Does case management help or hinder?

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By Anne Federwisch, OTR
Illustrations by Malcolm Garris/PhotoDisc
February 19, 1998

Who’s on your case — or more precisely, your patient’s case? If the condition is chronic, chances are it’s a case manager. But exactly what that case manager does varies by position and point of view.

Some see case managers as guiding patients through the healthcare maze, opening doors to treatment and services. Others see case managers as closing those doors and denying care to ensure a favorable bottom line.

"For managed care companies to turn that [the concept of a case manager as patient advocate] around to make this basically a gatekeeper to services is an abomination," said Jamie Court, director of Consumers for Quality Care, a healthcare watchdog group based in Santa Monica, California. "A case manager who is simply trying to cut costs is not a patient advocate, and case managers should always be patient advocates."

Educating the public

Case managers truly are patient advocates, said certified disability management specialist Kathy Moreo, RN, chair of the public relations committee for the Case Management Society of America (CMSA) and co-owner of Prime, a case management education company in Miramar, Florida. Yet she admits that the profession may not have made that clear to healthcare consumers and clinicians.

"We have as an industry grown so quickly and been so self-absorbed in how we want to deliver our services, and how we want to develop our standards of practice," she said. The number of certified case managers has grown from 11,000 in 1993 to approximately 18,000 today, she said. Because certification is optional, that’s only a fraction of the number of practicing case managers. "Now we need to educate the consumers, the legislators, etc.: Here is what our role is, and here are our limitations."

Suzanne Mintz, president and co-founder of the National Family Caregivers Association, agrees. "For consumers, it’s a relatively new term. They understand doctor and nurse, but not that many people have had interactions with case managers," she said.

Differing roles

But even the term case manager can have varied meanings, said Marjorie Barter, EdD, RN, an associate professor of nursing at the

University of California, San Francisco. "Case manager positions run the gamut from the traditional utilization review person in an insurance company to highly functioning clinical case managers who practice disease management. They are well-versed in treatment options and actually work with the clients to achieve optimum health. All these people function quite differently," Barter said.

Certified case manager Kathy Kucera, PhD, RN, president of the Dallas/Fort Worth chapter of CMSA and a senior case manager for a large, nonprofit insurance company, views the job more broadly. "I think that case management has more to do with looking at the total person and coordinating benefits, finding resources and alternatives for that person throughout the continuum of care," she said. "What I’m here to do is help them manage their benefits, the benefits that they have bought."

Getting what you pay for

Most people don’t know what their insurance policies cover until faced with a major illness or injury, Kucera said. She explains the intricacies to patients using a car analogy. If you didn’t pay for a Cadillac, you don’t get its luxurious accommodations. Likewise, if you didn’t pay for an insurance policy that covers 40 home health visits a year, you don’t get 40. "Sometimes it helps them understand that as a case manager, I’m not sitting here flipping a coin deciding who gets what."

Yet sometimes when she explains that a service is not covered, patients and clinicians consider her an adversary instead of an ally on the healthcare team. That "bad-guy" image is not deserved, Kucera said. "We’re not here making up these benefits as we go. There are criteria that we use. There are medical necessity guidelines that we use, and there’s the benefit package," she said.

That benefit package is what the patients—or their employers—buy. To cut costs, many employers have pared down insurance coverage for workers. "We are employed by our [insurance] companies, but at the same time, it’s the employers that have picked out what benefits to provide for employees," Kucera said.

Moreo agrees that case managers occasionally get a bum rap. "You can’t shoot the messenger," Moreo said. "The case manager, in his or her scope of practice, cannot accept or deny care. We don’t have that authority. We can make recommendations about how care can be rendered."

Containing costs

Kucera admits that in the past, the bottom line often dictated the course of treatment, which may contribute to current misunderstandings. But as outcomes have been analyzed, case managers and other health professionals realize that costly treatments sometimes can save money in the long run. And prevention and education are stressed, Kucera said.

Cost containment now often means maximizing benefits within a policy’s limits. "What that means is, if someone has a lifetime cap of $2 million, you want to protect that cap. You don’t want to use it up on one catastrophic injury," Moreo said.

By explaining options rather than dictating choices, case managers can help patients make informed decisions, Kucera said. "Frequently, the clients become empowered. They understand what [coverage] they have and how they want to use their benefits," she said.

Advising patients

Moreo recommends that case managers explain who is paying their salaries as a way to establish trust and communication with patients. Case managers "should reveal right from the get-go who their pay source is. If it’s the insurance company, say so," she said. Not all case managers are employed by insurance companies, Moreo added.

"They can also explain that their role as a case manager is to facilitate the process. Take the patient through the system in the least restrictive environment, trying to achieve the greatest level of quality," Moreo said. That aspect of case management appeals to patients, according to Court. "It’s helpful to have someone to guide you through the system," he said.

By working together, patients, families, clinicians, and case managers can achieve better results, according to Moreo. "If we all have a greater understanding of what each person’s role is along the continuum, we’ll have a greater understanding of how they fit into the puzzle," she said