Guest Column: Advocacy may be a balancing act for CMs

Remember needs of patients, hospitals, insurers

By Hussein Tahan, DNSc, RN, CNA
Commission for Case Manager Certification
Rolling Meadows, IL

For case managers working in an acute-care environment, advocacy is a fundamental principle of the services they provide. Advocacy may be described simply as "wanting, getting, and doing what is in the best interest of the patient and the family."

In practice, however, case managers find themselves acting as advocates not only for the patient and family but for the hospital and provider of care as well. The needs and priorities of these parties may result in conflicts case managers are pressured to resolve.

Here are some of the stakeholders whose interests the case managers must keep in mind:

The patient and family

Case managers advocate for the patient and family by ensuring that the plan of care is appropriate and that treatments, tests, and procedures are available and accessible.

It also means ensuring that the care provided is timely, of the utmost quality, and in the best interest of the patient and family.

Moreover, case managers ensure that the patient and family are making informed decisions about the care they opt to receive.

The hospital or provider

Case managers advocate for the hospital by working with the care providers (e.g., physicians, nurses, social workers, and others) toward a timely patient’s discharge and by negotiating with the insurance companies for the authorization of care and utilization of necessary resources.

These acts aim to enhance reimbursement and meet the hospital’s goals and targets while ensuring patients receive safe and quality services.

The insurance company

Working with representatives of insurance companies increases the complexity of the case manager’s role as an advocate. The demands of these companies (e.g., authorization and certification procedures, reimbursement methods, utilization management policies, and quality reviews) often add another dimension and player to the advocacy process.

Case managers are placed in situations where they are obligated to inform the patient/family and the provider of care that the insurance company has denied a particular treatment.

This presents a potential for conflict: Is the case manager advocating for the insurance company, the hospital/provider, or the patient/family? The patient’s perception of this aspect of the case manager's role impacts the patient-case manager relationship.

If the patient perceives the case manager to be advocating for the insurance company, the quality of their relationship is compromised, trust is jeopardized, and therefore, the case manager may fail in meeting the set goals.

Given those contexts, it's easy to understand why advocacy is a complex and demanding role for case managers. At all times, the needs of the patient and family are paramount, while dealing with the reality of the hospital's requirements and the demands of insurers.

In the managed care environment, with its emphasis on cost containment and resource allocation, the advocacy balance becomes even more delicate.

In research that I conducted recently, I found that case managers — often working as part of a collaborative team that includes physicians, social workers, and others within and outside the hospital environment used six main strategies for advocacy. They include:

Communicating with each other, the patient/ family, the hospital, the insurance company, and other community agents regarding care and related issues in attempts to ensure patients receive the care they need.

Teaching to ensure that the patient/family and other parties (especially physicians) were informed and knowledgeable about managed care regulations and practices, the decision-making processes at insurance companies, and procedures of denials and appeals. This is necessary for all involved to understand the reasons why certain decisions are made and their implications.

Resolving disagreements that may arise among any of the parties: patient/family, insurance company, hospital/provider. The main purpose is not to compromise care and its related outcomes.

Brokering of services needed by the patient and family while in the hospital or after discharge into the community. This is essential to ensure that patients access the services they need and in a timely fashion.

Obtaining consent to secure approval by the patient/family for treatments, tests, and procedures, and to confirm that the patient/family allows the hospital to appeal a denial on their behalf with the insurance company or state.

Supporting to provide emotional support and psychosocial counseling to reduce anxiety on the part of the patient/family during illness and treatment.

Further, case managers employ a negotiation strategy to balance the needs and demands of the three parties (i.e., the patient/family, the hospital/provider, and the insurance company), to resolve conflicts, and reach more desirable outcomes. For example, if an insurance company denies treatment that the physician and the hospital decide is necessary, the case manager (along with the other team members) will negotiate on behalf of the patient.

The goal will be to try to influence the insurance company to change its decision in favor of the patient and authorize treatment. If these efforts fail, the case manager and team members may turn to the physician and/or others at the hospital to negotiate with the insurance company.

In the ideal situation, the outcome of advocacy is a win-win solution, in which all three parties are happy. There are times, however, when one or more of the parties is not pleased with the initial outcome. In these instances, the case manager turns to negotiation skills in an attempt to reach the best solution possible.

Advocacy clearly is a balancing act, one that demands that the case manager, often working as part of a team, seek to meet the needs of the patient/family while satisfying the demands of the hospital/provider and the insurance company. These tasks are increasingly challenging. However, as case managers, we must not lose sight of advocacy as one of our fundamental roles and ethical obligations. To do so would not only undermine our effectiveness but also jeopardize the benefit we bring to the patients, their families, and the entire care continuum.

[Hussein A. Tahan, DNSc, RN, CNA, is the chair-elect of the Commission for Case Manager Certification (CCMC). The CCMC is the only certifying body for case management professionals accredited by the National Commission for Certifying Agencies. Hussein also is the director of nursing for Cardiovascular Services at Columbia University Medical Center, New York Presbyterian Hospital in New York City. Additionally, he is the co-author of The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice.

The article is based upon findings published in Tahan’s 2003 doctorial dissertation, "A Substantive Theory in Acute Care Case Management Delivery: Provision of Integrated Care Using a Collaborate Core Team" (UMI Number 3088430).]