1. Campagna, Vivian MSN, RN-BC, CCM

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Public policy does not occur in a vacuum. Laws, regulations, and programs evolve from a process of study, public comment, and input from parties directly involved or affected. In health care policy and legislation, expert testimony and direct feedback have helped write and support laws and programs such as Medicare and Medicaid regulations, the Health Insurance Portability and Accountability Act of 1996, and the Affordable Care Act (ACA). More recently, as administrative and legislative actions revisit the ACA, health care continues to be a dominant issue in public policy and for good reason: it touches every person needing quality and cost-effective care.


As advocates for our practice and our profession, case managers need to become aware of and involved in public policy. It starts with becoming educated about current trends and issues. According to the Centers for Medicaid & Medicare Services, health care expenditures in the United States, under current law, are projected to grow at an average annual rate of 5.5%, reaching $5.7 trillion by 2026. At this pace, health spending is projected to grow 1 percentage point faster than annual growth in U.S. gross domestic product. As a result, health expenditures will account for 19.7% of total U.S. gross domestic product by 2026, compared with 17.9% in 2016 (Centers for Medicaid & Medicare Services, 2018).


Demographics, including an aging population and more people with chronic conditions, continue to increase health spending. The Centers for Disease Control and Prevention (2016) finds that one in four Americans has multiple chronic conditions that last more than a year and require ongoing medical attention or that limit activities of daily living; in Americans 65 years and older, that number rises to three in four. These risk factors point to the need to improve efficiency and cost-effectiveness in pursuit of the Triple Aim: to improve the experience of care, improve the health of populations, and reduce the per capita costs of health care (Berwick, Nolan, & Whittington, 2008). Care coordination, as part of the case management process, plays an integral part in achieving the Triple Aim.


Although the benefits of care coordination as part of the case management process may be well known to professional case managers, they may be unfamiliar to policymakers, legislators, and the public at large. Public policy and consumer advocates, therefore, should understand the vital contributions that case management and care coordination make in furthering the goals of health care legislation and programs. This understanding is especially important in the current climate of continued uncertainty around the future of health care legislation and policies.


To further the lawmakers' understanding, the Case Management Society of America (CMSA) has established the Revised Case Management Model Act of 2017, which outlines key elements of a comprehensive case management program that should be implemented at both the federal and state levels. The Model Act, built upon an earlier version proposed in 2009, includes language to be used for legislative and regulatory initiatives. The CMSA encourages policymakers to review and use the Model Act for "legislative and regulatory initiatives geared to reducing health care costs, improving coordination and transitions of care, enhancing quality, and promoting better clinical outcomes" (CMSA, 2017, p. 3). By presenting a revised Model Act, the CMSA is helping ensure that case management and the benefits it brings to individuals, populations, and the health care system are part of current and future health care policy discussions.


As an extension of their collaborative to advance professional development and workforce development initiatives, the Commission for Case Manager Certification (CCMC) supports the CMSA's efforts, including participation in the CMSA's "Hill Day" to meet with federal lawmakers in late 2017. In my role as the CCMC's Chief Industry Relations Officer, I appreciated the opportunity to engage in legislative and public outreach around the case management process and its value in improving quality and outcomes. In addition, outreach to and education of policymakers and legislators promote "title protection" by clarifying what it means to be a professional case manager. The Model Act defines a professional case manager as "one who has the License/Certification to conduct an independent assessment, can use critical thinking skills and knowledge to develop an individualized Plan of Care, and can see that it is successfully implemented, impacting quality and safety" (CMSA, 2017, p. 8). This distinction sets case managers apart from those who perform nonclinical administrative tasks. With clear language about case management to use in legislation and program rules, policymakers can ensure that the individuals tasked with case management and care coordination are the most qualified and capable of making a measurable contribution to patients, their families, and across the healthcare system.


In addition, the Model Act language helps educate consumers about case management, giving them a savvy perspective about the services provided to them across the health and human services spectrum. Informed and empowered health care consumers are more likely to ask for the services of a case manager as they navigate a fragmented health care system. The Model Act also helps inform thinking, shifting away from the quantity of care delivered to focus on the quality of care. For example, one of the goals of the ACA was to move away from treating illness to emphasize preventing illness.


The case manager is indispensable in helping patients and their families achieve desired outcomes. Coordinating care, monitoring medications, and educating patients to improve their self-care are interrelated-all part of the case management process of assessing the patient, determining a care plan, monitoring outcomes, and adjusting the care plan as needed. From a public policy point of view, the case management process ensures that patients get access to the care they need, not only to treat their illnesses, but also as preventative care that improves outcomes and reduces health care spending over time.


Although it is very important for case management organizations such as the CCMC and the CMSA to speak with a united voice, particularly in Washington, this is not the only type of public policy advocacy. Individual case managers need to become involved by writing letters and e-mails and making phone calls to state and federal lawmakers. This can be daunting for case managers who are unfamiliar with the legislative process or who may feel like one voice out of millions. But they are not doing it alone. Case managers are part of a larger chorus, which includes the CMSA and the CCMC as the leading case management organizations. The current legislative environment calls for action, not silence or the assumption that someone else will speak up. Otherwise, the public policy outreach will fade to a faint echo, lacking the resonance of the entire profession, which includes more than 45,000 board-certified case managers (Certified Case Managers or CCMs) who are in practice today.


A key part of the message delivered to policymakers is the quantifiable value of case management. Ongoing field research, including the Role and Function Study conducted by the CCMC every 5 years, enables case managers to speak with the authority that is grounded in proven outcomes. It is not enough to share information anecdotally; the data we collect showcase the value of case management and care coordination as we advocate for others, giving patients and their families information and a better understanding of the services and treatment options available to them.


Patient advocacy and promotion of autonomy, key principles of case management, cannot be separated from professional practice. Individuals and families must understand their options as they make the best choices for themselves and their circumstances in pursuit of desired outcomes. Such intervention and education will become part of health care laws and program solutions only if case management continues to be recognized as being crucial to health care delivery today and in the future. For these reasons, public policy outreach must continue on behalf of our profession and for the patients and families for whom we advocate.




Berwick D. M., Nolan T. W., Whittington J. (2008, May/June). The triple aim: Care, health, and cost. Health Affairs, 27(3), 175-769. [Context Link]


Case Management Society of America. (2017). Case management model act: Supporting case management programs. Retrieved from


Centers for Disease Control and Prevention. (2016). Multiple chronic conditions. Retrieved from


Centers for Medicaid & Medicare Services. (2018). National health expenditure fact sheet. Retrieved from[Context Link]