Ethical conduct is at the very heart of case management practice and the Certified Case Manager (CCM) certification. As the Code of Professional Conduct for Case Managers states, "A Certificant will not violate the code of ethics governing the profession upon which the individual's eligibility for the CCM designation is based."
Yet even the code, which is published by the Commission for Case Manager Certification (CCMC), acknowledges that case managers may confront ethical dilemmas as part of their day-to-day practice. "Because case management exists in an environment that may look to it to solve or resolve various problems in the health care delivery and payor systems, case managers may often confront ethical dilemmas." Given the probability of facing ethical conflicts, case managers must constantly gauge their actions and decisions on an ethical basis-with objective evaluation.
Now consider the following scenario, which involves the case manager's ethical obligation of client advocacy, maintaining objectivity, resisting conflicts of interest, and not imposing her values on clients. A lawsuit stemmed from a workers' compensation case in which the plaintiff was the injured worker. In the midst of her deposition, the case manager who handled the employee's case was asked to discuss the scope of services provided. The attorney representing the employee then posed this question: "Do you agree that one of the primary objectives of case management is to save money by denying services?"
The case manager exploded, emphatically stating that this was "absolutely not" a primary objective of case management, and that the principal function of a case manager is to identify and secure the services that an individual needs.
Case managers are understandably uncomfortable with any hint or perception that their job is to deny services. Case managers are facilitators of treatment, which is a vital role in an increasingly fragmented healthcare arena, in which more patients have complex medical cases and are treated by more than one physician or specialist.
In their roles as the facilitator, however, case managers must raises questions, concerns, and issues-including whether a certain aspect of care or treatment is duplicative or unnecessary. Case managers do not make determinations of medical necessity; only a physician can. In order to practice ethically, the case manager cannot write anything in a report that could bias or prejudice the doctor or another individual making decisions about medical necessity that are outside the scope of the case manager's expertise. However, case managers can-and should-raise questions about an individual's care and treatment.
Case managers frequently face ethical dilemmas because they are answerable to more than one party, usually with conflicting points of view. Whether the case manager is hospital-based or insurer-based, they must advocate for the needs of the client, while balancing the demands of the insurer, hospital, or other third party.
In the scenario of the workers' compensation case, the case manager must provide for treatments and services that are medically necessary; to deny them would be an ethical and, presumably, legal violation (assuming they are covered in the insured's policy). However, if services are not medically necessary, then there is absolutely nothing wrong with a case manager questioning services that are not required for a person's recovery. Indeed, one would think the case manager is ethically required to do so.
When weighing the advisedness of services, there are at least three ethical questions that a case manager (or any healthcare professional) must raise:
1. How do you define a successful outcome in this particular case? Depending upon what outcome is envisioned, people will grant or deny treatment. However, there might not be one, single outcome in a case or an "outcome" might mean different things to different people. Different people might define success differently based upon the outcome they desire. Although outcome seems like a single, unitary word, outcomes have multiple dimensions. They have an impact on the patient, on the family, on the third-party payer, and on the healthcare professional who determines what can be done for the patient.Take the case of a spinal cord injury. One outcome could be the individual being able to engage in sexual intercourse again. Other outcomes might be diminishing a caregiver's burden, increasing the person's upper extremity range of motion, or increasing the number of activities of daily living that the person can perform. A successful outcome can mean different things to different people.
2. How probable is it that a particular outcome will be achieved? Obviously, different outcomes will have different probabilities. The probability of each desired outcome must be determined in order to evaluate whether to pursue a particular course of treatment. If a desired outcome has a 75% success probability, that certainly favors pursuing treatment to achieve it. If the outcome has only a 1% success probability, that treatment might need to be re-examined.
3. What is the treatment going to cost? The cost involved for a particular treatment is weighed against the probability of achieving a successful outcome. This is where the care allocation question comes in: determining what care and treatment should be pursued to achieve as successful an outcome as possible. Care allocation includes looking at factors such as what the person's insurance coverage provides, as well as the individual's or family's ability to pay. A particular treatment might have a high probability of success, but if a person's insurance does not pay for it, another source will have to be identified to cover the expense.
These three questions require a case manager or other healthcare professional to use his/her subjective judgment. These types of judgment calls are inherent in delivering or withholding clinical care. Although medical necessity is determined by physicians, case managers still can-in an objective and ethical manner-ask questions and raise issues or concerns about treatment delivered within a care plan.
As for the case manager who faced the attorney's question- "do you agree that one of the primary objectives of case management is to save money by denying services?"-in retrospect, another reply could have been given: "Case managers do frequently save third parties money by bringing certain services into question, but there is nothing wrong with that-as long as it's done ethically."