If that comparison favors the HMO—as we believe it will—the HMO will have sold itself. If it does not, then the HMO idea is bad and should be abandoned. 2 Among the innovative aspects of HMOs are the new vorational opportunities for paraprofessionals in medicine, nursing, dentistry, health care administration, social welfare, and other allied health professions. Certainly, with the emergence of a national health insurance system for the United States, the entire health field will have to address itself to the reorganization of health and social services, te the development of roles for health-related personnel, and to the revision of health care education and curricula. As a forerunner to such a large-scale undertaking, HMOs pose a unique opportunity for new vocations for health and social welfare administrators and educators. The purpose of this article is to review the developmental history of the prepaid group movement, assess current growth trends of the HMO structure, and project emerging professional roles for HMO manpower, particularly for the social service health specialist. It is hoped that the social work profession will prepare for the inception of HMOs by revising health curricula in schools of Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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social welfare, by developing unique HMO role models for social workers on the local level, and by devising a political strategy to insure that social services are adequately represented. DEVELOPMENT OF THE CONCEPT
To understand the present status of HMOs, a brief history of the prepaid group practice movement is in order. Prepaid group health care has moved through several phases. Theoretical components
In 1929 the Farmers' Union Cooperative Health Association of Elk City, Oklahoma, was the first prepaid group practice in the United States. By 1932 the committee on the cost of medical care of the American Medical Association endorsed voluntary enrollment in hospital-based, prepaid group-practice plans. During the next two decades, a number of large-scale operations were started in metropolitan areas: Ross-Loos Medical Clinic in Los Angeles, California (1929); Group Health Association in Washington, D.C. (1937); Kaiser-Permanente Medical Care Program on the west coast (1942), now operating in six regions; Group Health Cooperative of Puget Sound in Seattle, Washington (1947); Health Insurance Plan of Greater New York (1947); and Group Health Plan of Minneapolis, Minnesota (1957). On the whole, prepaid group practice demonstrated a viable type of organizational arrangement and medical cost control for consumer and provider. In the last three years, prepaid group health care has received national prominence. In his health message to the Ninety-second Congress in 1971, President Richard M. Nixon made the reorganization of health delivery services a focal point of his health program. 3 He proposed an HMO system that would offer comprehensive services to be purchased annually from a medical group at a prepayDownloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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"The language of the HMO legislation addressed the need to control costs through reorganizing the medical care system, to provide health maintenance and preventive health services, and to redistribute medical resources to insure their accessibility to residents of inner-city and rural areas."
ment rate through capitation contracts. Rather than relying on federal regulations, investment, and planning, Nixon envisioned economic and professional incentives based on the preventive maintenance of health. Consumers would be able to choose conventional health insurance or health maintenance contracts offered by a variety of competing organizations. The HMO program would theoretically generate a variety of organizational arrangements with physicians and would involve private corporations for capital resources in addition to government grants and loans for planning, construction, and initial operations. It would rely on a competitive market to control costs and improve distribution and would assume minimal government interference in internal organization. An HMO would contract with independent providers, employ its own medical staff, and own a hospital and dispersed clinics or arrange for accommodations in existing local hospitals. It would maintain a unified set of medical records, quality-control procedures, and administrative functions. The subscriber would be assured of a primary physician and access to specialized services for a fixed, prepaid fee. The administration's bill, however, failed to include a detailed list of basic and supplemental health services. This addition characterized the HMO counter-legislation introduced by Congressman William R. Roy and Senator Edward Kennedy. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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Data assessment and delivery debate National HMO legislation having been launched, a number of major issues related to prepaid group practice emerged for study and debate. These included the following: 1. Initial studies that either justified or questioned the extent to which prepaid group practice controlled costs, particularly differences in hospital use between members of prepaid group practices and persons with other forms of health insurance or the general population. 4 2. Cost control due to the lower ratio of prepaid group practice physicians to the patient population and other economies of scale such as division of labor, centralization, and specialization. 5 3. Organizational problems including the quality of care that can be maintained among various socioeconomic classes, socioeconomic population distributions served by prepaid group practice and those not included, efficiency of organization, and financing and provision of health services to a defined population, particularly pertaining to technical and psychosocial effectiveness. 6 These issues tended to question the extent to which the HMO concept could be adopted on a full-scale basis from a legislative program. In the meantime, health-related investigation into the HMO delivery system was heightened. Initial implementation Some HMO prototypes have existed in the form of prepaid group practice that has been in operation during the past four decades. However, during 1971 and 1972 the Nixon Administration began to fund feasibility studies in anticipation of the HMO system of delivery. The U.S. Department of Health, Education, and Welfare (HEW) established the Health Maintenance Organization Services within the Health Services and Mental Health Administration. Through general legislation to stimulate experimental means of health care delivery, approximately $10 million was Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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distributed for 86 HMO planning and development grants and 24 technical support activity grants and contracts. Funds were obtained from allocations for research and experimentation from comprehensive health services, regional medical programs, and health services research and development. At the same time, technical material on HMO organizational implementation appeared in numerous HEW publications. The subjects included establishing an HMO financial plan and accounting system, suggesting marketing techniques for a prepaid group practice, converting neighborhood health centers to health maintenance organizations, applying HMOs to medical and nursing education, and implementing a comprehensive HMO plan for a metropolitan area.? Various types of HMOs have been analyzed from the perspective of organizational planning. Greenberg and Rodburg, as well as Gintzig and Shouldice, have described various prepaid models of group practice organization in terms of sponsorship, facilities, funding, and management linkages. 8 Piemme and Schroeder have concentrated on a detailed analysis of university HMO structuren at Harvard, Yale, and Johns Hopkins. 9 Finally, Prussin has compared major prepaid group practices in terms of organization and management and has diagramed their service delivery system. 1 ° Legislative outcome The Health Maintenance Organization Act of 1973 was funded as an experimental program. It provided prepaid group practices (PGPs) with $25 million for a feasibility survey, planning, and initial development grants and contracts,. and $75 million for initial operating loans. Basic health services included (1) physician services, (2) inpatient and outpatient hospital services, (3) medically necessary emergency health services, (4) short-term outpatient evaluation services and crisis intervention mental health Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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services, (5) medical treatment and referral services for alcohol and drug abuse, (6) diagnostic laboratory and radiological services, (7) home health services, and (8) preventive health services. An HMO may also offer such optional supplementary health services as intermediate and long-term care, eye examinations, dental care, mental health services, long-term physical medicine and rehabilitative services, and provision for patients to obtain prescription drugs. The targets of the HMO program were inner-city and rural populations, which chronically lack many medical services. Provisions were made for regular employees as well as for migratory and seasonal workers who represent a broad spectrum in terms of age, social group, and income. Various arrangements among physicians and allied health personnel were established to attract a variety of medical manpower. Federal regulations were also set forth to insure quality and program evaluation, and an annual report to the secretary of the Department of Health, Education, and Welfare was authorized. Moreover, this legislation overrode restrictive state laws and practices regarding prepaid groups. In brief, the HMO legislation sought to demonstrate the viability of an alternative health care system over a four-year period. HMO GROWTH TRENDS
Between the enactment of the HMO Act of 1973 and the formulation of final federal regulations on October 18, 1974, the author conducted a national study of PGPs and HMOs to investigate various structural characteristics. Under the auspices of the Human Services Design Laboratory of Case Western Reserve University, School of Applied Social Sciences, a questionnaire on various operational aspects was developed and sent to health administrators of 173 prepaid group practice facilities. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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"Along with a mental health team, social workers can participate in short-term outpatient care and crisis intervention as well as in treatment and referral for alcohol and drug abuse—all of which are mandated as basic health services for an HMO."
Out of the potential group, 116 (67 percent) responded. However, 50 of the questionnaires (29 percent) were not used, leaving a 38 percent client sample (n = 66). Of the nonusable responses, 5 were unwilling to fill out the questionnaire, 24 considered themselves neither an HMO nor a PGP, 13 questionnaires were returned undelivered as having no forwarding or insufficient address, indicating that they were probably not operating, 5 were in the feasibility study phase, and 3 indicated tffat they were out of business. The survey attempted to ascertain the services provided by the four kinds of health groups—providers, insurers, consumers, and independents. Providers were defined as public and private hospitals, physician groups, private corporations, medical schools, and medical care foundations. Insurers were insurance companies and Blue Cross–Blue Shield that represented the recent emergence of business and health insurance elements into the prepaid group field. Consumers covered various consumer-oriented and labor unions. Independents were composed of a variety of organizations that could be described as self-sponsored and selfsupporting institutions as well as community nonprofit corporations. Some important aspects of the profile that emerged were the following: n Multiple sponsorships and insurers and independents appeared to be recent operations, whereas single sponsorships and providers and consumers existed among both new and old prepaid practices. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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nPrepaid group facilities were limited to clinics. Insurers and independents tended to have one clinic, while providers and consumers had a range of clinics. Providers tended to own their hospitals, but in many cases insurers, consumers, and independents made arrangements with existing health institutions for hospitalizations. nNew prepaid group practices seemed to have marginal levels of membership (e.g., 5,000 individual members). Single sponsorships were generally slightly larger than multiple-sponsored groups. Older established provider and consumer groups tended to have over 25,000 members. nPrivate nonprofit corporations characterized the structure of the majority of prepaid group practices. However, more research is required to determine to what extent private, profit-making elements are a part of a private nonprofit structure. nProvider, consumer, and independent governing boards appeared to have policy-making power, but insurers were divided on this matter. Consumer boards evidently exercised authority over control of the budget and approval of contracts and expenditures. On the other hand, insurersponsored boards seemed to be powerless over these matters. Providers and independents were between these two poles. Board representation findings were inconclusive except for those concerning consumer representatives. Independent and consumer sponsors were related to more consumer-oriented representatives than the rest. nClient composition (e.g., income, ethnic, and affiliated groups) was difficult to interpret because of the lack of adequate data. However, providers generally had employed and unemployed groups for members; insurers and consumers tended toward employed and a group of employed and unemployed; and independents appeared to serve the unemployed and a mixed group. nConcerning administrative management, insurersponsored management was decentralized, whereas consumers and independents were strongly centralized. ProDownloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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viders appeared to have both centralized and decentralized administrative management structures. n With respect to medical services, all sponsor types generally offered private physician services and diagnostic laboratory and radiological services. However, the remainder of the services varied. By and large, consumers tended to have their own staff and facilities for inpatient/ outpatient preventive health and medical health services, as well as facilities for treating alcohol and drug abuse. Insurers tended to make other arrangements for three of the services. Providers and independents used their own staff and facilities or made other arrangements. Independents occasionally provided dental care, providers used outside resources or offered no dental coverage, and insurers and consumers had none. On the whole, with the exception of insurers, a comprehensive range of services characterized providers, consumers, and independents either through their own staff and facilities or arrangements with existing health institutions. n With regard to patterns of staffing, physicians were both full- and part-time employees. General practitioners and internists were strictly full time, while obstetriciangynecologists, pediatricians, surgeons, optometrists, and urologists worked both full and part time. The rest of the medical subspecialties were part time. Full-time supportive staff members included nurses, X-ray technologists, laboratory technologists, and health administrators. Other personnel, such as dentists, nursing practitioners, physical therapists, physician assistante, health researchera, health educators, health planners, social workers, psychologists, nutritionists, and allied health professionals were listed as both full time and part time, if the responses identified them at all. Based on these findings, it appeared that the majority of prepaid group practices in the study sample were composed of relatively young organizations. Because of limited membership and capital resources and revenues, there was Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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"Whether academicians and professional leaders recognize the opportunities inherent in an HMO will be indicated by the quality and content of social work education offered to the graduate student and the practitioner in the immediate future."
a tendency to rely on interorganizational arrangements with existing health facilities, particularly for inpatient hospitalization and for medical services and specialists. Providers and insurers tended to represent traditional medical services that entered the field of prepaid group practice with minor alterations. In contrast, consumers and independents conformed more to federal standards in terms of comprehensive services and consumer participation and had greater decision-making power on the governing board. 11 By October 1974 there were 142 HMO-type plans in operation across the United States serving an estimated 5,300,000 enrollees. Most of these organizations were created since 1970 but none of them feil under the requirements of the 1973 HMO Act because they were not dependent on planning and implementation moneys. One wonders how many of these plans conform to the concept of an HMO set forth in P.L. 93-222. Four 13-week grant-funding cycles for the fiscal year 1975 were established with application deadlines due on June 30, 1974, September 2, 1974, November 4, 1974, and February 3, 1975. During the first cycle, which ended June 30, 125 applications for funding were received for a total request of $16,952,165. Grants were given to fifty projects for a total of $5,510,129. An analysis of these projects revealed that one-half were consumer or public sponsored and were either in the feasibility, planning, or initial stage of development. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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For the second cycle, fifty-one applications were filed for a total request of $5,572,477. Again, the consumer sponsor type was predominant. Thus, in light of the consumer and independent organizational profile researched by this author and the increase of consumer applicants for funding, HMOs have the potential of offering an alternative health system if these trends continue. 12 THE CALIFORNIA EXPERIENCE
However, there has been widespread financial abuse by several prepaid health plans that were recipients of MediCal contracts with the California State Department of Health. In the November 1973 Legislative Analysis Report, "A Review of the Regulation of Prepaid Health Plans by the State Department of Health," a number of problem areas were cited among forty-eight participating prepaid health plans: 1. Inadequate records and information on mandatory background checks of prospective health contractors. 2. Lack of high-quality criteria and procedures for evaluating care. 3. Excessive capitation rates in several cases, exceeding the 90 percent•of the cost policy that the Department of Health would experience under the fee-for-service MediCal system. 4. A saturation problem among Los Angeles and San Diego prepaid health plans in marketing and enrollment procedures resulting in increased competition for enrollees. 5. The need to slow down rotation of contract managers who were frequently transferred to other departments just when they began to acquire in-depth knowledge of the responsibilities of prepaid health plan contracts. 6. Misrepresentation of information by door-to-door solicitors of various health plans to prospective Medi-Cal clients, particularly in Los Angeles and San Diego. 7. Failure of many prepaid health plans to submit Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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quarterly financial service reports to the Department of Health. 8. The Jack of thorough medical audits that cover the structural arrangements, quantity, and quality of health care services being provided by each of the prepaid health plans. 9. The need for more detailed on-site study of individual operations by state contract managers. 10. Requirement for organizational and financial interrelationships between the prepaid health plan and closely related organizations to be delineated in order to determine discrepancies between nonprofit and profit-making operations." In April 1974 the Joint Legislative Audit Committee of the California Senate and Assembly stated that out of $56 5 million paid to 15 Prepaid Health Plan (PHP) contractors, only $27.1 million (48 percent) was expended for health care services whereas $29.4 million (52 percent) was for administrative costs or net profit. It was further concluded that the Department of Health had mismanaged the PHP program and the committee recommended its transfer to the Department of Finance. 14 During January and February 1975, Governor Edmund Brown, Jr.'s, administration began an intensive probe of the files of the California State Department of Health and submitted data to the State Attorney General for possible prosecution. 15 By March and April 1975, the Jackson Permanent Subcommittee on Investigations was holding hearings on the Medi-Cal prepaid plans and had charged a cover-up of fraud and other crimes under the California Department of Health during Ronald Reagan's administration." No doubt serious operational differences exist between local prepaid group operations and state and federal management structures. The California experience is a prime example of an alternative health system that purported to control cost but, despite a state monitoring and evaluation Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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process, was abused by manipulative and unethical administrators. SOCIAL WORK'S ROLE
In light of the preceding assessment, several realistic projections can be made for the professional role of a social worker in an HMO. nPrepaid group practices in operation before the 1973 HMO Act may not be able to support full-time social worker positions. This was indicated in the national study conducted by this author. nThere may be extensive lag between feasibility planning and full-kale operations among federally funded HMOs that are required to provide medical social services under the 1973 act. nAs a result, there may be an incremental development of health services, and social services may be offered on a contractual basis at a later stage of development when a particular HMO could afford expanded staff. nThe abuse of prepaid health plans in California may have negative impact on further HMO federal funding and programming and may affect the vocational opportunities for social workers. nBecause only twenty-nine (24 percent) out of seventynine HMO grant projects initiated in 1971 and 1972 were operating by October 1974, the mortality rate for current projects may be high.''r The social work profession must consider carefully these predictions for social services in HMOs. Moreover, a broad vocational strategy for a social service health specialist must be devised that will have a wide appeal to HMO administrators who are in the process of recruiting staff for planning and implementation. Such a model may include distinct areas of responsibilities for HMO feasibility planning and initial operations. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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Social planner and community organizer The social worker is uniquely qualified to handle various responsibilities in social planning and community organization. Such areas as identification of health and welfare needs of target populations; analysis of interorganizational arrangements for basic health services; appraisal of the current operations of delivering health care; procedures for instructing members in certain medical and emergency services; policy and procedures for the composition, selection, and operation of a governing board with consumer representation; and investigation of the accessibility of travel and transportation are all in the realm of the social worker who has expertise in the social and health aspects of planning. Furthermore, skills in community organization can be applied to determine the needs of elderly and high-risk populations. Not only must an HMO view these target populations as potential clients, but it must be responsive to local issues. In this sense, community organization is not a mechanism for recruitment but a means of feedback to design and shape services for the needs of a particular community. Social service and mental health practitioner Because there is a lack of initial capital and a lag before breaking even, the social worker may at first be required to perform a broad range of direct services. Medical social services such as case intake, presentations for staffing, brief casework, and aftercare arrangements have long been associated with social workers in health institutions. Along with a mental health team, social workers can participate in short-term outpatient care and crisis intervention as well as in treatment and referral for alcohol and drug abuseall of which are mandated as basic health services for an HMO. However, there are new horizons available to social workers who have the background and who are able to Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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function with patients and families in emergency health, home health, and family planning services. With therapeutic and information skills in these areas, a social worker can work with the medical staff in making a major contribution. Consumer resource and health educator
With the rise of consumerism in health care, the HMO Act of 1973 has sought to become responsive to consumer needs. One-third of the membership of each HMO policymaking board is to be composed of consumers of the health plan. Moreover, health education concerning the appropriate use of health maintenance and treatment services is required under federal legislation. To meet these provisions, an HMO staff member should be deployed to serve as a consumer resource and health educator. The social worker is a potential generator for health education in the form of printed material, visual presentations, and other forms of specific information. Health prevention screening programs can also be coordinated by a staff social worker. Furthermore, to develop consumer expertise in the field of health care, the social work—health specialist could be assigned to provide necessary technical background to consumer board members. An intensive course in the delivery of HMO services could be developed and required of the policy-making board. After the initial orientation, follow-up consultation could be arranged between the administrator and board members, using the social worker as a liaison. In addition to these roles, the social worker could serve as a consumer advocate and ombudsman. For example, the HMO Act of 1973 calls for meaningful procedures for hearing and resolving grievances between the HMO (including the medical group or groups and other health delivery entities providing health services for the organization) and its members. It also prohibits the expulsion of Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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any member because of his health status or his requirements for health services. Moreover, the social worker could organize an independent community-represented board of grievances to hear complaints from members of the health plan without fear of reprisal. In addition, the social worker could negotiate the board's decisions and recommendations with the HMO administration and medical staff. Needless to say, no one social worker could perform all these tasks. However, at an initial stage of HMO development, the professional social worker with health planning, treatment, and advocacy skills can be a core member of an HMO staff. Later, in full-scale operations, a social service department could effectively handle these distinctive areas. CONCLUSION
Health Maintenance Organizations offer a unique and broad professional role for social workers in the health care field. Given the fact that HMOs are in the experimental stage of development, there is ample opportunity for schools of social welfare to develop curricula. National Association of Social Workers chapters should lobby on state and local levels with emerging HMOs to design the role of the social service health specialist, and professional social workers should obtain necessary skills and credentials to meet the model proposed in this article. The social work profession needs a health specialist who possesses theoretical knowledge and practical skills in social planning and community organization, medical and mental health social services, consumer advocacy, and health education. Whether academicians and professional leaders recognize the opportunities inherent in an HMO will be indicated by the quality and content of social work education offered to the graduate student and the professional practitioner in the immediate future. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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About the Author Doman Lum, Ph.D., is Associate Professor of Social Work, California State University, Sacramento. A version of this article was presented at the National Conference on Social Welfare, San Francisco, California, May 14, 1975. The author acknowledges the assistance of Alfred H. Katz, Professor of Public Health and Social Welfare, University of California, Los Angeles, and Gregory M. St. L. O'Brien, Dean, School of Social Welfare, University of Wisconsin, Milwaukee.
Notes and Re ferences .
1. David Mechanic, "Human Problems and the Organization of Health Care," Annals of the American Academy of Political and Social Science, 399 (January 1972), pp. 5 -6. 2. Vernon E. Wilson, "HMOs: Hopes and Aspirations," Journal of Medical Education, 48 (April 1973), P. 8 . 3. Message from the President of the United States, on Building a National Health Strategy, 92nd Cong., 1 st sess., February 19, 1971, pp. 2- 10. 4. See Paul M. Densen, Eva Balamuth, and Sam Shapiro, Prepaid Medical Care and Hospital Utilization (Chicago: American Hospital Association, 1958); Densen, Balamuth, and Shapiro, "Prepaid Medical Care and Hospital Utilization in a Dual Choice Situation," American Journal of Public Health, 50 (November 1960), pp. 17101726; Paul M. Densen, Sam Shapiro, Ellen W. Jones, and Irving Baldinger, "Prepaid Medical Care and Hospital Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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Utilization," Hospitals, 36 (November 16, 1962), pp. 6368; Sam Shapiro, "Role of Hospitals in the Changing Health Insurance Plan of Greater New York," Bulletin of the New York Academy of Medicine, 74 (April 1971), pp. 374-381; National Advisory Commission on Health Manpower, "The Kaiser Foundation Medical Care Program," Report, Vol. 2 (Washington, D.C.: U.S. Government Printing Office), pp. 177-228; and Herbert E. Klarman, "Analysis of the HMO Proposal—Its Assumptions, Implications and Prospects," Health Maintenance Organi-
zation: A Reconfiguration of the Health Services Systems, Proceedings of the Thirteenth Annual Symposium on Hospita! Affairs, 1971 (University of Chicago, May 1971), pp. 28-29. 5. See Margaret C. Klein and Helen Hollingsworth, "Medical Care," in J. Frederic Dewhurst, ed., Americans' Needs and Resources (New York: Twentieth Century Fund, 1947), pp. 236-272; Herman M. Somers and Anne R. Somers, Doctors, Patients and Health Insurance (Washington, D.C.: Brookings Institution, 1967); Richard M. Bailey, "A Comparison of Internists in Solo and Fee-forService Group Practice in the San Francisco Bay Area," Bulletin of the New York Academy of Medicine, 44 (November 1968), pp. 1293-1303; Herbert E. Klarman, "Economie Research in Group Medicine," in R. E. Beanish, ed., New Horizons in Health Care (Winnipeg, Manitoba, Canada. First International Congress on Group Medicine, 1970), pp. 178-193; and Alfred Yankauer, John P. Connally, and Jacob J. Feldman, "Physician Productivity in the Delivery of Ambulatory Care: Some Findings from a Survey of Pediatricians," Medical Care, 8 (JanuaryFebruary 1970), pp. 35-46. 6. See Merwyn R. Greenlick, et al., "Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership Population in a Comprehensive Prepaid Group Practice Program," Medical Care, 10 (May–June 1972), pp. 187-200; Greenlick, "The Impact of Prepaid Group Practice on American Medical Care. A Critical Evaluation," Annals of the American Academy of Political and Social Science, 399 (January 1972), pp. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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100-113; Ernest W. Saward and Merwyn R. Greenlick, "Health Policy and the HMO," The Millbank Memorial Fund Quarterly, 5 (April 1972), pp. 147-176; and James A. Vohs, Richard V. Anderson, and Ruth Straus, "Critical Issues in HMO Strategy," New England Journal of Medicine, 286 (May 18, 1972), pp. 1082-1086. 7. See Accounting Manual, Financial Planning Manual, Marketing of Health Maintenance Organization Services, and Robert L. Biblo, Marketing Pre-paid Health Care Plans (Rockville, Md.: Health Maintenance Organization Service, all published in 1972). See also Roger W. Birnbaum, Prepayment and Neighborhood Health Centers: Guidelines for the Planning of our Conversion to a Health Maintenance Organization (Washington, D.C.: Office of
Health Affairs, Office of Economie Opportunity, 1972); Joseph L. Dorsey, "The Prepaid Physicians: Initial Efforts at the Harvard Community Health Plan," Medical Care, 11 (February 1973), pp. 12-20; Robert H. Kalinowski and Stephen J. Ackerman, eds., "HMO Program Development in the Academie Medical Center," Journal of Medical Education, 48 (April 1973); May Hornback, ed., Conference Proceedings, Health Maintenance Organization Concept and Functions (Madison: Department of Nursing, Health
Sciences Unit, University of Wisconsin, 1972), and Texas Instruments, Development of an Implementation Plan for the Establishment of a Health Maintenance Organization
(Dallas: Health Services and Mental Health Administration, U.S. Department of Health, Education, and Welfare, 1971). 8. Ira G. Greenberg and Michael L. Rodburg, "The Role of Prepaid Group Practice in Relieving the Medical Care Crisis," Harvard Law Review, 84 (February 1971), pp. 910-921; and Leon Gintzig and Robert G. Shouldice, Prepaid Group Practice: An Analysis as a Delivery System
(Washington, D.C.: School of Government and Business Administration, George Washington University, 1971), pp. 27-30. 9. Thomas E. Piemme and Steven A. Schroeder, "Issues of Governance of University-Sponsored HMOs," Journal of Medical Education, 48 (April 1973), pp. 44-52. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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10. Jeffrey A. Prussin, "HMOs: Organizational and Financial Models," Hospital Progress, 55 (April 1974), pp. 33-35; 55 (May 1974), pp. 56-59, 84; 55 (June 1974), pp. 60-63. 11. See Doman Lum, Comparison of Organizational Sponsorship and Service Arrangement Variables among Prepaid Medical Group Practices in the United States." Unpublished Ph.D. dissertation, Cleveland, Ohio, Case Western Reserve University, 1974. 12. Office of the Associate Bureau Director (HMO), Health Maintenance Organization Program Status Report, October 1974 (Rockville, Md.: Health Services Adminis-
tration, Bureau of Community Health Services, U.S. Department of Health, Education, and Welfare, 1974), pp. 2-4. 13. For more information, see A Review of the Regulation of Prepaid Health Plans by the State Department of Health (Sacramento: State of California, State Capitol,
November 15, 1973), pp. 1-50. 14. Joint Legislative Audit Committee, "Department of Health Prepaid Health Plans," (Sacramento: California Legislature, April 1974), pp. 1-52. 15. See such articles as "State Health Files Are Sealed," "State Moves in Health Plan Case," and "Attorney General Gets Data on Health Plan Scandals; " Sacramento Bee, January 14, 1975; February 6, 1975; February 12, 1975. 16. See "Fraud Under Reagan," "Probers Charge Health Department Under Reagan Covered Fraud," and "Jackson Says HEW Ignored Warnings of Medi-Cal Abuse," Sacramento Bee, March 13, 1975; March 14, 1975; April 3, 1975. 17. Health Maintenance Organization Program Status Report, p. 4.
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Health Maintenance Organizations—in which the subscriber is assured of a physician's care and access to specialized services for a fixed, prepaiet fee—are gaining national attention. On the basis of a study that examined the variations in services and structure, the author discusses the role changes that the HMO is forcing on the health professional.
of the Health Maintenance OrganiW zation Act of 1973 (P.L. 93-222), which President Nixon ITH THE PASSAGE
signed into law on December 30, 1973, the concept of prepaid group practice as an alternative to fee-for-service health care became a viable system for the delivery of health care. The language of the Health Maintenance Organization (HMO) legislation addressed the need to control costs through reorganizing the medical care system, to provide health maintenance and preventive health services, and to redistribute medical resources to insure their accessibility to residents of inner-city and rural areas. What serious impact will be made on these problems remains to be seen, but the HMOs do represent a potential change in the delivery of health care. HEALTH AND SOCIAL WORK, Vol. 1, No. 2, May 1976
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The HMO concept of health care is not a panacea for all ills inherent in health care delivery—restrained expectations are necessary as well. Mechanic cautioned that HMOs should not be oversold. The improvements for which the HMO system has a strong potential are limited to eliminating abuses and inefflciencies in the current organization, to providing greater continuity between preventive and other aspects of care, to moderating patterns of excessive hospital use, and to facilitating a high level of treatment through the use of ancillary assistance and good technical facilities. 1 Wilson stated: Perhaps the HMO's greatest influence will be the comparison of what happens to people who receive care under the HMO system versus those who get it under the fee-for-service system. If that comparison favors the HMO—as we believe it will—the HMO will have sold itself. If it does not, then the HMO idea is bad and should be abandoned. 2 Among the innovative aspects of HMOs are the new vorational opportunities for paraprofessionals in medicine, nursing, dentistry, health care administration, social welfare, and other allied health professions. Certainly, with the emergence of a national health insurance system for the United States, the entire health field will have to address itself to the reorganization of health and social services, te the development of roles for health-related personnel, and to the revision of health care education and curricula. As a forerunner to such a large-scale undertaking, HMOs pose a unique opportunity for new vocations for health and social welfare administrators and educators. The purpose of this article is to review the developmental history of the prepaid group movement, assess current growth trends of the HMO structure, and project emerging professional roles for HMO manpower, particularly for the social service health specialist. It is hoped that the social work profession will prepare for the inception of HMOs by revising health curricula in schools of Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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social welfare, by developing unique HMO role models for social workers on the local level, and by devising a political strategy to insure that social services are adequately represented. DEVELOPMENT OF THE CONCEPT
To understand the present status of HMOs, a brief history of the prepaid group practice movement is in order. Prepaid group health care has moved through several phases. Theoretical components
In 1929 the Farmers' Union Cooperative Health Association of Elk City, Oklahoma, was the first prepaid group practice in the United States. By 1932 the committee on the cost of medical care of the American Medical Association endorsed voluntary enrollment in hospital-based, prepaid group-practice plans. During the next two decades, a number of large-scale operations were started in metropolitan areas: Ross-Loos Medical Clinic in Los Angeles, California (1929); Group Health Association in Washington, D.C. (1937); Kaiser-Permanente Medical Care Program on the west coast (1942), now operating in six regions; Group Health Cooperative of Puget Sound in Seattle, Washington (1947); Health Insurance Plan of Greater New York (1947); and Group Health Plan of Minneapolis, Minnesota (1957). On the whole, prepaid group practice demonstrated a viable type of organizational arrangement and medical cost control for consumer and provider. In the last three years, prepaid group health care has received national prominence. In his health message to the Ninety-second Congress in 1971, President Richard M. Nixon made the reorganization of health delivery services a focal point of his health program. 3 He proposed an HMO system that would offer comprehensive services to be purchased annually from a medical group at a prepayDownloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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"The language of the HMO legislation addressed the need to control costs through reorganizing the medical care system, to provide health maintenance and preventive health services, and to redistribute medical resources to insure their accessibility to residents of inner-city and rural areas."
ment rate through capitation contracts. Rather than relying on federal regulations, investment, and planning, Nixon envisioned economic and professional incentives based on the preventive maintenance of health. Consumers would be able to choose conventional health insurance or health maintenance contracts offered by a variety of competing organizations. The HMO program would theoretically generate a variety of organizational arrangements with physicians and would involve private corporations for capital resources in addition to government grants and loans for planning, construction, and initial operations. It would rely on a competitive market to control costs and improve distribution and would assume minimal government interference in internal organization. An HMO would contract with independent providers, employ its own medical staff, and own a hospital and dispersed clinics or arrange for accommodations in existing local hospitals. It would maintain a unified set of medical records, quality-control procedures, and administrative functions. The subscriber would be assured of a primary physician and access to specialized services for a fixed, prepaid fee. The administration's bill, however, failed to include a detailed list of basic and supplemental health services. This addition characterized the HMO counter-legislation introduced by Congressman William R. Roy and Senator Edward Kennedy. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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Data assessment and delivery debate National HMO legislation having been launched, a number of major issues related to prepaid group practice emerged for study and debate. These included the following: 1. Initial studies that either justified or questioned the extent to which prepaid group practice controlled costs, particularly differences in hospital use between members of prepaid group practices and persons with other forms of health insurance or the general population. 4 2. Cost control due to the lower ratio of prepaid group practice physicians to the patient population and other economies of scale such as division of labor, centralization, and specialization. 5 3. Organizational problems including the quality of care that can be maintained among various socioeconomic classes, socioeconomic population distributions served by prepaid group practice and those not included, efficiency of organization, and financing and provision of health services to a defined population, particularly pertaining to technical and psychosocial effectiveness. 6 These issues tended to question the extent to which the HMO concept could be adopted on a full-scale basis from a legislative program. In the meantime, health-related investigation into the HMO delivery system was heightened. Initial implementation Some HMO prototypes have existed in the form of prepaid group practice that has been in operation during the past four decades. However, during 1971 and 1972 the Nixon Administration began to fund feasibility studies in anticipation of the HMO system of delivery. The U.S. Department of Health, Education, and Welfare (HEW) established the Health Maintenance Organization Services within the Health Services and Mental Health Administration. Through general legislation to stimulate experimental means of health care delivery, approximately $10 million was Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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distributed for 86 HMO planning and development grants and 24 technical support activity grants and contracts. Funds were obtained from allocations for research and experimentation from comprehensive health services, regional medical programs, and health services research and development. At the same time, technical material on HMO organizational implementation appeared in numerous HEW publications. The subjects included establishing an HMO financial plan and accounting system, suggesting marketing techniques for a prepaid group practice, converting neighborhood health centers to health maintenance organizations, applying HMOs to medical and nursing education, and implementing a comprehensive HMO plan for a metropolitan area.? Various types of HMOs have been analyzed from the perspective of organizational planning. Greenberg and Rodburg, as well as Gintzig and Shouldice, have described various prepaid models of group practice organization in terms of sponsorship, facilities, funding, and management linkages. 8 Piemme and Schroeder have concentrated on a detailed analysis of university HMO structuren at Harvard, Yale, and Johns Hopkins. 9 Finally, Prussin has compared major prepaid group practices in terms of organization and management and has diagramed their service delivery system. 1 ° Legislative outcome The Health Maintenance Organization Act of 1973 was funded as an experimental program. It provided prepaid group practices (PGPs) with $25 million for a feasibility survey, planning, and initial development grants and contracts,. and $75 million for initial operating loans. Basic health services included (1) physician services, (2) inpatient and outpatient hospital services, (3) medically necessary emergency health services, (4) short-term outpatient evaluation services and crisis intervention mental health Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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services, (5) medical treatment and referral services for alcohol and drug abuse, (6) diagnostic laboratory and radiological services, (7) home health services, and (8) preventive health services. An HMO may also offer such optional supplementary health services as intermediate and long-term care, eye examinations, dental care, mental health services, long-term physical medicine and rehabilitative services, and provision for patients to obtain prescription drugs. The targets of the HMO program were inner-city and rural populations, which chronically lack many medical services. Provisions were made for regular employees as well as for migratory and seasonal workers who represent a broad spectrum in terms of age, social group, and income. Various arrangements among physicians and allied health personnel were established to attract a variety of medical manpower. Federal regulations were also set forth to insure quality and program evaluation, and an annual report to the secretary of the Department of Health, Education, and Welfare was authorized. Moreover, this legislation overrode restrictive state laws and practices regarding prepaid groups. In brief, the HMO legislation sought to demonstrate the viability of an alternative health care system over a four-year period. HMO GROWTH TRENDS
Between the enactment of the HMO Act of 1973 and the formulation of final federal regulations on October 18, 1974, the author conducted a national study of PGPs and HMOs to investigate various structural characteristics. Under the auspices of the Human Services Design Laboratory of Case Western Reserve University, School of Applied Social Sciences, a questionnaire on various operational aspects was developed and sent to health administrators of 173 prepaid group practice facilities. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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"Along with a mental health team, social workers can participate in short-term outpatient care and crisis intervention as well as in treatment and referral for alcohol and drug abuse—all of which are mandated as basic health services for an HMO."
Out of the potential group, 116 (67 percent) responded. However, 50 of the questionnaires (29 percent) were not used, leaving a 38 percent client sample (n = 66). Of the nonusable responses, 5 were unwilling to fill out the questionnaire, 24 considered themselves neither an HMO nor a PGP, 13 questionnaires were returned undelivered as having no forwarding or insufficient address, indicating that they were probably not operating, 5 were in the feasibility study phase, and 3 indicated tffat they were out of business. The survey attempted to ascertain the services provided by the four kinds of health groups—providers, insurers, consumers, and independents. Providers were defined as public and private hospitals, physician groups, private corporations, medical schools, and medical care foundations. Insurers were insurance companies and Blue Cross–Blue Shield that represented the recent emergence of business and health insurance elements into the prepaid group field. Consumers covered various consumer-oriented and labor unions. Independents were composed of a variety of organizations that could be described as self-sponsored and selfsupporting institutions as well as community nonprofit corporations. Some important aspects of the profile that emerged were the following: n Multiple sponsorships and insurers and independents appeared to be recent operations, whereas single sponsorships and providers and consumers existed among both new and old prepaid practices. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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nPrepaid group facilities were limited to clinics. Insurers and independents tended to have one clinic, while providers and consumers had a range of clinics. Providers tended to own their hospitals, but in many cases insurers, consumers, and independents made arrangements with existing health institutions for hospitalizations. nNew prepaid group practices seemed to have marginal levels of membership (e.g., 5,000 individual members). Single sponsorships were generally slightly larger than multiple-sponsored groups. Older established provider and consumer groups tended to have over 25,000 members. nPrivate nonprofit corporations characterized the structure of the majority of prepaid group practices. However, more research is required to determine to what extent private, profit-making elements are a part of a private nonprofit structure. nProvider, consumer, and independent governing boards appeared to have policy-making power, but insurers were divided on this matter. Consumer boards evidently exercised authority over control of the budget and approval of contracts and expenditures. On the other hand, insurersponsored boards seemed to be powerless over these matters. Providers and independents were between these two poles. Board representation findings were inconclusive except for those concerning consumer representatives. Independent and consumer sponsors were related to more consumer-oriented representatives than the rest. nClient composition (e.g., income, ethnic, and affiliated groups) was difficult to interpret because of the lack of adequate data. However, providers generally had employed and unemployed groups for members; insurers and consumers tended toward employed and a group of employed and unemployed; and independents appeared to serve the unemployed and a mixed group. nConcerning administrative management, insurersponsored management was decentralized, whereas consumers and independents were strongly centralized. ProDownloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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viders appeared to have both centralized and decentralized administrative management structures. n With respect to medical services, all sponsor types generally offered private physician services and diagnostic laboratory and radiological services. However, the remainder of the services varied. By and large, consumers tended to have their own staff and facilities for inpatient/ outpatient preventive health and medical health services, as well as facilities for treating alcohol and drug abuse. Insurers tended to make other arrangements for three of the services. Providers and independents used their own staff and facilities or made other arrangements. Independents occasionally provided dental care, providers used outside resources or offered no dental coverage, and insurers and consumers had none. On the whole, with the exception of insurers, a comprehensive range of services characterized providers, consumers, and independents either through their own staff and facilities or arrangements with existing health institutions. n With regard to patterns of staffing, physicians were both full- and part-time employees. General practitioners and internists were strictly full time, while obstetriciangynecologists, pediatricians, surgeons, optometrists, and urologists worked both full and part time. The rest of the medical subspecialties were part time. Full-time supportive staff members included nurses, X-ray technologists, laboratory technologists, and health administrators. Other personnel, such as dentists, nursing practitioners, physical therapists, physician assistante, health researchera, health educators, health planners, social workers, psychologists, nutritionists, and allied health professionals were listed as both full time and part time, if the responses identified them at all. Based on these findings, it appeared that the majority of prepaid group practices in the study sample were composed of relatively young organizations. Because of limited membership and capital resources and revenues, there was Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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"Whether academicians and professional leaders recognize the opportunities inherent in an HMO will be indicated by the quality and content of social work education offered to the graduate student and the practitioner in the immediate future."
a tendency to rely on interorganizational arrangements with existing health facilities, particularly for inpatient hospitalization and for medical services and specialists. Providers and insurers tended to represent traditional medical services that entered the field of prepaid group practice with minor alterations. In contrast, consumers and independents conformed more to federal standards in terms of comprehensive services and consumer participation and had greater decision-making power on the governing board. 11 By October 1974 there were 142 HMO-type plans in operation across the United States serving an estimated 5,300,000 enrollees. Most of these organizations were created since 1970 but none of them feil under the requirements of the 1973 HMO Act because they were not dependent on planning and implementation moneys. One wonders how many of these plans conform to the concept of an HMO set forth in P.L. 93-222. Four 13-week grant-funding cycles for the fiscal year 1975 were established with application deadlines due on June 30, 1974, September 2, 1974, November 4, 1974, and February 3, 1975. During the first cycle, which ended June 30, 125 applications for funding were received for a total request of $16,952,165. Grants were given to fifty projects for a total of $5,510,129. An analysis of these projects revealed that one-half were consumer or public sponsored and were either in the feasibility, planning, or initial stage of development. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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For the second cycle, fifty-one applications were filed for a total request of $5,572,477. Again, the consumer sponsor type was predominant. Thus, in light of the consumer and independent organizational profile researched by this author and the increase of consumer applicants for funding, HMOs have the potential of offering an alternative health system if these trends continue. 12 THE CALIFORNIA EXPERIENCE
However, there has been widespread financial abuse by several prepaid health plans that were recipients of MediCal contracts with the California State Department of Health. In the November 1973 Legislative Analysis Report, "A Review of the Regulation of Prepaid Health Plans by the State Department of Health," a number of problem areas were cited among forty-eight participating prepaid health plans: 1. Inadequate records and information on mandatory background checks of prospective health contractors. 2. Lack of high-quality criteria and procedures for evaluating care. 3. Excessive capitation rates in several cases, exceeding the 90 percent•of the cost policy that the Department of Health would experience under the fee-for-service MediCal system. 4. A saturation problem among Los Angeles and San Diego prepaid health plans in marketing and enrollment procedures resulting in increased competition for enrollees. 5. The need to slow down rotation of contract managers who were frequently transferred to other departments just when they began to acquire in-depth knowledge of the responsibilities of prepaid health plan contracts. 6. Misrepresentation of information by door-to-door solicitors of various health plans to prospective Medi-Cal clients, particularly in Los Angeles and San Diego. 7. Failure of many prepaid health plans to submit Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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quarterly financial service reports to the Department of Health. 8. The Jack of thorough medical audits that cover the structural arrangements, quantity, and quality of health care services being provided by each of the prepaid health plans. 9. The need for more detailed on-site study of individual operations by state contract managers. 10. Requirement for organizational and financial interrelationships between the prepaid health plan and closely related organizations to be delineated in order to determine discrepancies between nonprofit and profit-making operations." In April 1974 the Joint Legislative Audit Committee of the California Senate and Assembly stated that out of $56 5 million paid to 15 Prepaid Health Plan (PHP) contractors, only $27.1 million (48 percent) was expended for health care services whereas $29.4 million (52 percent) was for administrative costs or net profit. It was further concluded that the Department of Health had mismanaged the PHP program and the committee recommended its transfer to the Department of Finance. 14 During January and February 1975, Governor Edmund Brown, Jr.'s, administration began an intensive probe of the files of the California State Department of Health and submitted data to the State Attorney General for possible prosecution. 15 By March and April 1975, the Jackson Permanent Subcommittee on Investigations was holding hearings on the Medi-Cal prepaid plans and had charged a cover-up of fraud and other crimes under the California Department of Health during Ronald Reagan's administration." No doubt serious operational differences exist between local prepaid group operations and state and federal management structures. The California experience is a prime example of an alternative health system that purported to control cost but, despite a state monitoring and evaluation Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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process, was abused by manipulative and unethical administrators. SOCIAL WORK'S ROLE
In light of the preceding assessment, several realistic projections can be made for the professional role of a social worker in an HMO. nPrepaid group practices in operation before the 1973 HMO Act may not be able to support full-time social worker positions. This was indicated in the national study conducted by this author. nThere may be extensive lag between feasibility planning and full-kale operations among federally funded HMOs that are required to provide medical social services under the 1973 act. nAs a result, there may be an incremental development of health services, and social services may be offered on a contractual basis at a later stage of development when a particular HMO could afford expanded staff. nThe abuse of prepaid health plans in California may have negative impact on further HMO federal funding and programming and may affect the vocational opportunities for social workers. nBecause only twenty-nine (24 percent) out of seventynine HMO grant projects initiated in 1971 and 1972 were operating by October 1974, the mortality rate for current projects may be high.''r The social work profession must consider carefully these predictions for social services in HMOs. Moreover, a broad vocational strategy for a social service health specialist must be devised that will have a wide appeal to HMO administrators who are in the process of recruiting staff for planning and implementation. Such a model may include distinct areas of responsibilities for HMO feasibility planning and initial operations. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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Social planner and community organizer The social worker is uniquely qualified to handle various responsibilities in social planning and community organization. Such areas as identification of health and welfare needs of target populations; analysis of interorganizational arrangements for basic health services; appraisal of the current operations of delivering health care; procedures for instructing members in certain medical and emergency services; policy and procedures for the composition, selection, and operation of a governing board with consumer representation; and investigation of the accessibility of travel and transportation are all in the realm of the social worker who has expertise in the social and health aspects of planning. Furthermore, skills in community organization can be applied to determine the needs of elderly and high-risk populations. Not only must an HMO view these target populations as potential clients, but it must be responsive to local issues. In this sense, community organization is not a mechanism for recruitment but a means of feedback to design and shape services for the needs of a particular community. Social service and mental health practitioner Because there is a lack of initial capital and a lag before breaking even, the social worker may at first be required to perform a broad range of direct services. Medical social services such as case intake, presentations for staffing, brief casework, and aftercare arrangements have long been associated with social workers in health institutions. Along with a mental health team, social workers can participate in short-term outpatient care and crisis intervention as well as in treatment and referral for alcohol and drug abuseall of which are mandated as basic health services for an HMO. However, there are new horizons available to social workers who have the background and who are able to Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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function with patients and families in emergency health, home health, and family planning services. With therapeutic and information skills in these areas, a social worker can work with the medical staff in making a major contribution. Consumer resource and health educator
With the rise of consumerism in health care, the HMO Act of 1973 has sought to become responsive to consumer needs. One-third of the membership of each HMO policymaking board is to be composed of consumers of the health plan. Moreover, health education concerning the appropriate use of health maintenance and treatment services is required under federal legislation. To meet these provisions, an HMO staff member should be deployed to serve as a consumer resource and health educator. The social worker is a potential generator for health education in the form of printed material, visual presentations, and other forms of specific information. Health prevention screening programs can also be coordinated by a staff social worker. Furthermore, to develop consumer expertise in the field of health care, the social work—health specialist could be assigned to provide necessary technical background to consumer board members. An intensive course in the delivery of HMO services could be developed and required of the policy-making board. After the initial orientation, follow-up consultation could be arranged between the administrator and board members, using the social worker as a liaison. In addition to these roles, the social worker could serve as a consumer advocate and ombudsman. For example, the HMO Act of 1973 calls for meaningful procedures for hearing and resolving grievances between the HMO (including the medical group or groups and other health delivery entities providing health services for the organization) and its members. It also prohibits the expulsion of Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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any member because of his health status or his requirements for health services. Moreover, the social worker could organize an independent community-represented board of grievances to hear complaints from members of the health plan without fear of reprisal. In addition, the social worker could negotiate the board's decisions and recommendations with the HMO administration and medical staff. Needless to say, no one social worker could perform all these tasks. However, at an initial stage of HMO development, the professional social worker with health planning, treatment, and advocacy skills can be a core member of an HMO staff. Later, in full-scale operations, a social service department could effectively handle these distinctive areas. CONCLUSION
Health Maintenance Organizations offer a unique and broad professional role for social workers in the health care field. Given the fact that HMOs are in the experimental stage of development, there is ample opportunity for schools of social welfare to develop curricula. National Association of Social Workers chapters should lobby on state and local levels with emerging HMOs to design the role of the social service health specialist, and professional social workers should obtain necessary skills and credentials to meet the model proposed in this article. The social work profession needs a health specialist who possesses theoretical knowledge and practical skills in social planning and community organization, medical and mental health social services, consumer advocacy, and health education. Whether academicians and professional leaders recognize the opportunities inherent in an HMO will be indicated by the quality and content of social work education offered to the graduate student and the professional practitioner in the immediate future. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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About the Author Doman Lum, Ph.D., is Associate Professor of Social Work, California State University, Sacramento. A version of this article was presented at the National Conference on Social Welfare, San Francisco, California, May 14, 1975. The author acknowledges the assistance of Alfred H. Katz, Professor of Public Health and Social Welfare, University of California, Los Angeles, and Gregory M. St. L. O'Brien, Dean, School of Social Welfare, University of Wisconsin, Milwaukee.
Notes and Re ferences .
1. David Mechanic, "Human Problems and the Organization of Health Care," Annals of the American Academy of Political and Social Science, 399 (January 1972), pp. 5 -6. 2. Vernon E. Wilson, "HMOs: Hopes and Aspirations," Journal of Medical Education, 48 (April 1973), P. 8 . 3. Message from the President of the United States, on Building a National Health Strategy, 92nd Cong., 1 st sess., February 19, 1971, pp. 2- 10. 4. See Paul M. Densen, Eva Balamuth, and Sam Shapiro, Prepaid Medical Care and Hospital Utilization (Chicago: American Hospital Association, 1958); Densen, Balamuth, and Shapiro, "Prepaid Medical Care and Hospital Utilization in a Dual Choice Situation," American Journal of Public Health, 50 (November 1960), pp. 17101726; Paul M. Densen, Sam Shapiro, Ellen W. Jones, and Irving Baldinger, "Prepaid Medical Care and Hospital Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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Utilization," Hospitals, 36 (November 16, 1962), pp. 6368; Sam Shapiro, "Role of Hospitals in the Changing Health Insurance Plan of Greater New York," Bulletin of the New York Academy of Medicine, 74 (April 1971), pp. 374-381; National Advisory Commission on Health Manpower, "The Kaiser Foundation Medical Care Program," Report, Vol. 2 (Washington, D.C.: U.S. Government Printing Office), pp. 177-228; and Herbert E. Klarman, "Analysis of the HMO Proposal—Its Assumptions, Implications and Prospects," Health Maintenance Organi-
zation: A Reconfiguration of the Health Services Systems, Proceedings of the Thirteenth Annual Symposium on Hospita! Affairs, 1971 (University of Chicago, May 1971), pp. 28-29. 5. See Margaret C. Klein and Helen Hollingsworth, "Medical Care," in J. Frederic Dewhurst, ed., Americans' Needs and Resources (New York: Twentieth Century Fund, 1947), pp. 236-272; Herman M. Somers and Anne R. Somers, Doctors, Patients and Health Insurance (Washington, D.C.: Brookings Institution, 1967); Richard M. Bailey, "A Comparison of Internists in Solo and Fee-forService Group Practice in the San Francisco Bay Area," Bulletin of the New York Academy of Medicine, 44 (November 1968), pp. 1293-1303; Herbert E. Klarman, "Economie Research in Group Medicine," in R. E. Beanish, ed., New Horizons in Health Care (Winnipeg, Manitoba, Canada. First International Congress on Group Medicine, 1970), pp. 178-193; and Alfred Yankauer, John P. Connally, and Jacob J. Feldman, "Physician Productivity in the Delivery of Ambulatory Care: Some Findings from a Survey of Pediatricians," Medical Care, 8 (JanuaryFebruary 1970), pp. 35-46. 6. See Merwyn R. Greenlick, et al., "Comparing the Use of Medical Care Services by a Medically Indigent and a General Membership Population in a Comprehensive Prepaid Group Practice Program," Medical Care, 10 (May–June 1972), pp. 187-200; Greenlick, "The Impact of Prepaid Group Practice on American Medical Care. A Critical Evaluation," Annals of the American Academy of Political and Social Science, 399 (January 1972), pp. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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100-113; Ernest W. Saward and Merwyn R. Greenlick, "Health Policy and the HMO," The Millbank Memorial Fund Quarterly, 5 (April 1972), pp. 147-176; and James A. Vohs, Richard V. Anderson, and Ruth Straus, "Critical Issues in HMO Strategy," New England Journal of Medicine, 286 (May 18, 1972), pp. 1082-1086. 7. See Accounting Manual, Financial Planning Manual, Marketing of Health Maintenance Organization Services, and Robert L. Biblo, Marketing Pre-paid Health Care Plans (Rockville, Md.: Health Maintenance Organization Service, all published in 1972). See also Roger W. Birnbaum, Prepayment and Neighborhood Health Centers: Guidelines for the Planning of our Conversion to a Health Maintenance Organization (Washington, D.C.: Office of
Health Affairs, Office of Economie Opportunity, 1972); Joseph L. Dorsey, "The Prepaid Physicians: Initial Efforts at the Harvard Community Health Plan," Medical Care, 11 (February 1973), pp. 12-20; Robert H. Kalinowski and Stephen J. Ackerman, eds., "HMO Program Development in the Academie Medical Center," Journal of Medical Education, 48 (April 1973); May Hornback, ed., Conference Proceedings, Health Maintenance Organization Concept and Functions (Madison: Department of Nursing, Health
Sciences Unit, University of Wisconsin, 1972), and Texas Instruments, Development of an Implementation Plan for the Establishment of a Health Maintenance Organization
(Dallas: Health Services and Mental Health Administration, U.S. Department of Health, Education, and Welfare, 1971). 8. Ira G. Greenberg and Michael L. Rodburg, "The Role of Prepaid Group Practice in Relieving the Medical Care Crisis," Harvard Law Review, 84 (February 1971), pp. 910-921; and Leon Gintzig and Robert G. Shouldice, Prepaid Group Practice: An Analysis as a Delivery System
(Washington, D.C.: School of Government and Business Administration, George Washington University, 1971), pp. 27-30. 9. Thomas E. Piemme and Steven A. Schroeder, "Issues of Governance of University-Sponsored HMOs," Journal of Medical Education, 48 (April 1973), pp. 44-52. Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
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10. Jeffrey A. Prussin, "HMOs: Organizational and Financial Models," Hospital Progress, 55 (April 1974), pp. 33-35; 55 (May 1974), pp. 56-59, 84; 55 (June 1974), pp. 60-63. 11. See Doman Lum, Comparison of Organizational Sponsorship and Service Arrangement Variables among Prepaid Medical Group Practices in the United States." Unpublished Ph.D. dissertation, Cleveland, Ohio, Case Western Reserve University, 1974. 12. Office of the Associate Bureau Director (HMO), Health Maintenance Organization Program Status Report, October 1974 (Rockville, Md.: Health Services Adminis-
tration, Bureau of Community Health Services, U.S. Department of Health, Education, and Welfare, 1974), pp. 2-4. 13. For more information, see A Review of the Regulation of Prepaid Health Plans by the State Department of Health (Sacramento: State of California, State Capitol,
November 15, 1973), pp. 1-50. 14. Joint Legislative Audit Committee, "Department of Health Prepaid Health Plans," (Sacramento: California Legislature, April 1974), pp. 1-52. 15. See such articles as "State Health Files Are Sealed," "State Moves in Health Plan Case," and "Attorney General Gets Data on Health Plan Scandals; " Sacramento Bee, January 14, 1975; February 6, 1975; February 12, 1975. 16. See "Fraud Under Reagan," "Probers Charge Health Department Under Reagan Covered Fraud," and "Jackson Says HEW Ignored Warnings of Medi-Cal Abuse," Sacramento Bee, March 13, 1975; March 14, 1975; April 3, 1975. 17. Health Maintenance Organization Program Status Report, p. 4.
Downloaded from https://academic.oup.com/hsw/article-abstract/1/2/29/765789 by Rutgers University Libraries user on 12 January 2018
