Erase the battle lines: How to cut out conflicts with MCO case managers
February 1, 1999 7 minutes read
Erase the battle lines: How to cut out conflicts with MCO case managers
The stronger the relationship, the easier it is to negotiate,’ experts say
As managed care penetration increases in markets across the country, so do tensions between hospital-based case managers and their payer-based counterparts. The managed care representative may too often be merely a voice on the phone, seemingly reciting a litany of rules without reference to the specific needs of the patient. And as hospitals add more and more managed care contracts, it becomes increasingly difficult to maintain effective relationships with managed care case managers on behalf of the patient and the facility.
But experts who’ve worked both sides of the fence say there are ways to reduce the inevitable conflicts that arise between case managers in the hospital and those working for a managed care organization (MCO). And reducing conflicts — by opening up lines of communication and seeking to align incentives — is the only way to get more of what you want from your relationships with MCOs.
"The stronger the relationship is, the easier it is to negotiate," says Deborah Smith, MN, RN, Cm, CNAA, executive vice president of American Medical Systems in Los Angeles. Smith, a former hospital case manager, also is lead author of the Little Rock, AR-based Case Management Society of America’s standards of practice. "When people know each other and understand each other’s motives, as well as the mission of each role, then they have a platform from which to work that’s far more effective than if they don’t that strength of relationship."
Smith adds that most people on both sides are motivated to do what they think is right. The problem is reaching a consensus on what the right thing is. "It’s easy to criticize somebody you don’t know and have never seen and who’s across the country on the telephone," she says. "What’s more difficult is understanding the various perspectives and the knowledge base that each [person] brings to the situation."
Toni G. Cesta, PhD, RN, director of case management at Saint Vincent’s Hospital and Medical Center in New York City, agrees that any successful negotiation with managed care companies depends first on finding some kind of common ground. "We’ve been successful many times in negotiating benefit changes because of our relationships [with payers]. Organizations that create an antagonistic relationship are not really going to get where they want to go," Cesta says. (For more on how Cesta has built positive relationships with managed care representatives, see related story, p. 23.)
But aligning incentives and finding common ground can be more difficult than it sounds, given the many and sometimes complicated points of contention between hospital case managers and their managed care-based counterparts. These include:
• Authorization.
"Hospital case managers often claim that with HMO X, their patients never get a certain test or a certain intervention," Smith says. "That’s probably overstated, but often their feeling of conflict comes because the patient needs something and the managed care case manager doesn’t see it the same way. So there becomes a conflict over authorization and medical necessity."
• Vendor selection.
"Sometimes the acute care case manager will want to use a particular vendor for quality purposes," Smith says. "Or something they know about the local terrain will lead them to select a certain long-term care facility. The MCO may have a different idea, either because it has a contractual relationship or because it’s not knowledgeable about the local community. Or they may just have a different opinion. So we see some struggle about what the patient needs for discharge and where they are going upon discharge."
• Lack of contact.
Joanna Kaufman, RN, MS, a managed care specialist and president of Pyxis Consultants in Annapolis, MD, says differing perspectives among managed care and hospital-based case managers often are a cause for conflict. And those conflicts are only exacerbated when case managers are forced to communicate by long distance.
"The acute care case manager is trying to do her best for the patient, and may develop a plan that is not consistent with what the MCO case manager’s plan might be," Smith says. "There’s a sense [from hospital case managers] that I’m here, I’m seeing the patient frequently, if not every day, and here’s this person on the telephone telling me what I’ve got to do.’ The problem is that the person with the leverage is the MCO case manager, while the person with perhaps more of a sense of rightfulness is the acute care case manager, because she’s right there on the scene."
• Access to patients.
Another issue, Smith says, is the question of who has "ownership" of the patient. Some hospitals insist on barring managed care case managers from having physical access to the patient as a way to decrease confusion on the part of the patient.
Kaufman, who has served both as a hospital nurse and as vice president for case management at a managed care company, says such an approach can be divisive and can undermine the quality of the hospital/managed care relationship. "I think that most managed case managers understand that hospitals have policies and procedures about access to patients," she says. "And it’s probably incumbent upon the managed care case manager to call the case manager at the hospital and have a discussion about what those policies and procedures are."
Smith says such negotiations regarding policy disagreements are more easily resolved if the managed care representative spends significant time at the facility. "When you have lunch or coffee with somebody and you see her day in and day out and you work together on a number of patients, you develop a sense of trust about what that person knows, what she’s trying to achieve, and how she’s going to achieve it," she says.
That kind of trust is particularly apparent in cases where health plans delegate discharge planning and utilization review duties for their high-risk patients to hospital case managers, says Sandra L. Lowery, BSN, CRRN, CCM, president of Consultants in Case Management Intervention in Francestown, NH. "Talk about trust," she says. "They’ve found a way to communicate at the same level. And I see that naturally occurring when everyone is trying to work together. Especially in hospital environments that have already accepted capitation, case managers should be providing the same level of service and the same model of service, whether they’re responding to a managed care organization or to their own organization. It’s only when there’s a disconnect between the two that problems occur."
Lowery adds that trust is possible only when case managers share common goals and principles of practice. But finding that sort of common ground is difficult, particularly because the roles and responsibilities of individual case managers can vary widely. "That’s where we find tremendous difficulty, because many case managers have the title but are not adhering to the national standards of practice," Lowery says.
And even if roles and responsibilities match up, viewpoints may differ widely. For example, while hospital case managers may be accountable for financial outcomes, they also must be accountable for clinical and functional outcomes, as well as patient satisfaction. Meanwhile, a managed care case manager may not consider her responsibilities that comprehensive.
One way hospital-based case managers can help to win over their MCO-based counterparts is to actively involve them in the case from the beginning, Kaufman notes. "More and more members have case management in their plan, but they don’t always come to the attention of the managed care case manager at first blush," Kaufman says. "One way for the hospital case manager to enhance communication and establish a positive relationship is to inquire whether the patient is known to the system or should be known to it."
Update MCO on problem patients
Another relationship builder is to give managed care case managers an occasional "heads up" on the status of problem patients. For example, Kaufman says, a patient familiar to both the hospital case manager and the MCO case manager is admitted again. "A simple follow-up phone call to the managed care case manager saying we’re going to put together a new plan, and we’ll keep you updated’ lets the managed are company understand that we’re working on this together," she says.
Good discharge planning practices also can help strengthen bonds with managed care case managers, Kaufman notes — especially when it comes to patients who may have complex ongoing care needs. "It’s very helpful if we know a good discharge plan has been put together, and there’s been input from all the appropriate sources and proper documentation," she says. "It strengthens whatever requests people have for equipment, nursing, and ongoing funding."
Smith says she believes case managers ultimately will have to work together not just to develop discharge plans but also master plans that cross the continuum and are agreed upon by both payers and providers. "That might be one way we could begin to fix the problem rather than just complain about the problem," she says. "We have to stop competing over whose patient it is and try to develop a sense of consistency for the patient and perhaps broaden our horizons. The issue of compartmentalization is still very real, and I look forward to being able to cross those bridges."
For more information, contact:
Sandra L. Lowery, BSN, CRRN, CCM, president of Consultants in Case Management Intervention, Francestown, NH. Telephone: (603) 547-2245.
Deborah Smith, MN, RN, Cm, CNAA, executive vice president, American Medical Systems, Los Angeles. Telephone: (213) 624-2225.
Joanna Kaufman, RN, MS, president, Pyxis Consultants, 917 Langdon Court, Annapolis, MD 21403. Telephone: (410) 216-6661.
Toni G. Cesta, PhD, RN, director of case management at Saint Vincents Hospital and Medical Center, 153 West 11th St., New York, NY 10011. Telephone: (212) 604-7992.
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