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1.
Abstract
Information and communication technology (ICT)-enabled
community networks may provide a range of services to residents. In an
evolutionary sense, it is possible to trace their beginning as free
Internet-access providers to purveyors of local content to portals offering
access to content and to interactive services – such as social services. This
paper is focused on the last – interactive tele-services in the social sector.
A community is geophysical entity where normal social life
is possible. A community may come to mean many things to its residents.
Fundamentally, it should meet the instrumental needs of residents – such as the
need for transportation, jobs, safe and clean public places, and healthcare
institutions. A community, in this sense, must offer a social and physical
support infrastructure for need fulfillment.
A utilitarian view of community argues an instrumental view
of community network function. Community networks can extend the reach of the
support infrastructure for need fulfillment; they can help adapt these structures
of support to the needs of residents with impairments and disabilities.
Community networks can help alter the social structure of choice and make it
more convenient for the needy to avail of services.
We collected data from two types of sources for our analysis
(1) selected Internet-based municipal web sites in New York communities, and
(2) field test of broadband application for health care benefits that was
implemented in Syracuse. We draw on our case studies of these networks to
suggest development trends. We analyzed the content (information and services
offered) of a subset of these networks.
We assess the networks in light of four normative frames.
First, the NY State Lt. Governor’s Task Force on Quality Communities’
principles targeting community and economic development. Second, the League of
Cities’ program promoting e-government. Third, social and economic priorities
acknowledged by the urban planning and community development agencies in target
communities. Fourth, project goals articulated by the municipal websites and
the field test of the broadband application. Given these frames, what
information and services do these networks currently offer residents? What is
the legitimate role(s) of a network in the community it purports to serve?
Our survey reveals a significant gap between the normative
frames and network function. While Internet-based networks did offer
information tailored to local needs, broadband networks did not. Neither type
of network offered extensive social services that are possible with the current
technology. Both the networks were minimally interactive (users could email the
Webmaster). The broadband networks served narrow populations on a
fee-for-service basis, and services were predominantly in distance learning/training.
The Internet-based networks were broader in the populations they served.
In conclusion, these networks were not viewed as policy
tools by community development interests, with the result that such interests
were not involved in network development process. Normative frames must be
translated into social technology policy guidelines before the connection
between the community network and the community’s needs work at the practical
level.
2. Background
to research
The term electronic government (and governance) points to the use of information and communications technologies (ICTs) to deliver public and social services. Crucially, it also refers to the increased interactivity between service providers and service users that electronic means make possible. Electronic government allows “re-localization” (Grieco, 2000) of government-citizen relations. In an increasingly global environment, where instrumental social relations may be spread out over a very large area (witness the growth in popularity of e-commerce) using ICTs, government entities can use the same means to provide needed services to and interact with constituents of geophysical localities, thus re-localizing their presence.
Electronic delivery of government services holds much promise. ICTs can isolate the service network – linking service providers and users – from the physical infrastructure of locality-based social communities. This means users would not have to rely on public transportation, for example, to physically get to the service delivery point but can avail of the service at a convenient location – a near-by public access point or even in their own home.
Isolating the access to services from physical infrastructures can help correct prevailing biases in the support infrastructures of communities. Support infrastructures are different from physical infrastructures. The former refers to the resources and mechanisms that an agent of government may make available to service users, such as a human support staff, services application and authorization procedures etc and the latter stands for resources such as public transportation and safe roads. Demographic changes in a community over time may put pressure on the physical infrastructure to be more responsive to the population’s service access needs. Local government may use ICTs to rethink service delivery in this changing environment while undertaking an overhaul of the physical infrastructures.
ICTs can help users time-shift their service access. No longer would the user be restricted to the provider’s business hours but can be served at her convenience. Time shifting is an important and valuable capability for populations that are “time-poor” – populations with little discretion in their schedules. Mothers of young children in low-income areas may be unable to free themselves long enough to go physically to a government location to avail of a service. Blue-collar workers work to tight schedules with little flex in them to permit time off. For such users, services that can be accessed asynchronously – that is, anytime -will be more useful than services that are only available at certain times.
Somewhat paradoxically, ICTs can help humanize the service experience for both users and service providers. In a project we describe below, ICT-supported Medicaid benefits certification was found to benefit users and their families: applicants could complete the critical step in the certification process – namely, the certification interview – from the comfort of their home or nursing facility. This alone was a major improvement over the manual process, which required that the applicant be physically present at the Medicaid administration offices in the county government building downtown. The ICT-supported process, in addition, allowed the applicant’s family members to be co-present at this key interview. This permitted family members to provide moral support to the applicant and to each other through the process. Furthermore, they could fill in information required by the elaborate certification process that the applicant may not have or may not remember.
It benefited providers by supporting
better coordination between certification specialists, who actually conducted
the interview, and other relevant staff at the county department. Importantly, the ICT-supported process helped
socialize specialists-in-training quicker by allowing them to observe the
interview; this had not been possible before with the manual process. It helped
improve communication between specialist and the caseworker at the healthcare
facility by permitting sustained contact, during and after the interview, on
the application, thus helping to make the process more efficient and effective.
This again had not been possible before with the manual process.
Electronic government can change the nature of relations between governmental entities and citizens. Two types of connectivity are possible: vertical and horizontal connectivity. Vertical connectivity is enabled when citizens can interact with government institutions. For example, a website may permit residents to email an organizational representative or the Webmaster with a request, complaint, or input of some other kind. The latter type -- horizontal connectivity -- is supported when citizens can interact with other citizens over the website. For example, they may be able to set up listservs and use an interactive chat room and email to sustain social relationships with other local residents. While both types of connectivity are important for electronic governance, horizontal connectivity is critical to the democratic ideal. It is citizen-to-citizen interaction that facilitates social control of service providers and the evolution of the service environment to meet new needs as they emerge. We see support for vertical and horizontal connectivity itself as a service that a network may offer through a website.
Broadly, ICTs may be used to deliver two types of services. These types are not mutually exclusive; a user may access one or both, and often through the same site. Informational services provide information and may collect information from users through electronic input forms. What we term high-touch services often support live, synchronous, person-to-person interactive transactions, and are often video-based. Tele-medicine services are an example of the latter, while BMV (or DMV) on-line license application and renewal may be an example of the former. Informational services can be (and indeed routinely are) delivered over dial-up technologies. High-touch services, on the other hand, are best delivered over broadband telecommunications technologies (broadband refers to transmission speeds of 384 thousand bits per second or above). Both vertical and horizontal connectivity may be supported by both types of service delivery environments. We see vertical and horizontal connectivity as two modalities of participative-ness described in Aurigi & Graham’s web site analysis typology (2000).
Electronic access can benefit users in many ways, such as convenience. Service providers may also see benefits, such as improved work coordination with intermediaries. But there are costs as well: users would need to computer literacy to use online services and access to physical locations if they do not have ICTs in their own home. Any e-government plan or initiative must think through social access issues -- issues that center on user skills sets and human support to assist the less-skilled, and ICT access – to ensure that anyone who wishes to access services online can in fact do so. Governments tend to overlook social access issues when planning e-government programs, thus unintentionally biasing access in favor of citizens who can readily command the necessary resources. The bias works against the resource-poor who, unfortunately, are the ones likely to benefit the most from flexible access.
Costs to service providers can be considerable as well. Successful e-service delivery calls for reworking work processes. Programming e-service applications calls for financial and skills resources and maintaining them calls for more of the same. To the extent that they entail work coordination across multiple organizations, such applications can be complex to design and may have unforeseen consequences for work division. In the Medicaid case above, we found that the benefits certification prototype shifted work from the county to the healthcare facilities, leading the latter to weigh its benefits versus costs for them. One of the facilities argued that the ICT-supported process taxed its caseworker more than had the manual process. In brief, costs can be high for service providers.
Governments must decide whether the benefits outweigh the costs. It is as much a social decision as it is a financial one. A good case can be made for the viability of delivering e-services to marginalized groups under certain social access support conditions. The case above on Medicaid certification showed clearly that e-service delivery would not merely be a “nice to have”, but rather, that it would be a “must have” for many aged and infirm applicants given their particular life circumstances. Consider the case of the mother who has just gotten off welfare and found work. But instead of being at work, she finds herself standing in line at government offices to apply for chilled care and other support provided by state and federal programs. This person would be far less inconvenienced if she could apply for benefits online at her convenience after office hours, from a public access point in her neighborhood (e.g., a public school).
Definitions of the term “community” often start with its utilitarian aspects. A community, according to Warren (1978), a sociological analyst of the American community, is taken to mean “the organization of social activities to afford people daily local access to those broad areas of activity that are necessary in day-to-day living” (Warren, 1978, p. 9). It is interesting that a community, in a psychological sense, may mean other things as well: it may stand for the sense of solidarity felt by residents for the locality they live in. It may refer to a sense of social connectedness between residents. Indeed, Selznick (1996), and Warren himself (1978), see its psychological connotations as legitimate dimensions of the term community. However, both also agree that a social community, at a minimum, must offer support for a broad range of activities that enable residents to sustain daily living. It follows that convenient access to basic services -- healthcare, education (and others that make possible normal social life) – must be deemed an essential aspect of community in the sociological sense.
2.1 E-government in action
Given its costs and benefits, what is the status of e-government principles or offerings in state and city government?
The New York State Lt. Governor’s task force report on
quality communities is a future-oriented look at improving community living.
The report is thoughtful and detailed, and offers analyses and recommendations
on pressing questions, such as public transportation and housing. It makes no
mention of e-government at the community level. Yet it is at the community
level that e-government approaches ay be most productive. For example, the senior
population (65 years and older) of central
The possibilities inherent in e-government have inspired
attempts to change how local government works. For example, the National League
of Cities supports a program they call Totally Web Government – an ambitious
initiative designed to promote and facilitate online municipal governance. The
Older Americans Act (OAA) now supports efforts on the part of county
governments to facilitate access to information relevant to seniors and their
caregivers over networked environments (chiefly the Internet). Local
governments routinely maintain a website as an information source as well as
for publicizing the local area to business interests. Some city governments go
much farther. The
3. Analysis of three municipal websites
In the present paper, we analyze three official municipal
websites –
Aurigi and Graham analyze the content of the website using three variables of informative-ness, participative-ness and grounded-ness. Informative-ness refers to capability of providing up-to-date information about the local community. Participative-ness includes the capability to encourage the community to be active participants and to interact with the peers within the social hierarchy. Grounded-ness illustrates the relationship that the website can create with its host city or community.
These sites all contained information of local interest,
often listing phone numbers and email addresses of government personnel and
elected officials. The sites provide some coverage of local culture and
history. They provide links to other relevant websites having local
information.
3.1 Web Site Analysis of
City of
The website, titled “City of
3.1.1 Structure Analysis:
The structure of the website is evaluated by taking into
account the technology that is used to design the website and the style of the
design itself. The City of
The web site uses server side scripts (like active server pages) to add dynamic properties to the website like the news scroll present in the first page (home page) of the website. A combination of server side scripting and database has been used manage the content of a few sections of the website. Most of the web pages within the website use Cascading Style Sheets (CSS), a technology that is more commonly used in contemporary websites to give a standard definition to the design of the web pages across the entire website. The website seems to be compatible with the two most popular web browsers, Internet Explorer and Netscape.
The home page of the website has a very brief welcome message to greet the people who visit the website. The homepage is also adorned by photographs that proudly display the archaic beauty of the city. There are links provided for web pages, both within the website and those that are external to the website, depending on the type of information that has been requested. The home page also showcases a very useful “Quick Find” section that consists of three different pull-down menus. One is to provide information on “How to do” the different things on the website like information on how to get a building permit. The other two sections are used for contact information of the various people that work for the city government and the various forms that are available. There is very little opportunity for any interaction, the only form being an e-mail. There is a link to the search page at the bottom of every web page on the website, along with a link to the home page (other than the home page itself), a link to the site map that displays all the different sections of the website on one page, and a link to the disclaimer page of the website.
The web pages that are at the second and lower levels of the website have a secondary menu that helps the users to navigate through the various sections of that particular topic like the web pages under the topic “About Syracuse”. The design of the secondary menu is simple and consistent across all the different sections and the various topics of the website. Information contained as documents about the various programs or agenda of the various committees could be opened using Microsoft Word or an Acrobat Reader software depending on the format in which the document is stored.
3.1.2 Content Analysis:
Content analysis of the website is based on three typologies; informative-ness, participative-ness and grounded-ness.
Informative-ness:
The content present in the website provides extensive
information about the functioning of the city government. The website is mostly
designed to be utilized by the people who live in the city and who are
interested in the activities of the
On the other hand, the website also has information for
outsiders who are interested in knowing the city better. There is a separate
section of the website titled “About Syracuse”, that provides a little
historical information including the history of industrial and economic
development, landscapes, education and religion. Demographic information like
the cost of living, unemployment rate are available to the statisticians who
are interested in the demographics of the
Participative-ness:
Organizations within the city government like the City Council have regular meetings in which the board members participate to discuss and formulate agendas. The website consists of information about the schedule of council meetings and a calendar of events for the various committees within the council. There are no discussion boards or chat rooms that encourage the people to participate in the activities of the government or to request information or services. The only form of communication that is possible via the website is through email.
Participation of the community could be encouraged with the combination of advanced networking technologies and multimedia features through the internet (like video conferencing). Simple forms could be created for the users to request information or service. The website has a disclaimer that it does not collect any type of information from the user of the website. This restricts the government from the opportunity for better and easier way of providing service to the people and the community.
Grounded-ness:
The website stands as an online representation of the local
city government of
The current news in the website is focused on the everyday events that are a part of the local community and about the people that are a part of the community. The website also has interesting information about the political, economical and industrial history of the city. Unarguably, there is a strong sense of ground-ness of information that is present on the website.
3.2 Web Site Analysis of
City of
The “City of
3.2.1 Structure Analysis:
The website is a content-oriented website though it also
includes a little functionality in some of the sections of the website. Each
web page is adorned with a picture that depicts a view of the city or a place
of interest in
The website uses the Cascading Style Sheet (CSS) technology
to give a consistent look to the web pages. Server side scripts are also used
to give dynamic properties to the website. The documents are stored in PDF file
format or in WORD format. These are the most commonly used software for reading
documents across the world. Advanced technology like video streaming is used to
share information regarding the meetings that take place within the city government.
However, only one video file, regarding the city’s sanitation plan, is
currently available for the community. The website is consistent on both
Internet Explorer and Netscape browsers. Advanced technologies are used to
provide GIS services of the
3.2.2 Content Analysis:
Informative-ness:
Similar to the “City of
Most of the information in document form are stored as word
(*.DOC) or acrobat reader (*.PDF) files as discussed above. Some unique and
very useful features that were not to be found in the “city of
Participative-ness:
There are provisions within the website (under the section “ePayments” in the main menu) for interactive communication by requesting online services through forms. Some of the service requests need you to be a registered user in order to login and request for permits and other services. You can register as a user by providing some basic personal information like your name, address, phone number and e-mail address. A user name and a password would then be e-mailed to your e-mail address that you provide. This interactive feature available serves as an effective channel of communication between the people and the officials working for the local government.
Information regarding the council meetings and the calendar
of events are updated on a regular basis. This encourages the local community
to participate in the everyday activities of the city and be an active citizen
of the
Grounded-ness:
There is a strong local flavor when you visit the homepage
of the website made possible by the pictures, the icon of the website and the
title of the website. Most information available in the website pertains to the
city of
3.3 Web Site Analysis of
3.3.1 Structure Analysis:
The website of the City of
The website has been designed using a combination of scripting language (Java scripts) and basic HTML language. Unlike the above two websites analyzed, this website does not use cascading style sheets as a part of their design making it all the more cumbersome to maintain consistency in design across all the web pages within the website. The news section of the website has a basic content management system that has been designed using a combination of database and scripting language making it easy and simple to update the contents of the web pages. Most information is available in the “html” format though some documents are available in “PDF” or “doc” format. There are separate sections titled “e.gov online services” that are used for online transactions like making payments. Only this section of the website has a privacy policy for the users. There is no general disclaimer for the website as available in the previous two websites analyzed. It could only be assumed that the IT department within the city government is responsible for the content of the website and the time-validity of the information.
3.3.2 Content Analysis:
Informative-ness:
One of the intended uses of this website is as a channel of
communication that could be utilized by the local community to contact the
city. To serve the above purpose, the website has the telephone directory of
city departments and the e-mail address of some administrators within the city
government. The website also has message boards that allow the users to post
messages. These messages are monitored by a city official and then shared with
the community. Currently, there are messages on the websites that were posted
by the users, though the date and name of the person who had posted the message
is not available on the website. This is another way of interactive
communication that lacks in the websites of
Other information includes current activities within the
community, information for outsiders about
Participative-ness:
The city believes the best possible solution for social problems could be obtained with the mutual co-operation of the city as well as the local community. Based on this concept, the city has been divided into Neighborhood Empowerment Teams (NET). Each NET has a particular portion of the website dedicated to the community within that particular region. The people within this region participate in interactive dialogues expressing and sharing their concerns with their neighbors and the city officials as well. With this practice, the city encourages the people to participate in the activities of the government and in the social development.
The website also
encourages participation through interactive communication with the city via
e-mail, and also through forms available within the website. Another unique
feature of the website is the language translation facility that would be most
useful for the non-English speaking community in
Grounded-ness:
The icon used as a part of the template used to design the
web pages is a representation of the
3.4 Comparative analysis of
the three municipal websites:
Providing local information and facilitating contact with government bodies and elected officials is an undoubtedly important function of a government site. But we were equally interested in the number of transactional services that a resident or a visitor could access over the site. Here, the picture is less promising. Two of the websites analyzed supports online payment capability or any form of transactional service capability. With this site, a user can complete a transaction with local government entirely online; the other sites do not support online transactions.
Almost all the three websites analyzed have some form of
vertical connectivity; a visitor can email the
Webmaster. Two of the websites (
4. E-services over broadband: Lessons from
a field test
Next, we describe an online transactional service prototype developed for a broadband environment. The prototype was tested and formally evaluated under field conditions. The study highlights the benefits to users and service providers of online transactional systems, but also discusses the costs involved.
Over a thirteen month period starting in February, 2000, a
county in central
4. 1 The M/CC process
M/CC applicants’ eligibility for benefits is certified through the process. A patient checks into a facility. Self-pay patients (i.e. those with no health insurance) apply for benefits if they cannot pay for care. The facility caseworker pre-screens applicant and schedules an interview with the M/CC specialist (the specialist). The interview (which is between 45 and 60 minutes long) is the most important step in certification. The specialist evaluates the applicant’s financial need before making a decision on her eligibility.
Interviews are conducted face-to-face (FTF) at the DSS. The applicant is usually present; a representative may substitute for the applicant. The M/CC supervisor (the supervisor) observed:
“We need to get a
good interview up front. Typically what happens is this: the applicant has an
incomplete form. We ask them for supplementary information so we can reduce the
delay in certifying applicants. When benefits are approved we only go back up
to a point to reimburse the facility. The facility loses if process drags out
or if the application is denied”.
Delays affect the applicant (uncertainty about the care situation) and the M/CC unit as well. Specialists spin their wheels following-up with the applicant and/or caseworker to complete the application. The supervisor likened this to “playing chess by mail”.
The M/CC unit was established in 1998 as part of M/CC process reform. Pre-1998, M/CC and regular Medicaid applicants (i.e. those that were not eligible for M/CC benefits) were lumped together, resulting in delayed service. M/CC applicants were especially affected due to the convoluted nature of the certification process. The reforms sought to make the process more direct, improve coordination between the M/CC unit and the facilities, and obtain higher quality information through the interview.
5. Outcomes
With video interviewing (VI), the certification interview lasted 25 minutes on average compared with the 45-60 minute duration with the FTF interview. Nineteen out of the 25 applicants who participated in the VI trial were approved (five applicants expired before a decision) more expeditiously relative to FTF.
5.1 Applicant interface
With VI, the applicant could be interviewed at the facility itself. Recall that, with FTF interviews, the applicants had to go over to the DSS downtown. With the interview now occurring at the facility itself, the specialist and the facility’s caseworker could better coordinate their actions during the interview.
The interview is centered on the benefits application form; the aim is to complete it during the interview. With VI, the visual focus throughout stays on the applicant. In the sessions we observed, the specialist went through the application item-by-item with the applicant. Questions were addressed to the applicant, who responded herself or asked the caseworker to respond on her behalf. The caseworker, who was co-present with the applicant at the facility, participated fully but unobtrusively via the audio channel. VI’s visual focus on the applicant made the experience direct and personal; the applicant was in-charge. The combination of visual and audio affordability made for a productive interview. Work efficiency was gained without jeopardizing the human face of the experience for the applicant. The direct interface with the specialist and caseworker’s at-hand assistance helped “de-demonize” the M/CC process.
With the FTF interview, the applicant was by herself. The caseworker was usually not co-present; she would have to take off from work to attend the session at the unit, and this was infeasible. She was unable to work with the applicant or the specialist during the interview.
VI also permitted applicant’s family to participate in the process, noted the nursing home caseworker. Involving relatives was vital to personalizing the experience for the applicant. Relatives could contribute financial information to complete the application, provide moral/emotional support during the interview, which can be stressful for the applicant, and help lessen the “stigma from Medicaid”.
The M/CC supervisor had feared that applicants might reject VI, but they responded very favorably. Those who picked VI liked its convenience. They also viewed the M/CC process as user-friendly on account of VI-enabled social support: the co-presence of the caseworker and relatives with the applicant during the interview. One family commented: “This was so easy, it was nothing like what we heard it would be”.
5.2 Process control
With VI, respondents had more control over M/CC process. The applicant is interviewed at the facility, leaving no room for no-shows (we found no voluntary no-shows with VI). She is a “captive audience”. With no no-shows, the hospital caseworker said: “Now it is up to the unit to follow-through. The applicant is there to be interviewed”.
VI
helped tightly–couple specialist and caseworker with the applicant. The
facility could be certain the scheduled interview did occur. The specialist and
the caseworker knew exactly what was needed to complete the application. The
applicant was reassured that the specialist’s needs were communicated directly
to the caseworker.
Direct communication cut out the attorney. Many applicants retained an attorney to help them through the M/CC process (the process had gotten “demonized” and applicants were fearful of losing everything). The caseworker would hand all documentation to the attorney, who then worked with the specialist. The attorney relayed specialist’s requests to the facility. The M/CC supervisor referred to this as a “three-ring circus”:
“The facility most of the time heard from the family representatives or attorney regarding how the process was going…Sometimes the attorney or the family would tell the facility that all was well…and that they had provided the information we needed. This all the while not following through on what we had asked for. After several months, the facility would hear the application was denied…”
5.3 “I am the face of
Medicaid”
5.4 Specialist-caseworker interface
Specialists-in-training
observed the interviews. VI hastened socialization: trainees got acquainted
with caseworker early via the interview. “I could put a name to a face from my
very first case”, an M/CC specialist said. VI provided a rich channel for
sustained professional /social relationship-building. The 1998 reforms enjoined
periodic specialist-caseworker meetings to catalyze a community of practice,
with collaborating actors sharing work-related information and learning. Such
meetings were convened but were formal affairs where the unit updated
facilities on policy. VI facilitated activity-driven, one-on-one virtual
conferences through interviews and follow-up consultations centered on the
application. VI enabled facilities to be “integral players” in the M/CC
process. This strengthened relationships to promote ongoing learning on the
M/CC process, which was complex, specialized, and information-intensive.
5.5 Job enrichment
VI enabled caseworkers to acquire specialized knowledge by working directly with the M/CC specialist on the application. The M/CC unit’s trial evaluation report notes:
“Being exposed to the process, the caseworker…builds on their knowledge. This knowledge can be used to inform potential applicants about documentation requirements long before they apply for benefits. By being informed early, a potential applicant can begin to collect this information and have it ready. Benefits to the unit and the facility are a reduction in application processing time and the ability to bill for services sooner”.
The caseworker’s job is clerical and is limited to pre-screening and interview scheduling. With VI, she was interacting with the M/CC specialist on specialized tasks. The hospital caseworker had been opposed to VI but became a proponent because VI enriched her job and made her more effective in it. With a few more sessions under her belt she “could go work for the county as a specialist”. VI refreshed and augmented the twice-yearly in-service training provided by the unit.
Following-up with interview no-shows was a frustrating and unproductive part of a caseworker’s job. Such applicants were elusive and unresponsive once they left the facility. With VI, no-shows were eliminated. So in place of unproductive follow-up work, the caseworker now was working with the specialist and the applicant on the application, and this change in the nature of work was viewed as personally rewarding.
5.6 Change in the division
of labor
Pre-VI, workload distribution between partners was symmetric with that of authority. The M/CC unit had more authority and did more. The M/CC specialist did the interview, followed up with the applicant/caseworker/attorney and decided on the application, and photocopied the voluminous documentation for the applicant’s case file. With VI, facilities were doing more than they did before, while the M/CC unit was doing less. With the interview now occurring at the facility, it fell to the caseworker to photocopy documents and fax/courier copies to the unit. The caseworker also participated in the interview. This was not required under the trial protocols developed by the unit, but applicants needed help with the VI prototype and the M/CC process and the caseworker had to help out. Besides the pre-screening (a pre-VI holdover), the caseworker now did more – photocopying and faxing/couriering copies, pre-application vetting, and interview participation, and these added an extra two hours of work per applicant in the case of the hospital caseworker. It was a little less in the case of the home aide as the pre-interview vetting had been a part of her services pre-trial.
6. Conflict
The hospital’s fiscal officer (fiscal officer) was concerned over the workload. VI had increased M/CC-work from 50 to 65 per cent of his caseworker’s role, short-changing her non-M/CC responsibilities. Her manager asked for an assistant to assist with application filing; the expedited Medicaid reimbursements would easily justify the position (the supervisor argued similarly).
The fiscal officer argued that the M/CC unit, not the facilities, was the bottleneck. Only the unit could decide eligibility and this was the bottleneck. Facilities could speed-up filing but cases would only accumulate at the unit, awaiting a decision. VI had cut interview duration substantially. Decision time had been cut but not as dramatically. An applicant may request a bank statement but had no control over when it was received. VI enabled staff to coordinate case file assembly and start the documentation process early, but had no control over institutions external to the activity system. Decisions could not be made without complete documentation.
Real efficiencies could only result from expedited
decisions, and this was possible only if the hospital could make them itself.
He had pressed for such powers (long before the trial) but had been
unsuccessful. It was a question of power, not facilities’ competence to decide,
he felt. The M/CC unit did not want to “deputize” facilities. Workload shift
from VI-use accentuated an already contentious issue between hospital and unit.
In 1998, the unit eliminated specialist positions it funded at the facilities
for financial reasons. Since then, facilities had to support their own staff
(caseworkers) in those positions. The fiscal officer wanted an expanded role
and more power for the hospital to justify increased expense from VI.
The fiscal officer’s concerns were a consistent theme in his reactions. He was not convinced VI could expedite reimbursement without radical change to the authority structure. He had invited a representative of the state attorney general’s office to a research interview to appraise her on VI’s implications for his hospital. He endorsed VI-use (for the PR, he added). But he fully intended to revisit the power issue with the attorney general seeking fundamental change in law governing facilities’ role, and the outcome of that discussion was likely to influence his long-term outlook on VI at his hospital.
As an interim step within the current unit-dominated authority structure, the fiscal officer wanted two changes to how VI was currently used: on-demand M/CC interviews and VI for regular Medicaid, which contributed more to his bottom-line than did M/CC.
He wanted on-demand M/CC interviews. Currently, there was one schedule for both FTF and VI. The applicant had to be given a choice of interview format per state law. If she picked VI, she was scheduled in two weeks (same as FTF). Meanwhile, the facility was spending money on patient care not knowing what the decision on certification would be. He had expected VI would speed-up scheduling. As it was, the wait was too long.
His vision was this: a patient walks into the facility with no insurance coverage. She is directed to a near-by room for a VI session to evaluate her eligibility. On-demand interviews would help facilities cut costs by evaluating an applicant before services were provided and by starting the certification process at the earliest possible point, expediting reimbursements. The hospital lost $1.5m annually from un-recovered M/CC costs; on-demand interviews could cut this substantially.
In the unit’s view, on-demand VI was infeasible. The application had to be documented, and this was time-consuming: “If an application comes in with inadequate documentation, we cannot make a decision and the pending process will grow. Documentation takes time, so the bottleneck is there, not with us”, the M/CC supervisor noted. The number of unsubstantiated applications would explode with on-demand interviews. More specialists would have to be recruited to handle the increased volume, and this was extremely unlikely in a climate of cost-cutting. Specialists’ time would have to be scheduled differently. Furthermore, state law prohibited walk-in Medicaid eligibility interviews.
The
fiscal officer’s second proposal was as radical as his first. He was more
interested in using VI with regular Medicaid. The hospital lost $4.5m annually
under regular Medicaid (far more than under M/CC), so his motivation was clear.
Given their long-term care needs, M/CC applicants could be billed at the
facility; they were more accessible for revenue recovery. Regular Medicaid
applicants might check in on Friday evening and leave on Sunday, complicating
recovery. “Catching them as they walked in the door” with on-demand interviews
was the answer. The trail did not cover regular Medicaid because applicants had
to be fingerprinted and the county was not ready to consider electronic
fingerprinting.
Workload shift from VI-use negatively affected the nursing home as well but provoked no questions on domain and ideological consensus with the unit. Unlike the hospital, the home handled M/CC cases exclusively, and M/CC reimbursement was critical to it. The home was the first to appoint a caseworker in 1998 when the unit eliminated positions at the facilities. Because their revenues were dependent on M/CC, the administrator felt it was their responsibility to ensure they filed valid applications. He believed facilities were the bottleneck, not the unit. To the extent VI helped in process improvement (he was convinced it did) he was an enthusiastic proponent of it. He had no issue with the unit’s control over eligibility decisions. The unit’s authority over eligibility was sanctioned under state law, and he was not prepared to challenge it. Furthermore, he believed he could justify additional expense from VI (if necessary) against anticipated reimbursements. The fiscal officer saw VI as a cost item; for the administrator, its benefits outweighed the costs.
Non-economic reasons also played a part. The supervisor extolled the home as a model of “how to do M/CC right”. The home’s service orientation seemed stronger than the hospital’s; neither the caseworker nor the administrator saw the increased workload from VI as a burden as it helped applicants file valid applications in a socially-supportive environment. The administrator saw the home as a service delivery innovator; VI was one of many innovations he had sponsored at the home. He was a veteran and an M/CC insider: he had worked on the 1998 reforms with the M/CC supervisor. Concurring with the supervisor in spirit, he viewed VI as a relationship-building tool to further reform goals. To the fiscal officer it was a de-contextualized tool, an interview modality option.
The M/CC unit was very pleased with the field test of the prototype and declared it a success. However, VI is unlikely to become a standard option for the M/CC benefits certification interview because the state would have to approve VI. At this writing, it does not appear that state approval is likely.
7. Conclusion
We examined three municipal websites from the perspective of e-governance and found a mixed bag. While all three sites provided ample information on local government and the local area, not all of them supported online transactional services and broad interactivity. The quality of transactional service provided through these websites was mostly limited to service requests and payments. We then looked at a transactional service prototype over broadband that was successfully field tested by the county. We offer the latter here to outline what is possible in terms of e-service delivery.
The trial is now concluded and the unit fully intends to produce and utilize VI. “In my 20 years at the county, I have not seen a technology promise fundamental process improvement as VI”, said the county’s top Medicaid official at the trial’s conclusion. All major area hospitals and nursing homes are expected to participate in an extended trial-to-production initiative recently proposed by the unit. We will continue to build on the present research as VI diffuses.
A network that aspires to be truly open should provide interactive, publicly accessible features to support direct interaction between residents and the service providers and among themselves. A network that does not provide the means (e.g., listservs, chat rooms, email) to residents in support of horizontal connectivity is in effect insulating itself from influence by residents. Support for horizontal connectivity may be common in dial-up community networks (such as Freenets) but cannot be taken for granted in broadband community networks, as we found out.
8. Bibliography
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Venkatesh, M., and Shin, D.H. (2000).
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