Consumer revolution ignites demand for more accountability in health care
Here are ways CMs can avoid getting burned
This month, Case Management Advisor brings you a special report from the Seventh Annual Case Management Society of America Conference: Upward Bound, held May 31 through June 3 in Boston.
If one word echoed resoundingly throughout the four-day conference, that word was "accountability." Industry leaders predict case managers will be held increasingly accountable for the legal, ethical, financial, and even social consequences of their case management interventions.
We have combined highlights of conference presentations and private interviews with nationally recognized case management, legal, and health care professionals to explain what this new era of accountability means to you.
A consumer revolution that started as a small trickle of discontent now rages like a river through the health care delivery system. The anger of the American public seems to swell in direct proportion to the rate at which managed care brings on changes and restrictions in health benefits. As a result, Americans are taking their frustrations to the doors of their legislators and courts of law in record numbers, sending managed care organizations, providers, and soon, many predict, case managers reeling under the weight of new government regulations and high jury awards.
If you find this hard to believe, look for a moment at the evidence. It was consumer pressure that led to government action to mandate longer hospital stays for women following childbirth and put an end to so-called drive-through mastectomies. Consumer pressure also prompted the National Committee for Quality Assurance (NCQA) in Washington, DC, to develop and continue to refine its Health Plan Employer Data and Information Set (HEDIS 3.0) report cards for managed care organizations.
In June, the Texas legislature approved a bill that allows consumers to sue health maintenance organizations (HMOs) for medical malpractice. A similar New York bill that goes into effect this September allows consumers to collect medical negligence awards if they prove their illness worsened because their insurance company denied, delayed, or reduced payment. (For more details about the current legal environment in case management, see Case Management Advisor, March 1997, pp. 41-44.)
The implications for your case management practice could be devastating unless you realize now that you will be held increasingly accountable for your case management decisions. "Accountability means the case manager must be able to justify or explain the rationale for each case management decision that he or she makes based on logical reasoning and scope of individual practice," says Cynthia E. Whitaker, RN, BSN, CCM, president of RNS Healthcare Consultants, a case management firm in Sacramento, CA, and president of the Case Management Society of America (CMSA) in Little Rock, AR.
Consumers increasingly are demanding explanations for how decisions are made in health care delivery, adds Mark E. Meaney, PhD, health care ethicist with the Center for Ethics in Health Care at St. Joseph’s Health System in Atlanta. There are certain basic ethical principles that can serve as the basis for any decision you make in terms of allocation of resources. "If case managers consider every hard case in light of those ethical rules, it can help them prepare an answer to anybody from the outside that questions their decision-making process." (For further discussion of case management ethics, see story, p. 138.)
In addition to increased state and federal legislative regulation of the health care delivery, experts predict that case manager report cards are looming on the horizon. "I believe that in the next several months, case management companies and case management departments will be audited and given report cards," says Mary F. Gambosh, RN, CDMS, CCM, president of Mary F. Gambosh Limited, a case management company in Richmond, VA, and past president of CMSA. (For more predictions about the future of case management, see story, p. 136.)
"I have seen this increased demand for case management accountability coming for years," says Marlys Severson, RN, CCM, president of SCM Associates, a case management firm in Cypress, CA, and immediate past president of CMSA. "If case managers want to have a place at the table, to have a say in what we do, we must lead the effort to measure case management outcomes. We must make ourselves accountable." To earn its place at the table of accountability, CMSA established the Center for Case Management Account- ability (CCMA) to help identify which outcomes case managers could be held accountable for and how those outcomes could be measured. (For more information about CCMA, see story, p. 137.)
In the meantime, the key to scoring well on case management audits or report cards when they arrive is carefully following established case management process, says Gambosh. "We have to be able to defend our decisions with all parties. We are accountable."
Here are the seven steps Gambosh suggests case managers follow as they work each case:
• Assess current patient care.
• Assess current and future patient needs.
• Establish treatment options.
• Link treatment plan with the funding source and the patient.
• Implement the treatment plan.
• Monitor the treatment plan.
• Report to the funding source and all members of the treatment team.
"As case managers work through this process, we must be ready to defend our decisions, because we must make decisions all along the way," Gambosh says. It also helps case managers to ask simple questions throughout the process. Those questions include:
• What was the status of the case when it was referred to me?
• What is the present status of the case?
• What is the current plan of action?
• How long will it take to complete?
• How much is it going to cost?
• What is the projected outcome?
Navigating care plans
"The answers to these questions become the road map to managing your cases," Gambosh explains. "We have to listen carefully to everybody. We have to bring together the problems. Put them on paper and decide how we are going to solve them. The key to future survival in case management is to come to the table with an open mind and work to get paid for what you know and not only for what you do. Case managers who continue to be narrowly task-oriented will always be looking for a new job."
And case managers who fail to listen carefully and fully explain every option may find themselves in a court of law, she cautions. "If the care plan is not fully covered, case managers must explore the possibilities of adjunct funding. Then, we must learn to do the best we can with what we have and move on. However, case managers must never withhold a proper recommendation because it may not be covered, or they could wind up explaining why they withheld it in court."
Solving the value equation
Attorneys agree. "Case managers should disclose all options, even if some aren’t covered," says Stephen J. Schanz, JD, LLM, publisher of Parameters, Guidelines and Protocols, a monthly health care law newsletter by Legamed Publishing in Raleigh, NC. "You should always give your best independent judgment about options. If only three of the four options are covered by the patient’s insurance policy, you should still tell them about the fourth uncovered option. The patient should retain some say whether he or she wishes to pay out-of-pocket for a desired, unreimbursed option." (For a brief look at how accountability affects your work environment, see story, p. 136.)
Case managers who have always strived to deliver cost-effective, quality health care for their clients need not lose sleep over this new era of case management accountability, say health care industry experts.
"Business demands that case managers deliver value in health care. Value means simply the best attainable quality at the lowest justifiable cost. It is an equation that is never finally solved," explains Sean Sullivan, BA, LLB, president and chief executive officer for the National Business Coalition on Health in Washington, DC. "To survive," Sullivan says, "case managers must continue to come up with new solutions to the value equation."
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