By Toni Cesta, PhD, RN, FAAN

Introduction

This month, we will discuss principles related to ethics and how they affect one’s role as an RN case manager or a social worker. These principles include patient advocacy, which applies to all the roles and functions that case managers perform. Patient advocacy relates to the ethical principle of beneficence. According to this principle, the case manager works with the physician and other members of the interdisciplinary healthcare team to advance the best interests of the patient and family. This ethical issue focuses on promoting the interests of others, whether it be preventing harm or improving the situation for the patient/family.

Case managers must weigh and balance the possible benefits against potential risks of an action, intervention, treatment, and decisions, especially concerning care options. They also are expected to protect and defend the rights of their patients/families and help those unable to speak or assist themselves, especially during unsafe or potentially dangerous situations. Beneficence is an ethical principle that directs the healthcare professional to promote the safety and well-being of his or her patients.

The Case Manager and Social Worker as Patient Advocate

An essential role of the case manager is patient/family advocate. In this role, the case manager may be presented with conflicting choices. Using the principle of beneficence, the case manager always should select the choice that will advance the best interests of the patient and family. Everything a case manager or healthcare professional does should be subordinate to the patient’s interest. As a patient advocate, the case manager must provide patients and their families with the information necessary to make better informed decisions concerning their healthcare services and must support those decisions.

The Commission for Case Manager Certification (CCMC) describes advocacy in case management as a process that promotes beneficence, justice, autonomy, self-determination, and independence for clients/patients and their families or caregivers. It involves educating clients about their rights, benefits, and healthcare and human services, facilitating informed decision-making, and considerations for the client’s values, beliefs, interests, and culture.

Case managers should balance the risks with benefits when deciding on the plans of care. They also must educate patients and families about potential undesired effects before implementing a care plan or discharge plan. Case managers in these situations can counsel and educate their patients about their options and ensure that the patient understands the risks and benefits and can make informed decisions.

For example, social workers and case managers face such dilemmas when offering patients and their families a list of post-acute choices. Some may experience better safety and quality outcomes than others. By assisting patients in making informed decisions, case managers ensure that patients understand the potential risks and benefits for the decision to be considered ethical.

The traditional ethical ideal of the case manager as a patient advocate directs the case manager to act in ways that will maximize the best interests of his or her own patients and their families.

Ethics and Third-Party Payers

Like other healthcare providers, case managers and social workers need to adjust to the changing circumstances of managed care. This requires rethinking some of the traditional ethical ideals that have formed the profession.

The transfer of decision-making authority to the health insurance plan has, in turn, transformed the relationship between healthcare professionals, case managers, social workers, and their patients and families. Physicians are no longer in a position to freely provide their patients with all the care that might reasonably be expected to benefit them in any setting of their choosing. During the fee-for-service era, care providers could act with little concern for costs. In so doing, it was commonly thought, they discharged their duty of beneficence. But, in the current healthcare reimbursement system, the provider is at an increased financial risk due to utilization management practices of payers and value-based reimbursement. The free-handed approach is no longer a viable option.

Case managers can function as patient advocates in the following two ways:

• Ensure that ethics consults are called when necessary;

• Ensure that patients’ interests are fully represented and protected in these consults.

Organizational Ethics

Case managers and social workers are more likely to encounter issues related to organizational ethics than clinical ethics. The type of ethics consult that a case manager is likely to call for differs in significant respects from the traditional clinical ethics consult. The clinical consult largely centers on how individual practitioners can best resolve ethical conflicts that arise when they are treating their patients; for example, deciding whether to terminate care or treatment. However, the conflicts that arise in the context of case management, health insurance, and managed care utilization management procedures and decisions are more organizational. In some respects, these conflicts can better be grouped under a category of “Organizational Ethics” rather than the traditional “Clinical Ethics.” Organizational ethics requires the participation of those who understand systems of care, utilization management procedures, and insurance plans, rather than clinical care.

If an organization has not created an organizational ethics committee, case managers should advocate for one to assist in solving ethical dilemmas, such as those related to utilization management procedures, resource allocation and utilization, and discharge or transitional planning. Utilization management committees are not enough; they are not the best forum to address ethical concerns of an organizational nature. Organizational ethics committees must include participants who are not traditionally present in clinical ethics committees. These include experts in insurance plans and agreements, administrative processes, and systems of care.

Organizational ethics committees should be subcommittees of the organizationwide ethics committee and should report their issues and decisions to the ethics committee regularly.

Organizational ethics deal with an organization’s behaviors related to the individuals represented by that organization (including patients, care providers, and other employees), the community, and other organizations. There are several different categories of organizational ethics. However, the types of organizational ethics conflicts that case management professionals must address will be limited to the unique roles that they play inside the healthcare organization. For example, the roles that case managers play give rise to the types of conflicts for which an ethics consultation would be appropriate:

• Resolving care-related conflicts;

• Preventing delays in treatment;

• Increasing and facilitating access to care and resources;

• Brokering services within and outside the healthcare organization;

• Obtaining authorizations for treatments from insurance plans and managed care organizations;

• Advocating for patients while working with insurance and managed care.

To illustrate an organizational ethics issue, consider the following case.

Organizational Ethics Consult Case Study

Mr. Gaynor was found unconscious. He was admitted to the ICU of a nearby out-of-network hospital. He remained in the hospital for six months before he was discharged to his home in another state. Two weeks later, Mr. Gaynor experienced another syncopal episode. His wife requested that the ambulance bring him back to the original hospital. The physician from the hospital agreed that this would best serve the patient’s medical and health interests. However, because the patient was “out of network,” the case manager was called to decide whether the admission was appropriate.

Cases like this have become more common in an era of insurance and managed care restrictions. In this type of case, case managers best discharge their ethical responsibilities by deliberating with others to determine the appropriate response. However, the people the case manager would most likely need to consult will differ from those a physician or nurse would consult in a dilemma of clinical ethics. In addition to the patient’s family, physician, and a trained ethicist, the case manager also should consult a member of the managed care department, legal department, patient relations, and social work.

Examples of Categories of Organizational Ethics

Healthcare Business

• Cost shifting;

• Billing practices;

• Financial incentives;

• Resource allocation;

• Conflicts of interest.

Societal and Public Health Considerations

• Serving the medically underserved;

• Antidumping issues (EMTALA);

• Discrimination against patients;

• Public disclosure of clinical errors;

• Guardianship.

Healthcare Advertising

• Making unrealistic promises;

• Endorsing specific medical products;

• Marketing of healthcare institutions.

Scientific and Educational Issues

• Education of future healthcare providers;

• Performing research and clinical trials.

General Business Practices/Relationships

• Employees;

• Vendors;

• Payers;

• Outside agencies.

Given the training and institutional role in today’s healthcare system, case managers and social workers must develop skills for collaborating with physicians, nurses, patients, and family members on developing comprehensive and integrated healthcare delivery plans. These collaborative skills are needed to engage effectively in deliberative decision-making to resolve problems of organizational ethics likely to arise under managed care plans and the utilization management restrictions imposed on your practice.

Methods of Approaching Ethical Dilemmas

Case managers sometimes have to choose between the needs of the patients vs. the needs of the organization. This is particularly true as it relates to the balance between the cost and the delivery of healthcare services. Managing care with limited resources requires case managers to oversee their patients’ journeys through the healthcare system with an eye toward eliminating inefficiency and unnecessary expense — especially from duplication and fragmentation of services. In organizations using bundled payment systems, case managers must balance the needs and interests of patients to stay within a fixed budget.

Cost containment often is disparaged as a financial rather than a medical and quality goal. This is only partly true; cost-containment techniques are essential to provide people with affordable healthcare. When case managers function within a legitimate health insurance and managed care environment to limit costs, they are not merely serving the interests of insurance companies but are serving the interests of society as well.

Below are some methods to use when approaching these dilemmas:

• Enforce and promote mutual trust among all parties involved.

• Maintain the patient’s confidentiality, privacy, right to choose, and self-determination.

• Affirm the dignity and worth of each party.

• Project commitment to truthfulness.

• Respect diversity of values and difference of opinion, including right of refusal of care.

• Ensure congruence between verbal and nonverbal communication.

• Avoid being task-oriented.

• Allow sufficient time for each ethical issue.

• Spend enough time with the patient, family, and other healthcare providers for each dilemma faced.

• Meet with patients and families in private rooms and comfortable settings.

• Believe that good communication results in desirable outcomes.

• Assume and project a sense of responsibility and accountability.

• Always involve others in shared decision-making, regarding the issue at hand.

• Deliberate with a consistent set of values and goals.

• Distinguish ethical problems from other general patient care management issues.

• Seek the assistance of others when unable to address the issue independently.

• Be thorough and timely in gathering information; value uncertainty over confidence.

• Always apply the institutional policies and procedures; they are intended to support and guide practice.

• Document pertinent information in the patient’s medical record.

• Remember to always be patient-centered and allow patient-driven care planning. Keep benefits patient-focused rather than healthcare team-focused.

• Avoid premature closure on issues. This prevents confirmation bias and deciding on the issue before all the facts have been gathered and examined.

• Be mindful; ask if anything could have been done differently; check whether anything important was missed.

• Promote disclosure and transparency, especially when an error occurs or in case of bad news. Be honest, compassionate and empathetic, tell the truth, and build trust through effective and respectful communication.

Rethinking Ethics

Case managers must rethink ethical self-understanding to fit today’s competitive and challenging healthcare environment. Like the traditional physician/patient relationship, the traditional nurse/patient and social worker/patient relationship is transformed once cost containment becomes an issue. Under health insurance plans, nurses — and case managers in particular — may have conflicting loyalties. They have obligations both to their patients and to the payer organization for which they work. Balancing these obligations in an ethically appropriate way requires no longer thinking in terms of maximizing the interests of their patients. Recognizing this important point is the first step in reformulating the traditional ideal of the case manager and social worker as patient advocate.

Often, case managers advocate for the patients they serve and execute care plans to safeguard what is in the best interest of patients. However, case managers also must work with representatives of the health insurance plans and payers to ensure effective use of healthcare resources and adherence to the insurer’s utilization management procedures, such as provision of a treatment after it has been authorized by the health insurance plan. In such situations, waiting for authorization may result in delaying treatment, which may ultimately cause suboptimal outcomes. The case manager in these situations struggles between safeguarding the patient while meeting the expectations of the health plan.

Summary

This month, we discussed the basic tenets of ethics as they apply to case management professionals in today’s world of managed care, value-based purchasing, and cost containment. We will conclude next time with some real-world examples and ethical standards that apply to all case management professionals.