ETHICAL
IMPLICATIONS

        Court cases over the past ten years, regarding managed care cost containment procedures and service provider liability, have resulted in several ethical concerns for social work professionals to be aware of.  A key consensus among court rulings in recent years places responsibility on both the service provider (social worker, psychologist, physician) and managed care companies.  What does this mean?  If a negative outcome results from the denial of reimbursement by a managed care reviewer the client has a right to take legal action.  However, the service provider shares some of the responsibility for the negative outcome.  Why?  Service providers are expected to actively object to a utilization review decision if it is at odds with the provider's clinical judgement of what is best for the client.  Managed care companies often argue that they cannot deny treatment, they can only deny reimbursement to the service provider.  Therefore, service providers are at risk of being held liable for ethical decision making on behalf of their clientele.  Social Workers must adhere to the National Association of Social Workers Code of Ethics and educate themselves about legal concerns regarding managed care procedures.
          
           A Few Legal Questions:
1.  Is a social worker's cooperation with a managed care company inherently in conflict with his/her fiduciary responsibilities, confidentiality, truth telling, and loyalty to their clients?
2.  Are social workers colluding with managed care personnel to violate client's civil rights?
3.  To what degree is the social worker liable should an unforeseen outcome occur about which the client was given no warning?
4.  Is it always in the client's best interests for social workers to attempt to explain the limits of confidentiality in a managed care environment?

The Managed Care Challenge: NASW Response

1.  Setting standards for how social worker's should work in a managed care enviroment.
2.  Develop clear protocols for communication between service providers and managed care personnel.
3.  Legislation: Lobbying for patient/client rights and confidentiality.
4.  Litigation
5.  Advocacy on behalf of clients and social work professionals.

Confidentiality and Technology:

Be aware of the following forms of technology that have the potential to violate a client's right to confidentiality.

1.  Telephone Reviews
2.  Voice Mail
3.  Fax Machines
4.  Cellular Phones
5.  Unregulated and unprotected databases

Recommendations for change in managed care confidentiality procedures:

1.  Service providers must recognize their obligation to refuse to comply with managed care objectives that violate a client's rights.
2.  Replace unregulated computer databases with a depersonalized coding system.
3.  Restrict access to client data to certain managed care personnnel and block sensitive information.
4.  Contracts with managed care should stipulate confidentiality regulations.
5.  Outpatient case notes should not be copied into databases of managed care companies.
6.  Client should have the opportunity to review records that have been given by a social worker to a 3rd party payor.
7.  Client records should be destroyed after service is concluded.
8.  Clients should be notified everytimes their records are provided to a managed care company and have the right to deny the dissemination of these records.
9.  Gatekeepers and case reviewers for managed care companies should be identifiable and held to the same standards of confidentiality as the professionals providing services.
10. Providers should refuse managed care contracts that include nondisclosure clauses.

To find further information about Managed Care and Social Work Ethics contact your local NASW chapter.

                             National Office:
                             NASW 
                             750 First Street
                             N.E.,Suite 700
                             Washington, D.C. 20002-4241
                          
                             www.socialworkers.org

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