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By Toni Cesta, PhD, RN, FAAN
In October, we began our discussion on ethical issues of relevance to case management professionals. The principles should provide case managers with a framework when dealing with the tensions between providing quality healthcare and containing costs. However, it is doubtful that the tension can be overcome completely. Even when payers or health insurance plans make legitimate decisions, healthcare professionals may sometimes find that they cannot support these decisions in good conscience. How you respond to these dilemmas is significant in terms of maintaining ethical integrity. For example, consider the case study presented below.
A 54-year-old male patient, Mr. Jameson, was taking beta-blockers for his hypertension. He went to his primary care physician, complaining of a dry cough. Mr. Jameson was diagnosed with nasal polyps, and the cough was attributed to post-nasal drip. Both Mr. Jameson’s physician and the case manager believed that precipitated the need for a total systems review. However, he could not undergo these tests due to limits set by the health insurance plan. As a result, Mr. Jameson’s symptoms were addressed from a cost-only approach, and a specialist denied him care.
In this case, both Mr. Jameson’s physician and his case manager confronted a conflict between their obligation to promote his best interests and their obligation to work within the cost-containment guidelines established by the insurance plan. To determine how they should have responded to this conflict, we first need to distinguish between two scenarios. In the first scenario, the insurance plan did not make a legitimate coverage decision. In other words, it failed to adhere to the principles of impartiality, publicity, and contestability.
What should Mr. Jameson’s physician and his case manager do in this scenario? One option is to adopt the role of the “saboteur.” Saboteurs seek to circumvent the coverage limits imposed by the insurance plan or payer by falsifying diagnoses to obtain coverage for services they think the patient needs or deserves. In general, this type of response is ethically unacceptable. It requires healthcare professionals to engage in deception, and it does nothing to improve the decision-making processes of the health insurance plan.
A better response is for Mr. Jameson’s physician and case manager to press for changes to how the insurance plan makes coverage decisions. The physician should appeal the decision, thereby advocating on behalf of this patient. If more aggressive actions become necessary, they might advise Mr. Jameson to take legal action against the insurer as a way of putting external pressure on the insurer to make changes. They also may consider lobbying the insurer to establish public appeals procedures that would allow patients to challenge the coverage decisions. Finally, if the insurer is sufficiently unresponsive to making changes, they should consider limiting their involvement with the insurer as much as possible.
Even the best-intentioned insurers or payers can make coverage decisions that strike healthcare professionals as misguided. In this case, Mr. Jameson’s physician and case manager still may believe that the coverage decision was incorrect. How should they respond? Clearly, they should not engage in sabotage. The role of the saboteur is ethically questionable even when the coverage decisions are illegitimate. With legitimate decisions, it is plainly an ethical mistake to falsify diagnoses. It is deceptive, and it frustrates the legitimate financial and societal goal of containing healthcare costs.
Mr. Jameson’s physician and case manager believed that a total systems review was necessary. After this was denied, they should not attempt to circumvent the insurer’s legitimate decision-making procedures. Instead, they should serve as Mr. Jameson’s advocate in the appeals process for denial of service. They should not argue that Mr. Jameson has a claim to all possible medical care that might reasonably be expected to benefit him; rather, they should argue either that the cost-containing policies that affect him ought to be revised or that an exception should be made to these policies in Mr. Jameson’s case. If they are unsuccessful, they should explain to Mr. Jameson that they have done all they could, given the policies of their organization. They also should explain that although they disagree with the insurer’s decision, they recognize that the organization has a legitimate interest in containing costs and provision of services in the most appropriate level of care or setting. Finally, if they are aware that a total systems review for Mr. Jameson would have been provided by a different insurer, they should inform him of this fact.
As this case illustrates, the ethics of cost-containment largely involve an ability to function responsibly in an organizational setting. This requires a shift in perspective from that of an individualist who strives to do all he or she can do for the patients to that of a cooperator who strives to perform his or her role well within the organization. This shift in perspective suggests that many ethical problems that arise under utilization management procedures of health insurance plans cannot be resolved by individualistic or monological reasoning. Rather, they are problems of organizational ethics that require case managers to engage in shared decision-making — not just between the physician and patient, but also between patient care representatives, discharge planners, social workers, other providers, and hospital administrators. This highlights an important ethical role for the case manager under commercial health insurance plans. As the person responsible for coordinating the delivery of care to patients, case managers also must assume responsibility for initiating shared decision-making to resolve ethical problems.
The following principles are based on social work’s core values of service, social justice, dignity and worth of the person, human relationships, integrity, and competence:
Help those who are in need, address social problems, and place the interests of others above self-interest.
2. Social justice
Challenge social injustice and pursue changes on behalf of those who are vulnerable or oppressed.
3. Dignity and worth of the person
Respect a person’s inherent dignity and worth. Treat everyone respectfully and in a caring manner, mindful of individual, cultural, and ethnic differences.
4. Importance of human relationships
Recognize the importance of relationships and vehicles of change. Engage people as partners in the healing process.
Be trustworthy, honest, and responsible, and promote the ethical principles within organizations.
Practice within one’s areas of competence and develop professional expertise. Strive to learn and sharpen skills and apply them in practice.
The NASW also highlights several standards of ethical social work practices, including responsibilities toward the client, colleagues, practice settings, as professionals, the social work profession, and to the broader society. (More information is available at: https://bit.ly/2yYU7h5.)
The Commission for Case Manager Certification (CCMC) identifies several values of case management practice and rules of conduct. Although these apply for those certified by CCMC, the code is applicable to the larger body of case management.
The underlying values are as follows:
1. Case management is a means for improving health, wellness, and autonomy of patients through advocacy, communication, education, identification resources, and service facilitation.
2. Recognize the dignity, worth, and rights of all people.
3. Understand and commit to quality outcomes for clients and appropriate use of resources. Empower clients in an objective and supportive way.
4. Know that everyone, including the client, his or her support systems, and the healthcare system, benefits when a client reaches optimal wellness and functioning.
5. Case management is guided by the ethical principles of autonomy, beneficence, nonmaleficence, justice, and fidelity.
The rules of conduct are listed in terms of unethical practices and as violation statements that may result in denial or sanctions from CCMC, including revocation of the individual’s certification. Case managers certified through CCMC are expected to abide by these rules.
Rule 1: Intentionally falsifying an application or other documents;
Rule 2: Felony conviction;
Rule 3: Violation of the code of ethics on which the certified case manager credential is based;
Rule 4: Loss of the primary professional credential;
Rule 5: Professional misconduct;
Rule 6: Violation of the rules and regulations of the certification exam.
The CCMC code also describes several standards for ethical case management practice, including client advocacy, professional responsibility, case manager/client relationships, confidentiality, privacy, security and recordkeeping, and professional relationships. (More information is available online at: https://bit.ly/2PcBQUc.)
In its 2010 Standards of Practice for Case Management, the Case Management Society of America (CMSA) emphasizes ethics as one of its standards of practice and highlights advocacy as another. It states that case managers should:
1. Practice and behave in an ethical manner. Abide by the tenets of the ethical codes underlying professional backgrounds and credentials (e.g., nursing, social work, rehabilitation counseling). Case managers may demonstrate ethical behaviors by:
a. Knowing the five ethical principles: beneficence, non-maleficence, autonomy, justice, and fidelity;
b. Recognizing that the primary obligation is to the patient/client;
c. Maintaining respectful relationships with peers, employers, and other professionals;
d. Recognizing that laws, rules, policies, insurance benefits, and regulations sometimes conflict with ethical principles. Case managers must address the conflicts to the best of their abilities and seek consultation as necessary.
2. Advocate for the client/patient at the point of healthcare service delivery, administration of health insurance benefits, and policy level. Case managers can advocate for patients by:
a. Encouraging the patient’s self-determination, informed and shared decision-making, autonomy, growth, and self-advocacy;
b. Educating other healthcare professionals about respecting the patient’s needs, strengths, and goals;
c. Facilitating the patient’s access to healthcare services and educating the patient and family about available services;
d. Preventing and eliminating disparities in accessing high-quality care and outcomes;
e. Expanding or establishing services and for patient-centered changes in policy;
f. Advocating for the patient when conflicts arise regarding cost-constraints and limited resources.
(Find out more about CMSA’s standards at: https://bit.ly/28KokSc.)
According to the American Nurses Association (ANA) Code of Ethics for Nurses with Interpretive Statements, case managers are expected to promote, advocate, and strive to protect the health, quality, safety, and rights of patients. The ANA explains this role with a focus on safeguarding the patient’s right to privacy and confidentiality. It also emphasizes protecting patients engaged in research studies and addressing questionable healthcare and impaired practices. (Find out more at: https://bit.ly/2ZcQIbi.)
Other case management-related professional organizations describe case managers as patient advocates and are explicit about how they demonstrate such role expectations. For example:
• NASW, in its standard on advocacy and leadership for social work case managers, states that case managers should advocate for the rights, decisions, strengths, and needs of their clients and access to healthcare resources, supports, and services.
• The American Case Management Association (ACMA), which focuses primarily on hospital-based case managers, includes advocacy as one of its standards of practice and scope of services. It states that “advocacy is the act of supporting or recommending on behalf of patients/family/caregivers and the hospital for service access or creation, and for the protection of the patient’s health, safety, and rights.”
To enhance the role of advocacy and meet ethical expectations in practice, ACMA offers these guidelines:
- Determine who is the legal decision-maker, whether the patient or a surrogate;
- Share information on benefits, risks, costs, and treatment alternatives (including no treatment);
- Protect the patient’s self-determination and respect care choices and wishes, including advance directives and informed decisions;
- Promote culturally competent care;
- Work with the payer/insurer to ensure that the patient accesses his or her full benefits. Negotiate exceptions when needed;
- Balance resources with patient preferences and seek expert assistance (e.g., ethics committee) to resolve conflicts and ethical dilemmas;
- Address suspected cases of abuse, neglect, or exploitation; for example, referring such cases to appropriate agencies or personnel. (Find more information at: https://bit.ly/31CXQu8.)
The CMSA explains in its standards that case managers educate “the client, the family or caregiver, and members of the healthcare delivery team about treatment options, community resources, insurance benefits, psychosocial concerns, case management [services], etc., so that timely and informed decisions can be made.” In addition, CMSA emphasizes the importance of empowering the patient and family to solve problems and explore alternate care options to enhance the achievement of desired outcomes. These activities must be incorporated into the shared decision-making framework, especially when the case manager explains to the patient and family that they have a choice, and while they discuss options for care.
Ethics plays a large role in the work of case management professionals. Take some time to review and understand the ethical standards that apply to you and your professional area of practice so that you can protect yourself and your patients while providing the best standard of care.
Financial Disclosure: Author Melinda Young, Author Jeanie Davis, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, and Nurse Planner Toni Cesta, PhD, RN, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.