This article was downloaded by: [University of Sydney] On: 04 January 2015, At: 14:32 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/ loi/wshc20
BOOK REVIEWS Toba Schwaber Kerson DSW, a
PhD , Marcia L Martin PhD b
c
, Leon S. Anisfeld DSW & Haworth Continuing Features Submission a
Graduate School of Social Work & Social Research, Bryn Mawr College , Bryn Mawr , PA, 19010 b
Graduate School of Social Work and Social Research, Bryn Mawr College, Bryn Mawr, PA c
Assistant Clinical Professor, Dept of Community MedicineSW, Dept of Psychiatry, Mt Sinai Medical School, New York, NY Published online: 26 Oct 2008.
To cite this article: Toba Schwaber Kerson DSW, PhD , Marcia L Martin PhD , Leon S. Anisfeld DSW & Haworth Continuing Features Submission (1992) BOOK REVIEWS, Social Work in Health Care, 17:2, 101-112, DOI: 10.1300/J010v17n02_08
Downloaded by [University of Sydney] at 14:32 04 January 2015
To link to this article: http://dx.doi.org/10.1300/ J010v17n02_08
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and
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BOOK REVIEWS'
MEDICARE AND MEDIGAPS: A GUIDE TO RETIREMENT HEALTH INSURANCE. Susan Hellman and Leonard H. Hellman. Newbury Park, California: Sage Publications Znc., 1991,80pages, $16.85, soficover. Medicare and Medigaps presents an overview of many of the major problem areas in retirement health insurance. Since 97% of Americans over age 65 are partially insured through Medicare, Medicare is the primary focus of the book which is a helpful handbook for the Medicare recipient and for health professionals who are new to the system. The book addresses the following subjects: (1) the history, financing and eligibility requirements for Medicare, (2) hospital insurance through Part A of Medicare, (3) outpatient services through Part B of Medicare, (4) ways to insure for services which are not or only partially covered through Medicare, (5) reasons and procedures for appealing Medicare decisions, (6) means for f i g claims, (7) benefit programs other than Medicare and (8) Medicaid. To structure the presentation of this crucial but dry information, Medicare and Medigaps uses the technique of asking and answering often posed questions regarding the program. All material is presented as specifically as possible using the least possible amount of jargon. In the chapter that addresses Medicare Part A, the authors outSocial Work in Healfh Care, Vol. 17(2) 1992 O 1992 by The Haworth Press, Inc. All rights reserved
I OI
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Line the eligibility requirements for hospital admission and the basic inpatient benefits. They are also careful to describe which services are not covered such as the first three pints of blood for transfusion and care in a hospital outside the United States. In this same chapter, the authors explain skilled nursing facility benefits and the differences between those services and the kinds of custodial services that are most usually associated with nursing homes in the minds of most people. In this regard in describing intermediate or custodial care the authors say, "Even though the patient's family thinks the patient may need "skilled care," Medicare has the final say. Of course, the patient may appeal" (p. 11). The discussion of Medicare Part A also includes a description of home care and hospice services. The chapter on Medicare Part B discusses in some detail the physician services covered. Although the authors list "clinical social workers employed by an outpatient mental health center that accepts assignment" (p. 17) as providers of mental health services, they do not include social workers in their primary reimbursable group that they erroneously refer to as physicians and which includes psychiatrists, psychologists, osteopaths, dental surgeons, chiropractors, optometrists and podiatrists. There is a reasonably elaborate description of the kinds of durable medical equipment for which Medicare will pay and the claim system for Part B of Medicare. Since the facts related to claims are equally tedious and important, the authors offer case examples which illustrate the facts of both assigned and unassigned claims. The chapter called "Filling Medicare Gaps" begins with the reminder that Medicare was designed to cover between 40% and 50% of a person's health care costs. Thus, it explains:
Part A of Medicare does a good job of covering an inpatient hospital stay, which would otherwise be very expensive, but does not do a good job covering long-term nursing home or home health care. Because Part B of Medicare only covers one third of the person health care costs for physician and outpatient services, most Americans choose to supplement Medicare with one or more of the following options: purchase a Medicare supplemental insurance policy, continue or con-
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vert employer group insurance, join a health maintenance organization, purchase long-term care insurance, purchase indemnity benefits insurance policies, apply for Medicaid, if eligible, use veterans or retired military benefits, if eligible, or pay out of their own pocket. (p. 23) The authors proceed to explain these options in what is the most useful part of the book. They describe an "ideal" Medicare supplemental insurance package, an "ideal" long-term care policy and the measures for locating a good Medicare supplement. Chapter 5 presents the reasons and procedures for appealing Medicare decisions such as denial of coverage or paying too little for a service. The authors even spell out scenarios for how to appeal when the patient disagrees with the hospital's decision that inpatient care is no longer necessary. For example,
If you are hospitalized, your liability for payment generally begins on the 3rd day after receiving the written notice if no review request is filed. However, if an "immediate review" is requested by telephone, by letter, or by filing Form SSA2649 by noon of the 1st workday after receiving the notice, you cannot be made to pay for the hospital care until after the PRO makes its decision . . . (p. 39) One section of the book that provides information on how to file claims and organize paperwork. It describes the use of Medicare codes, reasons why one medical visit sometimes incurs more than one bill and the document (EOMB)that Medicare mails every beneficiary that demonstrates what services have been covered, when they were rendered and by whom, the billed charge, the approved charge, the amount deducted and finally what Medicare paid. The inclusion and explanation of various Medicare forms is also very helpful. A short section of the book presents other benefit programs including those for federal, state and local employees, veterans and railroad retirees. Of course, these programs could and do have handbooks of their own, but their inclusion helps the authors present a richer picture of retirement health insurance. The final chapter is
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a four page description of the Medicaid program that is directed primarily at the processes through which a person who requires nursing home placement can become eligible for Medicaid. My primary suggestion for a second edition would be the addition of a section listing names, addresses and phone numbers of state and federal offices which the service recipients may need to contact. Obviously, I found this handbook to be extremely clear and useful. Medicare recipients and their families need all of the information in this volume. I suspect that experienced social workers in the many institutions and organizations that serve Medicare recipients are aware of much of this information, but social workers new to these areas would be well served by this book. Toba Schwaber Kerson, DSW, PhD Graduate School of Social Work and Social Research Bryn Mawr College
AIDS-RELATED PSYCHOTHERAPY. Mark G. Wiiarski. New York: Pergamon Press, 1991, 194 pages. Mark G. Wiiarski has written AIDS-Related Psychotherapy from his own experience, questions, and search for answers. He is a clinical psychologist and faculty member at Montefiore Medical Center, Bronx, New York, and he was a staff psychologist for the Spellman Center for HIV-Related Disease at St. Clair's Hospital and Health Center, New York. Winiarski calls it a book about competence and healing and indeed he examines that balance between skill and compassion, so delicate in AIDS-related psychotherapy. The book is brief (194 pages) but thorough, and represents a wondefil and impressively complete handbook for psychotherapists working with HIV-positive persons. The inclusion of case vignettes serves to enhance the discussion of skills and issues identified by the author.
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Wiiarski divides his book into five parts: "Introduction to AIDS-Related Issues," "The Work of Psychotherapy," "The Therapist's Feelings," "Other HIV-Related Issues," and "Resources." The Introduction provides the reader with a very usable outline of medical and sociopolitical issues. While the author recognizes the controversial and changing nature of these issues, he nonetheless provides comprehensive medical information and a concise identification and analysis of the sociopolitical and economic issues. In Part 2 on "The Work of Psychotherapy," Winiarski provides the reader with a somewhat prescriptive yet quite functional intake assessment outline. As he suggests, because of the constantly changing and volatile nature of HIV infection, a baseline assessment is crucial to the ongoing intervention. The author also identifies the critical psychotherapy themes that the clinician must be prepared to address with clients, including the issues of why me and the accompanying denial, the feelings of shame and guilt, the threat of abandonment and betrayal, the loss of control and resulting dependency, the uncertainty about the future, and the fear of dying. He introduces the clinician's monitoring function which demands an awareness and understanding of extremely complex medical, psychiatric, neuropsychological, and neurological symptoms and disorders and their implications. Winiarski correctly notes that service delivery in the area of AIDS is a process that merges technical knowledge, consultation services, and case management with the more traditional psychotherapy skills. Part 3 on The Therapist's Feelings is particularly valuable. Again Winiarski provides a compendium of the issues that arise and are exacerbated for the ciiician working with HIV-positive persons. He outlines a 12question exercise designed to help clinicians explore their own feelings around death, pain, abandonment, God, and family. One must confront such questions as, "Why me?", "Will I die in pain?", "Can you stand to look at me?", and "Is there a God?" The exercise serves to stress the parallel nature of the client and worker processes, and demands that clinicians begin to distinguish between responses they give directly to a client and those responses which reflect their own real feelings. The challenge to clinicians is, as Wiiarski suggests, to explore
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what they bring to psychotherapy sessions. There is a great deal for both the HIV-positive person and the therapist to bear and Winiarski's emphasis in this part of the book on the need for those engaged in HIV-related work to care for themselves is welcome. In Parts 4 and 5, Wiarski explores remaining issues such as HIV screening, prevention counseling, the intravenous drug user, concerns of the womed well, spirituality, and resource identification. The topics are again covered with clarity and precision. The book is an excellent guidebook for the clinician just beginning HIV-related work, and a supportive and affirming handbook for the experienced therapist. The material is presented in a quite didactic style but the infusion of Winiarski's own professional and personal experiences takes the edge off of the somewhat prescriptive tone. I read the book with enthusiasm and a sense of familiarity. For me, Winiarski captured something of the universal in AIDS-related work.
Marcia L. Martin, PhD Bryn Mawr College, Graduate School of Social Work and Social Research Bryn Mawr, PA
SERIOUSAND UNSTABLE CONDJTION:FINANCING AMERICA'S HEALTH CARE. Henry J. Aaron. Washington, D.C.: The Brookings Institution, 1991, I58 pages, $22.95, cloth, $8.95, paper.
As would be predicted, Serious and Unstable Condition: Financing America's Health Care is an excellent book, interesting, challenging and highly accessible. In Chapter 1, "What is the problem?" Henry J. Aaron, Director of the Economic Studies program at the Brookings Institution, says there is diminishing support for the current health care system in the United States. As does every other intelligent student of health care, he sees the problems as (1) ever escalating costs, (2) ever increasing numbers of uninsured
Book Reviews
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and (3) unevaluated services. Aaron foresees an inescapable debate in the 1990's on the restructuring of payment health care in the United States. This debate will have seemingly paradoxical goals: the control of costs and extension of financial access. Aaron fit addresses economic issues in health care. He points out that the problem of rising health expenditures occurs because even well-informed patients have little incentive to weigh the benefits and risks of diagnosis or therapy against the full cost of care. In 1989 insurance spared patients more than nine-tenths of the total cost of hospitalization and more than three-fourths of the costs of physicians' services. As a result, patients have every incentive to seek care that they think will bring even modest benefits and have little reason to consider cost. @. 9)
In addition there are difficulties in determining whether physicians act as faithful agents for their patients since the physicians have the power to determine demand for their own services. Aaron says that the role of competition in the financing and provision of health care is seen as salvation or fantasy. What is referred to as the health care industry is in actuality many diverse markets that produce a wide range of goods and services and includes 650 insurance companies including 78 Blue Cross and Blue Shield Plans. He maintains that market based efforts such as independent practice associations, health maintenance organizations, preferred provider organizations, managed care and efforts by business purchasers to hold down premiums have reduced hospitalization rates but not total health care spending because "the structural characteristics of insurance make such success improbable" (p. 29). Aaron raises very interesting questions around issues such as experience rating in which the potential insured are rated according to clearly identifiable personal characteristics that can predict great differences in medical costs. He says the disadvantages to the nation of such a system outweigh the advantages. H< draws four propositions from his discussion of the economic issues in medical care.
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First, insurance creates incentives for patients to demand and for physicians to provide health care that is expensive relative to benefits. Second, powerful forces are reducing the capacity of insurance to serve as many people in the future as it has in the past. Third, any system of health insurance that rests on many separate, privately negotiated contracts and that involves multiple channels of payment to providers for each patient will have major advantages, but these advantages will be purchased at enormous administrative cost. Fourth, multiple channels of payment inherent in the current U.S. financing system make it difficult or impossible to reduce the amount of low-benefit, highcost care. (p. 37) In the chapter related to organization and financing, Aaron comes to a similar conclusion to that in his 1984 Brookings publication, The Painful Prescription: Rationing Hospital Care. The only way that health spending can be reduced is in the curtailment of care that is beneficial but very costly, in the rationing of health care especially to the very ill. Then he asks, "Is there an ethically supportable politically sustainable way to ration care?" (p. 53). Aaron addresses international comparisons in the fourth chapter of the book. Accounting in part for the great difference in spending is the ready availability of new high technology in the United States. Again, in one of those short explanatory lists that I find so helpful in his writing, Aaron lists four possible explanations for the high costs in the United States; (1) Generous remunerating of physicians, (2) Spending more on services of little medical benefit than do other countries, (3) Providing methods of health care production may be less efficient than in other countries, (4) Perhaps buying a larger quantity of beneficial health care (p. 89). Finally, Aaron lays out the terms of the debate on the financing of health care. He says the debate cannot become serious until the system deteriorates further, the federal budget deficit is reduced and the president or a presidential candidate makes the reform of health care finance a critical issue. It seems that as of now the first and third condition are moving into place, but the budget deficit is again growing. Aaron explores several options such as voluntary incrementalism
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that can take the form of risk pools, tax credits, the extension of Medicaid, development of private insurance plans for long term care coverage and competition; or some form of mandatory employment-based insurance of which Aaron describes two illustrative plans. The first, proposed by the National Leadership Commission on Health Care, suggests that employers pay at least 314 of the costs of health care and anyone not covered by an employmentbased plan be covered by a new universal-access program offering the same benefits. The second, proposed by the state of Hawaii covers almost all of the population through a mandatory employment-based arrangement in which employers are required to pay at least half of the costs of services but cannot be required to pay more than 1.5% of wages, plus Medicaid and another state health insurance program. The plan offers limited coverage and requires premiums and co-payments. These or any other plan would have to develop strategies for extending coverage without further inflating health care costs. To solve these problems, Aaron proposes a universal access, single-payer health plan providing acute and long term care coverage that rests on four propositions. First, the system of employer sponsored and financed insurance for workers and family members would continue. Second, public coverage or public payment for private insurance would be extended to cover the presently uncovered. Third, control of health care spending would be concentrated. Fourth, the government would establish a floor for coverage, but the allocation and design of benefits should differ regionally. As always, Aaron provides the material for rich debate and thoughtful discussion.
Toba Schwaber Kerson, DSW, PhD Professor Graduate School of Social Work and Social Research Bryn M a w College
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SOCIAL WORK. DISABLED PEOPLE AND DISABLING ENVIRONMENTS. Michael Oliver, editor. London, England: Jessica Kingsley Publishers, Ltd. 1991,203 pages, hardcover.
Social Work:Disabled People and Disabling Environments is an edited collection of essays on the experience of the disabled in Great Britain. A basic tenet of the book is that in order for goods and services to favorably affect self-concept, one must control the assessment of one's own needs and participate in formulating and implementing policies to meet these needs. The essays discuss such critical questions as the definition of disability from many perspectives (Finkelstein, pp. 19-39) and the different organizations working for rather than with the disabled. The definition of disability and the type and degree of aid offered greatly depend on the context of policy formulation; that is, where, how, and by whom a decision is made, and methods of counting and assessing needs of specific disabled populations (Abberley, pp. 156-176). We learn that the non-disabled continue to assess the needs of disabled populations (d'Abouville, pp. 64-85) and that resources for the disabled are often too little, too late, and too generally conceived. In many instances, rather than having special programs developed for them, the disabled may require specific and time limited assistance that could be integrated into existing programs for the nondisabled. In fact, the process often operates in reverse beginning with various resources, a specific set of values, and the dorninance of particular individuals, groups and institutions. In order to utilize the existing resources and institutions to maintain the status quo the dominant non-disabled sector identifies as disabled those individuals who utilize the existing order. Instead of basing the context on the needs of the person or group, the disabled individual or group is assigned and accommodates to a particular context. This issue is reflected in the title of the book, Disabled People and Disabling Environments. Such a state of affairs, in which the ablebodied are in positions of power denies the disabled a sense of self-determination and leaves them in a position of dependency on the able-bodied majority. Several essays raise the question of program integration. Self-
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help organizations such as the Spinal Cord Injury Association demonstrate that program integration is practical and possible. By virtue of the fact that service recipients also participate in program evaluation, self-help organizations achieve optimal use of resources and concurrently establish the disabled as the major political architects of their own collective future. Perhaps some would raise the question of conflict of interest, and social workers could be used in these contexts as liaisons between the provider and the recipient of aid, between the political and economic leadership of the programs in question. Major suggestions made in this volume include:
1. Needs of the disabled should be determined by the disabled; 2. Formulation, implementation and evaluation df programs for the disabled should involve the disabled. 3. Maximum participation of the disabled works to counteract marginality and the sense of disability; 4. Programs that are devised must meet the needs of the specific group in question and should establish the most efficient use of resources to meet these needs; 5. The physically disabled who are the recipients of aid may function as program evaluators, thus optimizing the use of resources and maximizing self-determination. It is the thesis of this book that primarily through political means the very context in which the disabled are served defines them as disabled. For example, by defining an individual as too disabled to determine need or distribute and administer resources, society creates a vicious cycle. The editor of this book suggests one solution to this difficulty, the changed context of a supportive environment. In such an environment the recipient of services need not be defined as disabled. Here, the supportive environment acts as a ladder out of a valley of disability by creating an environment where the policy-making process creates an escape route for the physically disabled client. The essays in this volume deal forthrightly with the global issues sketched in this review. A number of case studies of particular disabled populations such as the disabled young and children
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with physical disabilities and their families as well as particular issues concerning the role of the social worker add data to the often theoretical and political bent of the collection. Although the work focuses on the British experience, with minor substitutions of specific facts, it is equally applicable to the experiences of the disabled and the politics of disability in the United States. Leon S. Anisfeld, DSW Assistant Clinical Professor Department of Community Medicine (Social Work) Department of Psychiatry Mt, Sinai Medical School New York, NY
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/ loi/wshc20
BOOK REVIEWS Toba Schwaber Kerson DSW, a
PhD , Marcia L Martin PhD b
c
, Leon S. Anisfeld DSW & Haworth Continuing Features Submission a
Graduate School of Social Work & Social Research, Bryn Mawr College , Bryn Mawr , PA, 19010 b
Graduate School of Social Work and Social Research, Bryn Mawr College, Bryn Mawr, PA c
Assistant Clinical Professor, Dept of Community MedicineSW, Dept of Psychiatry, Mt Sinai Medical School, New York, NY Published online: 26 Oct 2008.
To cite this article: Toba Schwaber Kerson DSW, PhD , Marcia L Martin PhD , Leon S. Anisfeld DSW & Haworth Continuing Features Submission (1992) BOOK REVIEWS, Social Work in Health Care, 17:2, 101-112, DOI: 10.1300/J010v17n02_08
Downloaded by [University of Sydney] at 14:32 04 January 2015
To link to this article: http://dx.doi.org/10.1300/ J010v17n02_08
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and
Downloaded by [University of Sydney] at 14:32 04 January 2015
use can be found at http://www.tandfonline.com/page/ terms-and-conditions
Downloaded by [University of Sydney] at 14:32 04 January 2015
BOOK REVIEWS'
MEDICARE AND MEDIGAPS: A GUIDE TO RETIREMENT HEALTH INSURANCE. Susan Hellman and Leonard H. Hellman. Newbury Park, California: Sage Publications Znc., 1991,80pages, $16.85, soficover. Medicare and Medigaps presents an overview of many of the major problem areas in retirement health insurance. Since 97% of Americans over age 65 are partially insured through Medicare, Medicare is the primary focus of the book which is a helpful handbook for the Medicare recipient and for health professionals who are new to the system. The book addresses the following subjects: (1) the history, financing and eligibility requirements for Medicare, (2) hospital insurance through Part A of Medicare, (3) outpatient services through Part B of Medicare, (4) ways to insure for services which are not or only partially covered through Medicare, (5) reasons and procedures for appealing Medicare decisions, (6) means for f i g claims, (7) benefit programs other than Medicare and (8) Medicaid. To structure the presentation of this crucial but dry information, Medicare and Medigaps uses the technique of asking and answering often posed questions regarding the program. All material is presented as specifically as possible using the least possible amount of jargon. In the chapter that addresses Medicare Part A, the authors outSocial Work in Healfh Care, Vol. 17(2) 1992 O 1992 by The Haworth Press, Inc. All rights reserved
I OI
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Line the eligibility requirements for hospital admission and the basic inpatient benefits. They are also careful to describe which services are not covered such as the first three pints of blood for transfusion and care in a hospital outside the United States. In this same chapter, the authors explain skilled nursing facility benefits and the differences between those services and the kinds of custodial services that are most usually associated with nursing homes in the minds of most people. In this regard in describing intermediate or custodial care the authors say, "Even though the patient's family thinks the patient may need "skilled care," Medicare has the final say. Of course, the patient may appeal" (p. 11). The discussion of Medicare Part A also includes a description of home care and hospice services. The chapter on Medicare Part B discusses in some detail the physician services covered. Although the authors list "clinical social workers employed by an outpatient mental health center that accepts assignment" (p. 17) as providers of mental health services, they do not include social workers in their primary reimbursable group that they erroneously refer to as physicians and which includes psychiatrists, psychologists, osteopaths, dental surgeons, chiropractors, optometrists and podiatrists. There is a reasonably elaborate description of the kinds of durable medical equipment for which Medicare will pay and the claim system for Part B of Medicare. Since the facts related to claims are equally tedious and important, the authors offer case examples which illustrate the facts of both assigned and unassigned claims. The chapter called "Filling Medicare Gaps" begins with the reminder that Medicare was designed to cover between 40% and 50% of a person's health care costs. Thus, it explains:
Part A of Medicare does a good job of covering an inpatient hospital stay, which would otherwise be very expensive, but does not do a good job covering long-term nursing home or home health care. Because Part B of Medicare only covers one third of the person health care costs for physician and outpatient services, most Americans choose to supplement Medicare with one or more of the following options: purchase a Medicare supplemental insurance policy, continue or con-
Book Reviews
103
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vert employer group insurance, join a health maintenance organization, purchase long-term care insurance, purchase indemnity benefits insurance policies, apply for Medicaid, if eligible, use veterans or retired military benefits, if eligible, or pay out of their own pocket. (p. 23) The authors proceed to explain these options in what is the most useful part of the book. They describe an "ideal" Medicare supplemental insurance package, an "ideal" long-term care policy and the measures for locating a good Medicare supplement. Chapter 5 presents the reasons and procedures for appealing Medicare decisions such as denial of coverage or paying too little for a service. The authors even spell out scenarios for how to appeal when the patient disagrees with the hospital's decision that inpatient care is no longer necessary. For example,
If you are hospitalized, your liability for payment generally begins on the 3rd day after receiving the written notice if no review request is filed. However, if an "immediate review" is requested by telephone, by letter, or by filing Form SSA2649 by noon of the 1st workday after receiving the notice, you cannot be made to pay for the hospital care until after the PRO makes its decision . . . (p. 39) One section of the book that provides information on how to file claims and organize paperwork. It describes the use of Medicare codes, reasons why one medical visit sometimes incurs more than one bill and the document (EOMB)that Medicare mails every beneficiary that demonstrates what services have been covered, when they were rendered and by whom, the billed charge, the approved charge, the amount deducted and finally what Medicare paid. The inclusion and explanation of various Medicare forms is also very helpful. A short section of the book presents other benefit programs including those for federal, state and local employees, veterans and railroad retirees. Of course, these programs could and do have handbooks of their own, but their inclusion helps the authors present a richer picture of retirement health insurance. The final chapter is
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a four page description of the Medicaid program that is directed primarily at the processes through which a person who requires nursing home placement can become eligible for Medicaid. My primary suggestion for a second edition would be the addition of a section listing names, addresses and phone numbers of state and federal offices which the service recipients may need to contact. Obviously, I found this handbook to be extremely clear and useful. Medicare recipients and their families need all of the information in this volume. I suspect that experienced social workers in the many institutions and organizations that serve Medicare recipients are aware of much of this information, but social workers new to these areas would be well served by this book. Toba Schwaber Kerson, DSW, PhD Graduate School of Social Work and Social Research Bryn Mawr College
AIDS-RELATED PSYCHOTHERAPY. Mark G. Wiiarski. New York: Pergamon Press, 1991, 194 pages. Mark G. Wiiarski has written AIDS-Related Psychotherapy from his own experience, questions, and search for answers. He is a clinical psychologist and faculty member at Montefiore Medical Center, Bronx, New York, and he was a staff psychologist for the Spellman Center for HIV-Related Disease at St. Clair's Hospital and Health Center, New York. Winiarski calls it a book about competence and healing and indeed he examines that balance between skill and compassion, so delicate in AIDS-related psychotherapy. The book is brief (194 pages) but thorough, and represents a wondefil and impressively complete handbook for psychotherapists working with HIV-positive persons. The inclusion of case vignettes serves to enhance the discussion of skills and issues identified by the author.
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Wiiarski divides his book into five parts: "Introduction to AIDS-Related Issues," "The Work of Psychotherapy," "The Therapist's Feelings," "Other HIV-Related Issues," and "Resources." The Introduction provides the reader with a very usable outline of medical and sociopolitical issues. While the author recognizes the controversial and changing nature of these issues, he nonetheless provides comprehensive medical information and a concise identification and analysis of the sociopolitical and economic issues. In Part 2 on "The Work of Psychotherapy," Winiarski provides the reader with a somewhat prescriptive yet quite functional intake assessment outline. As he suggests, because of the constantly changing and volatile nature of HIV infection, a baseline assessment is crucial to the ongoing intervention. The author also identifies the critical psychotherapy themes that the clinician must be prepared to address with clients, including the issues of why me and the accompanying denial, the feelings of shame and guilt, the threat of abandonment and betrayal, the loss of control and resulting dependency, the uncertainty about the future, and the fear of dying. He introduces the clinician's monitoring function which demands an awareness and understanding of extremely complex medical, psychiatric, neuropsychological, and neurological symptoms and disorders and their implications. Winiarski correctly notes that service delivery in the area of AIDS is a process that merges technical knowledge, consultation services, and case management with the more traditional psychotherapy skills. Part 3 on The Therapist's Feelings is particularly valuable. Again Winiarski provides a compendium of the issues that arise and are exacerbated for the ciiician working with HIV-positive persons. He outlines a 12question exercise designed to help clinicians explore their own feelings around death, pain, abandonment, God, and family. One must confront such questions as, "Why me?", "Will I die in pain?", "Can you stand to look at me?", and "Is there a God?" The exercise serves to stress the parallel nature of the client and worker processes, and demands that clinicians begin to distinguish between responses they give directly to a client and those responses which reflect their own real feelings. The challenge to clinicians is, as Wiiarski suggests, to explore
Downloaded by [University of Sydney] at 14:32 04 January 2015
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what they bring to psychotherapy sessions. There is a great deal for both the HIV-positive person and the therapist to bear and Winiarski's emphasis in this part of the book on the need for those engaged in HIV-related work to care for themselves is welcome. In Parts 4 and 5, Wiarski explores remaining issues such as HIV screening, prevention counseling, the intravenous drug user, concerns of the womed well, spirituality, and resource identification. The topics are again covered with clarity and precision. The book is an excellent guidebook for the clinician just beginning HIV-related work, and a supportive and affirming handbook for the experienced therapist. The material is presented in a quite didactic style but the infusion of Winiarski's own professional and personal experiences takes the edge off of the somewhat prescriptive tone. I read the book with enthusiasm and a sense of familiarity. For me, Winiarski captured something of the universal in AIDS-related work.
Marcia L. Martin, PhD Bryn Mawr College, Graduate School of Social Work and Social Research Bryn Mawr, PA
SERIOUSAND UNSTABLE CONDJTION:FINANCING AMERICA'S HEALTH CARE. Henry J. Aaron. Washington, D.C.: The Brookings Institution, 1991, I58 pages, $22.95, cloth, $8.95, paper.
As would be predicted, Serious and Unstable Condition: Financing America's Health Care is an excellent book, interesting, challenging and highly accessible. In Chapter 1, "What is the problem?" Henry J. Aaron, Director of the Economic Studies program at the Brookings Institution, says there is diminishing support for the current health care system in the United States. As does every other intelligent student of health care, he sees the problems as (1) ever escalating costs, (2) ever increasing numbers of uninsured
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and (3) unevaluated services. Aaron foresees an inescapable debate in the 1990's on the restructuring of payment health care in the United States. This debate will have seemingly paradoxical goals: the control of costs and extension of financial access. Aaron fit addresses economic issues in health care. He points out that the problem of rising health expenditures occurs because even well-informed patients have little incentive to weigh the benefits and risks of diagnosis or therapy against the full cost of care. In 1989 insurance spared patients more than nine-tenths of the total cost of hospitalization and more than three-fourths of the costs of physicians' services. As a result, patients have every incentive to seek care that they think will bring even modest benefits and have little reason to consider cost. @. 9)
In addition there are difficulties in determining whether physicians act as faithful agents for their patients since the physicians have the power to determine demand for their own services. Aaron says that the role of competition in the financing and provision of health care is seen as salvation or fantasy. What is referred to as the health care industry is in actuality many diverse markets that produce a wide range of goods and services and includes 650 insurance companies including 78 Blue Cross and Blue Shield Plans. He maintains that market based efforts such as independent practice associations, health maintenance organizations, preferred provider organizations, managed care and efforts by business purchasers to hold down premiums have reduced hospitalization rates but not total health care spending because "the structural characteristics of insurance make such success improbable" (p. 29). Aaron raises very interesting questions around issues such as experience rating in which the potential insured are rated according to clearly identifiable personal characteristics that can predict great differences in medical costs. He says the disadvantages to the nation of such a system outweigh the advantages. H< draws four propositions from his discussion of the economic issues in medical care.
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First, insurance creates incentives for patients to demand and for physicians to provide health care that is expensive relative to benefits. Second, powerful forces are reducing the capacity of insurance to serve as many people in the future as it has in the past. Third, any system of health insurance that rests on many separate, privately negotiated contracts and that involves multiple channels of payment to providers for each patient will have major advantages, but these advantages will be purchased at enormous administrative cost. Fourth, multiple channels of payment inherent in the current U.S. financing system make it difficult or impossible to reduce the amount of low-benefit, highcost care. (p. 37) In the chapter related to organization and financing, Aaron comes to a similar conclusion to that in his 1984 Brookings publication, The Painful Prescription: Rationing Hospital Care. The only way that health spending can be reduced is in the curtailment of care that is beneficial but very costly, in the rationing of health care especially to the very ill. Then he asks, "Is there an ethically supportable politically sustainable way to ration care?" (p. 53). Aaron addresses international comparisons in the fourth chapter of the book. Accounting in part for the great difference in spending is the ready availability of new high technology in the United States. Again, in one of those short explanatory lists that I find so helpful in his writing, Aaron lists four possible explanations for the high costs in the United States; (1) Generous remunerating of physicians, (2) Spending more on services of little medical benefit than do other countries, (3) Providing methods of health care production may be less efficient than in other countries, (4) Perhaps buying a larger quantity of beneficial health care (p. 89). Finally, Aaron lays out the terms of the debate on the financing of health care. He says the debate cannot become serious until the system deteriorates further, the federal budget deficit is reduced and the president or a presidential candidate makes the reform of health care finance a critical issue. It seems that as of now the first and third condition are moving into place, but the budget deficit is again growing. Aaron explores several options such as voluntary incrementalism
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that can take the form of risk pools, tax credits, the extension of Medicaid, development of private insurance plans for long term care coverage and competition; or some form of mandatory employment-based insurance of which Aaron describes two illustrative plans. The first, proposed by the National Leadership Commission on Health Care, suggests that employers pay at least 314 of the costs of health care and anyone not covered by an employmentbased plan be covered by a new universal-access program offering the same benefits. The second, proposed by the state of Hawaii covers almost all of the population through a mandatory employment-based arrangement in which employers are required to pay at least half of the costs of services but cannot be required to pay more than 1.5% of wages, plus Medicaid and another state health insurance program. The plan offers limited coverage and requires premiums and co-payments. These or any other plan would have to develop strategies for extending coverage without further inflating health care costs. To solve these problems, Aaron proposes a universal access, single-payer health plan providing acute and long term care coverage that rests on four propositions. First, the system of employer sponsored and financed insurance for workers and family members would continue. Second, public coverage or public payment for private insurance would be extended to cover the presently uncovered. Third, control of health care spending would be concentrated. Fourth, the government would establish a floor for coverage, but the allocation and design of benefits should differ regionally. As always, Aaron provides the material for rich debate and thoughtful discussion.
Toba Schwaber Kerson, DSW, PhD Professor Graduate School of Social Work and Social Research Bryn M a w College
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SOCIAL WORK. DISABLED PEOPLE AND DISABLING ENVIRONMENTS. Michael Oliver, editor. London, England: Jessica Kingsley Publishers, Ltd. 1991,203 pages, hardcover.
Social Work:Disabled People and Disabling Environments is an edited collection of essays on the experience of the disabled in Great Britain. A basic tenet of the book is that in order for goods and services to favorably affect self-concept, one must control the assessment of one's own needs and participate in formulating and implementing policies to meet these needs. The essays discuss such critical questions as the definition of disability from many perspectives (Finkelstein, pp. 19-39) and the different organizations working for rather than with the disabled. The definition of disability and the type and degree of aid offered greatly depend on the context of policy formulation; that is, where, how, and by whom a decision is made, and methods of counting and assessing needs of specific disabled populations (Abberley, pp. 156-176). We learn that the non-disabled continue to assess the needs of disabled populations (d'Abouville, pp. 64-85) and that resources for the disabled are often too little, too late, and too generally conceived. In many instances, rather than having special programs developed for them, the disabled may require specific and time limited assistance that could be integrated into existing programs for the nondisabled. In fact, the process often operates in reverse beginning with various resources, a specific set of values, and the dorninance of particular individuals, groups and institutions. In order to utilize the existing resources and institutions to maintain the status quo the dominant non-disabled sector identifies as disabled those individuals who utilize the existing order. Instead of basing the context on the needs of the person or group, the disabled individual or group is assigned and accommodates to a particular context. This issue is reflected in the title of the book, Disabled People and Disabling Environments. Such a state of affairs, in which the ablebodied are in positions of power denies the disabled a sense of self-determination and leaves them in a position of dependency on the able-bodied majority. Several essays raise the question of program integration. Self-
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help organizations such as the Spinal Cord Injury Association demonstrate that program integration is practical and possible. By virtue of the fact that service recipients also participate in program evaluation, self-help organizations achieve optimal use of resources and concurrently establish the disabled as the major political architects of their own collective future. Perhaps some would raise the question of conflict of interest, and social workers could be used in these contexts as liaisons between the provider and the recipient of aid, between the political and economic leadership of the programs in question. Major suggestions made in this volume include:
1. Needs of the disabled should be determined by the disabled; 2. Formulation, implementation and evaluation df programs for the disabled should involve the disabled. 3. Maximum participation of the disabled works to counteract marginality and the sense of disability; 4. Programs that are devised must meet the needs of the specific group in question and should establish the most efficient use of resources to meet these needs; 5. The physically disabled who are the recipients of aid may function as program evaluators, thus optimizing the use of resources and maximizing self-determination. It is the thesis of this book that primarily through political means the very context in which the disabled are served defines them as disabled. For example, by defining an individual as too disabled to determine need or distribute and administer resources, society creates a vicious cycle. The editor of this book suggests one solution to this difficulty, the changed context of a supportive environment. In such an environment the recipient of services need not be defined as disabled. Here, the supportive environment acts as a ladder out of a valley of disability by creating an environment where the policy-making process creates an escape route for the physically disabled client. The essays in this volume deal forthrightly with the global issues sketched in this review. A number of case studies of particular disabled populations such as the disabled young and children
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with physical disabilities and their families as well as particular issues concerning the role of the social worker add data to the often theoretical and political bent of the collection. Although the work focuses on the British experience, with minor substitutions of specific facts, it is equally applicable to the experiences of the disabled and the politics of disability in the United States. Leon S. Anisfeld, DSW Assistant Clinical Professor Department of Community Medicine (Social Work) Department of Psychiatry Mt, Sinai Medical School New York, NY
