Who should come first for CMs: patients or employers?

Walking a tight rope between advocacy and finances

Suppose you're a hospital case manager under pressure to move patients to another level of care and free up beds for patients boarding in the emergency department. What do you do if you think a patient really needs to stay in acute care?

Or maybe, you're a case manager for a health plan that has a program to provide bonuses to staff for keeping down the cost of care. If a patient has a certain benefit and needs the services, what do you do?

Both of these scenarios describe dilemmas for case managers who want to do the best for their patients but are being pulled in another direction by divided loyalties or financial considerations.

On the one hand, the case managers' roles and responsibilities have been defined by the employer, and they know that their job security might depend on bed turnover or moving patients to a lower level of care. On the other hand, they know their patients' needs, points out Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a case management consulting firm based in Huntington, NY.

"In today's healthcare environment, many case managers feel the ethical pull because of finances," Mullahy says. "In the past, nurses and social workers never had to be involved with money matters and never were directed to push patients out of the hospital. We did not have the technology to enable patients to survive, and few lived long enough to use a million dollars worth of benefits."

Because healthcare is being run like a business, case managers find themselves reporting to business managers who might not understand or be sympathetic to ethical dilemmas. "Just as we want the CEO, the hospital director, or the medical director to understand our role, we have to comprehend their need to balance the budget. They face the same ethical dilemmas and are as unequipped as we are to address them," Mullahy says.

John Banja, PhD, professor, Department of Rehabilitation Medicine, and medical ethicist at the Center for Ethics at Emory University in Atlanta, says, "Balancing the best interest of patients and employers is a problem that is always present in the healthcare field. However, our primary obligation is to the people we serve, and that's our patients. That's what ethical healthcare is all about."

It's never ethical to provide someone with less than what he or she is reasonably owed and reasonably needs, Banja says. "If a patient needs a service and is reasonably owed it, a case manager's ethical responsibility is to see that he gets it," he adds.

All healthcare professionals, regardless of their discipline, should make being a patient advocate their greatest priority, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm. The standards of practice for case managers developed by the Case Management Society of America (CMSA) and the Code of Professional Conduct for Case Managers developed by the Commission for Case Management Certification (CCMC) emphasize that case managers' first responsibility is to their patients or clients, Kizziar points out. "Regardless of the area of practice, the purpose of case management is to remain on the side of the patient and the outcome," she says. "If we do right by the patient by being a good steward of their funds and ensuring that they get what they need, we'll be successful in our jobs, and the patients will have the best outcomes."

Case managers have always been faced with the issue of serving too many masters, says Annette Watson, RN-BC, CCM, MBA, president and founder of Watson International Consulting, with headquarters in Mount Laurel, NJ, and chair of the Commission for Case Management Certification (CCMC), an organization representing more than 30,000 certified case managers. This issue is especially prevalent in organizations and areas of practice in which the case management role might include utilization management and other roles that are not consistent with the CMSA standards of practice or the CCMC code of conduct, Watson says.

"If someone is being true to the definition of case management and true to the role as defined by professional organizations, they will always put the patient first. The first duty of a certified case manager is to the patient, and no role is more important than the advocacy role," she adds.

So how do you put your patient first and still keep your employer happy? First of all, case managers and patients should keep in mind that there is no guarantee of unlimited free healthcare for anyone. Kizziar says, "Being a provider doesn't mean giving patients the Cadillac of everything that is available and being a payer doesn't mean cutting costs on everything. As case managers, we should work to get patients the best possible services for this particular episode of care, and being a good steward of their funds means doing it in the most cost effective way. (For more information on being a good steward of patient resources, see related article, below.)

Provider case management is not about managing the length of stay, it's about controlling the cost of care, Kizziar points out. "You can meet any length of stay requirements every single time but can still go broke if you don't monitor the cost of care. Case managers should make sure patients get what they need when they need it without any extra tests or procedures," she says. For example, a patient who is hospitalized with pneumonia doesn't need a colonoscopy as an inpatient procedure, Kizziar adds.

Banja says, "Case managers should use their wisdom and experience to look at all the variables and make good choices for their patients." The case manager's obligation to the patient is often constrained by the contractual relationship spelled out in an insurance policy or workers compensation benefit if the patient is injured on the job, he says. Taking the contractual approach to advocacy has a lot going for it, particularly if you keep in mind that a patient's benefits are likely to be what he or she chose, Banja says. "Most patients have a lot of choices when it comes to insurance coverage, and when they have a claim, they get what they pay for," he adds. "But there are instances when a person is legally entitled to, say, 10 treatments and needs them, but because of money incentives, the case manager will strongly try to persuade the powers that be to cut it off at five visits. That will go down as an attempt to defraud an individual for personal gain."

Real dilemmas arise when there are new treatments, modalities, interventions, and research on a particular disease. Every patient wants the latest and greatest treatments, but sometimes third-party payers won't pay for a new treatment, deeming it "experimental" or not an improvement over what is already out there, Banja says.

"This is an issue that case managers deal with daily," he says. "There are new treatments coming down the pike every day for a variety of conditions. We have to determine how to do what is best for the patient and use his or her resources judiciously."


For more information, contact:

  • John Banja, PhD, Professor, Department of Rehabilitation Medicine, a medical ethicist at the Center for Ethics at Emory University, Atlanta, GA. E-mail: jbanja@emory.edu.
  • B.K. Kizziar, RN-BC, CCM, CLP, Owner of B.K. & Associates, Southlake, TX. E-mail: bkandassoc@verizon.net.
  • Catherine M. Mullahy, RN, BS, CRRN, CCM, President and Founder of Mullahy and Associates, Huntington, NY. cmullahy@mullahyassociates.com.
  • Patrice Sminkey, Chief Staff Executive for the Commission for Case Management Certification, Mount Laurel, NJ. E-mail: psminkey@ccmcertification.org

Advocating means being a good steward

Keep limits to coverage in mind

Being an advocate for your patients is more than just trying to get them every treatment available. It's being a good steward of their healthcare funds so they'll have benefits for treatments in the future, says B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm.

"Nobody has an unlimited bucket of resources," Kizziar says. "Case managers in all practice areas should be aware that patients are going to have needs after this particular episode of care and conserve their resources whenever possible."

The first step in the process is to be informed about your patients' benefits and resources and develop a plan to make them work for the best possible transition of care, she adds. Look at your patients' lifetime benefits while developing a treatment plan, Kizziar says. "For instance, if a chronically ill patient needs home care, look at the annual limit on home care visits. It might be wonderful if he could get five visits a week but if the limit is only 20 for the whole year, suggest the minimum he can get by with so he'll have funding to last the rest of the year," she suggests.

Remember that even when a patient has no lifetime maximum, that doesn't mean he or she has a blank check for healthcare costs. Even unlimited lifetime benefits usually have some kind of annual maximum, Kizziar points out. "Case managers should be concerned about doing the right thing for the patient at one particular time. Patients don't necessarily need a comprehensive total work up if they come in for one particular ailment. Part of the role of case managers is to partner with the physician to ensure that patients get what they need to transition as smoothly and appropriately as possible," she says.

Case managers should ensure that their patients know all the options for care and become actively engaged in the healthcare process and decision making. Case managers should also provide the information they need to make informed decisions, Kizziar says.

Beware of making personal judgments about what patients can or can't afford if their insurance doesn't cover a particular service, says John Banja, PhD, professor, Department of Rehabilitation Medicine, and a medical ethicist at the Center for Ethics at Emory University in Atlanta. "Often healthcare professionals make up their mind as to how much patients can afford, and they don't mention a modality if they think the client can't afford it. This is always a mistake. You never know what the client or patient has in the way or resources. Case managers should always inform the patient about whatever reasonable options there are and not make judgments about what he or she can afford," Banja says.

For example, if a patient could benefit from home care but doesn't have coverage for it, talk to the family. They might be able to find a way to pay for it. Kizziar says, "In healthcare we tend to think we know what is best for our clients, and we have made them dependent on us. But with the changing healthcare environment, it's critical to help them become more engaged in their own care plans. This means giving them more information about what is covered and what is not, and giving them the option, and letting them make their own decisions," Kizziar continues. Doing otherwise takes the decision process away from the patients, she adds.

In some cases, when spending a little more now can save a lot more later, providers and payers might be able to work out a way for patients to get what they need, Banja says. For example, a patient might have a limit of 10 physical therapy benefits, but when he is reaching the limit, the case manager sees that he is doing so well that if he has five more visits, he could be entirely fit to return to work and avoid reinjuring himself. In this case, not only would the patient benefit, the third-party payer also might benefit by saving money down the road, he says.

"The case manager could make a plea for the insurer to cover extra visits. If that doesn't work, she could ask if the physical therapist would give a self-pay patient a discount and ask the patient if he's willing to pay a reduced rate out of pocket," Banja suggests.