Demands and Case Manager Advocacy

by Stefani Daniels with thanks to Emily Friedman
Published on Mar 29, 2019

 A friend of mine with a long and distinguished career in health policy once told me that he had come to the saddening and bitter conclusion that the only way to achieve significant change in the hospital industry is to get the payers to force change.  In the end, he said, hospitals won't change when they feel the heat, but rather when they see the fire!

Another friend of mine from a Connecticut hospital has said that hospital execs do not tend to change unless a certain level of anxiety has been reached - otherwise they are just too comfortable to do much, even if there is pressing need.  

I would add, out of my own dubious wisdom, that once hospital execs decide that they do want to change, all too often they do so at the speed of light; heading off in the wrong direction, bumping into chairs, tripping over rugs, and causing all kinds of damage along the way.

These days, all three dynamcis are in play.  The payers are making big-time demands, providers have reached their critical mass of anxiety (actually I think it's more like terror), and everyone from physicians to large healthcare systems is running around like the proverbial chicken that is missing part of its anatomy.

 When such an environment develops, my instinctive tendency is to mutter, "Case manager, beware!." I have been muttering that a lot lately.  Why?  Because everywhere I look I see the shift to the payer-as-driving-force theory take hold.  The new marketplace influences the services that are provided - or not provided;  the ongoing manic focus on shorter length of stay - depite arguments that the patient is just not ready and the risk of readmission looms high; and the basic philosophy that the less you do, the more money you make. In the midst of these changes, the hospital case manager, whose basic ethical responsibility is advocacy, must walk a fine line between what the patient/family believes is best for them and what can actually be achieved. 

For decades, the hospital payment system has induced the demand for more and more services and it's hard to just stop when consumers have no real sense about today's financial incentives. Hospital execs missed an opportunity when Medicare introduced its MSPB metric as an indicator of efficiency and should have prompted adoption of the tenets of the Choosing Wisely campaign and the use of evidence-based treatment guidelines.  There is a large body of evidence that reports that evidence based guidelines not only improve patient safety, they reduce costs of care. Unnecessary services contribute as much as $210 billion in wasteful healthcare spending in the U.S. annually, according to one estimate from the Institute of Medicine. 

Using evidence based guidelines is just one of many incremental improvements I can conjure up for our distressed hospital industry.  But what really gets my imagination roiling are the images of care coordimation by a single consistent resource for our most vulnerable patients across settings; patients being informed of practical and appropriate care options and educated to improve healthcare literacy and engage in self-care; and the personal attention by hospital based transitional care coordinators and healthcare workers supporting community-based healthcare recovery efforts or palliative care support. 

The bottom line:  Hospital case managers must be vigilent in their advocacy efforts to balance the demands of multiple stakeholders without loosing sight of the patient.