The WCHotSeat returns for lucky Episode 13 on May 13th at noon Eastern. That seems well-designed, but I think it was a mere happenstance. The various Hot Seats have addressed pharmacology, treatment delays, regulatory complexities, the changing workforce of workers' compensation, and more. They are free to attend and all the prior episodes are available for re-viewing at WCHotSet.com. There is some binge-worthy watching during this time of social distancing. Episode 13 will address case management, perceptions, and realities (Friend or Foe).
There is an inherent friction in the delivery of case management services in workers' compensation. Back in the day, claims were managed almost exclusively by adjusters. There would be appointments scheduled, care rendered, and questions asked. One of the challenges in that paradigm was the second-hand communication that it fostered. The adjuster was dependent upon the doctor appropriately documenting, the doctor's staff interpreting and relaying, and the patient understanding. There evolved from that paradigm a more involved and hands-on process of managing the interactions between patient and care provider.
The role of case manager, according to myamericannurse.com, is
"a collaborative process of assessing, planning, facilitating, coordinating, evaluating, and advocating for options and services to meet an individual’s and family’s comprehensive health needs and promoting patient safety, care quality, and cost-effective outcomes."
That is a long sentence, which bears reading through more than once. The focus is on the health needs and yet has the caveat of "cost-effective." The case manager role is described in various publications to include "advocate," "collaborator," "influencer" and more.
Thus, the case manager is in the midst of an age-old conflict through which patients have long struggled: cost and efficacy. This is often part of our individual decision-making process. We regularly struggle with the cost/benefit analysis in making personal or family purchases. We are familiar that we might struggle with the conflict between the television or vacation we want to have (versus can afford), our desire to have it sooner or later, and our rate of accumulating or borrowing the funds for such a purchase. That such a conflict would be a part of medical decisions we undertake might seem alien. It is, however, part of what we do. And, it is applied in the larger context of workers' compensation as well.
The Centers for Disease Control (CDC) explains that both cost-benefit analyses (CBA) and cost-effectiveness analyses (CEA) are part of the process of measuring the "net benefit" of any particular "intervention." In a systemic analysis, the example used by the CDC is "an intervention to reduce trans fats in the food supply." This change would lead to cost savings in the overall delivery of medical care by affecting the need for medical care (demand). The overall evaluation includes assigning monetary value to avoid "direct medical costs," to the gains in "quality of life," to averting "fatal heart attacks," and the value of years of increased life expectancy.
Similarly, the efficacy of care may likewise present an issue in a micro sense. For a particular patient, there may be benefits attributable to some surgical procedure over another, some surgical specialist over another, some therapeutic intervention over another, the efficacy of care now versus care delayed, and more. The care that is sought, from whom, and when may all play a role in recovery and perceptions of quality treatment, by patient or payer. Thus, the cost/benefit analysis may well be a factor in the case manager's contribution to decision-making.
The Annals of Internal Medicine note that there are various views on the quality of medical are in America. Some perceive that recommendations may be driven by factors other than patient needs ("7 in 10 respondents believed that physicians are more likely to perform unnecessary procedures when they profit from them"). There are perceptions that the delivery of medical care here is not efficient ("approximately 30% of the $2.5 trillion the United States spent on health care in 2009 (or $765 billion) was waste"). There is a call for abandonment of the "fee for service" model of care delivery. In some developing compensation models. provider fees may perhaps be tied to the success of the care, measured by the patient or others. In such a transition and new paradigm, the role of case management may be increasingly critical.
The fact is, there is room for discussion about both the cost and the benefits of medical care in America.
There is also a perception that some medical decisions are affected by fear or uncertainty. What a medical professional may opine is in the patient's best interest may not be what the patient wants or something in which the patient believes. There are a remarkable number of influences that may color our personal judgment as regards undergoing a medical procedure. Examples might include the severity of injury and discomfort, our perceptions as to the probable success of the proposed intervention, information gathered from the internet, and recommendations of our acquaintances or relatives regarding the care proposed.
There are those who lament that the workers' compensation systems do not include compensation for pain, discomfort, and diminished capacity for the enjoyment of life. Anyone who has ever suffered a serious accident or illness might recount that such effects are possible. Workers' compensation generally provides only medical care and disability/impairment benefits. Thus, the benefits (damages) that are received may be limited to time missed from work. Some have suggested therefore the potential for some patient disincentive to undertaking some medical interventions. If that exists, others would argue that this is merely one of many factors in the patient's cost/benefit analysis.
A patient may logically and rationally ask whether the care will bring improvement. There may be some tendency to postpone a risk, such as surgery, in hopes that some other, less invasive or serious, modality (physical therapy) will bring about notable improvement. That tendency might be driven in a patient based on the outcomes, predictions, and risks. Likewise, a payer (employer or insurance agent) might similarly weigh the chances based on the potential to avoid the more expensive care (surgery) and the cost of a recuperative period that would accompany it.
The case manager came to be seen as the "hub of communication and information" in the treatment process, as noted in the September/October 2016 edition, Volume 21, Number 5, of Professional Case Management. This described the involvement of case management in participating in "interdisciplinary teams, . . . tracking outcomes" and thus being, again, in the "hub" of the wheel with the patient who is experiencing care and treatment potentially from a variety of specialty and sub-specialty providers.
It is apparent that the goals of the patient and the payer may have both coincidence and distinctions, as do the interests of the patient and the payer. The case manager is in the midst of conflicts both external (patient v. payer) and internal (doctor v. doctor, modality v. modality, probability v. probability). The decisions may be monetary or personal, and in the end may not be the easiest decisions to either evaluate or conclude.
And, through it all, there is the likelihood of the presence of a case manager. The case manager is part interpreter, part information gatherer, part translator, part evaluator, and part advisor. The website nurse.com published a post in 2014 Legally Speaking: Case Managers and Liability. It provides a reinforcing perspective on the varied and difficult roles of case managers and suggests that the role presents the potential for conflict of interest. Particularly, this might arise from "basing a decision concerning a patient's care on cost savings alone, without regard to the quality of the treatment regimen." Not to say that cost is not "a" factor for consideration, but a caution against it being "the" consideration. Might the same conflict exist for the patient, payer, or others in the equation?
The article cautions managers to know and understand their own "personal values" that might influence performance. It suggests knowledge of "ethical principles required in healthcare." And, unsurprisingly, it suggests the value of knowledge of the "many laws that impact" the case manager role. Though each of these might be narrow and specific in any particular case, they are each likewise potentially reasonably broad and systemic in the overall role perspective.
Thus, there may be conflict in the analysis of what is right for a patient. The case manager is asked to play a diverse and intimate role in such analyses and to do so in the midst of competing interests or concerns of the various individuals involved (patient, provider, payer, and more). This may be a precarious position of trust with multiple principles and principals.
In various discussions at professional events, I have had opportunities to discuss patient care with a great many attorney advocates, medical professionals, payers, and case managers. A common thread is that there are diverse perspectives from which to view decisions regarding care. Thus, I have met payers, patients, advocates, and providers who laud the case manager, and others who deride them. This may come down to the particular case manager in a setting, or perhaps the particular payer, patient, provider, or critic. The permutations of personality and potential conflicts is noteworthy.
Tune in to the next WorkersCompensation.com HotSeat for an in-depth examination of the case manager's function and perceptions. The guests will be Rosalie Faris, a nationally known case manager, and Phyllis Phillips, a former adjudicator and litigator now serving as a mediator in the resolution of workers' compensation issues. They bring decades of experience, a national perspective, and a critical eye. It will be an intriguing exploration of the role and challenges.
