- Email: [email protected]
“Reasonable and Necessary”: Some case management considerations
CM ETHICS
“REASONABLE AND NECESSARY”: SOME CASE MANAGEMENT CONSIDERATIONS John D. Banja, PhD
A
s it pertains to treatment decisions in health care, the concept of “reasonable and necessary” (R&N) care seems utterly indispensable. It speaks directly to the standard of care, which must exist if we are going to distinguish professional practice from quackery. R&N care also informs our budgeting of health care resources. Treatments that are not reasonable or necessary do not serve a clinical purpose and presumably do not serve the patient’s welfare. Providing a treatment that is neither reasonable nor necessary constitutes a waste of health care resources and a waste of the money used to finance those resources. The purpose of this article is to discuss three aspects of the R&N concept that intersect with the work case managers do.
Issue #1: Reasonable and Necessary Care Determinations are Probabilistic Although it would be impossible to deliver health care without the notion of R&N care, there is a mountain of literature attesting to how troublesome the notion is. Case managers know this all too well. Health plan definitions of R&N that use words like “appropriate,” “beneficial,” acceptable,” and “cost effective” and that look to the decision making of a community of “reasonable and prudent” practitioners are hardly useful in difficult cases. Also, when a great deal of money hangs in the balance of R&N decisions and when one of the case manager’s roles is to secure effective care in the most cost-effective manner, additional pressures are imposed on R&N decision making that would not exist in a world of limitless resources. The first point I would like to discuss about the R&N construct, though, is how it often involves a determination of probability. Here is an example: TCM 24
November/December 2005
Mrs. Jones arrives at the emergency room of her local hospital complaining of headache and neck pain. She has no fever and the attending physician proceeds to rule out other likely suspects: muscle sprain, arthritis, migraine, and so forth. An radiograph of her neck shows nothing abnormal, and a few hours later, Mrs. Jones is discharged. Twelve hours later she returns, complaining of no relief. A more elaborate examination follows but again reveals nothing, and she is discharged. Six hours later, Mrs. Jones begins experiencing urinary incontinence and numbness, weakness, and tingling in her legs. When she returns to the emergency room with these symptoms, diagnostic tests reveal an epidural spinal abscess. Sadly, the correct diagnosis and treatment come too late, and Mrs. Jones is left with paraplegia. This case was referred to an attorney, who later had to drop it, because he could not find any experts who would testify that Mrs. Jones’ physicians did anything wrong. Everything they did, as documented in the medical records, seemed R&N, even though the professionals failed to discern a catastrophic disease process. Interestingly, the attorney told me that his theory in the case was that rather than the physicians’ ruling out the usually self-limiting causes of neck pain and headache, he believes they should have begun by asking themselves, “What is the worst thing that might be causing these symptoms?” and start the differential diagnosis process there. But, he could find no physician agreeing with his theory, perhaps because if health care was commonly practiced that way, it would become enormously time consuming and hopelessly expensive. The old adage of “whenever you hear the sound of hooves, expect horses, not zebras,” nicely captures the probabilistic dimensions of R&N treatment decisions.
But, when that rare zebra does appear, as it did with Mrs. Jones, health professionals might encounter an indescribably angry and miserable patient demanding to know why her condition was “allowed” to proceed to catastrophic proportions. Case managers doubtlessly frequently encounter these situations. In fact, I was recently involved in a malpractice case against a case management firm because it was alleged that one of the firm’s case managers did not facilitate aggressive measures to have her client diagnosed and treated in a timely fashion. In my opinion, this allegation failed to appreciate the facts that the client’s attending physician, who had been treating the patient all along, did not believe that a referral to specialty care was immediately indicated, and that a zebra-like syndrome was present that took considerable time to diagnose with confidence— namely, reflex sympathetic dystrophy. So how should the case manager respond to the utterly bewildered client who angrily asks why Dr. Smith waited so long to do X, to refer him to Dr. Y, or to change his medicines? Now, it might indeed be the case that Dr. Smith is not the brightest light in the medical firmament, or that the clinical environment in which Dr. Smith works does not permit him to spend as much time with patients as he would like, or that cost constraints force Dr. Smith to render less care or to postpone ordering expensive tests longer than he would prefer. But just as often, I believe, the answer is that health professionals do not have crystal balls that can predict the outcomes of their perfectly reasonable diagnostic and treatment strategies—that is, that doing what is perfectly R&N can nevertheless result in tragic outcomes that are not the health professional’s fault, such as what occurred with Mrs. Jones. Unfortunately, R&N decisions are inevitably imperfect
and fallible, because one can never guarantee that any health care decision rests on perfect data, or that the data, even if it is perfectly present, will be interpreted correctly, or that the individual patient will respond the way everyone else does. The point for case managers is that when they are confronted by irate patients who demand perfection in an imperfect world, the case manager should be able to call on a repertoire of communication techniques that begin with acknowledging the patient’s anger and grief, for example, “Mr. Smith, this must be bewildering for you as to why the diagnosis wasn’t made sooner. You’re terribly angry, and I’m so sorry that it took so long for your doctor to figure out what’s wrong.” With that as an empathic start, the case manager can then continue by saying something like, “I would strongly urge you to talk to your physician about your concerns. Although I can’t speculate on why your doctor chose to do what she did, she might be able to explain it in a way that would be very helpful to you. If you don’t bring any of this up, however, you might continue to be suspicious about the quality of care you’ve received. And that may not help your recovery, which we want to concentrate on now.” In these kinds of conversations, the case manager must work very hard to contain her urge to be defensive— especially if the client is blaming her as well as the doctor; acknowledge her client’s anger and attempt, through an empathic approach, to defuse it; respond to whatever unrealistic or uninformed ideas the client may have about his care up to that point, without the case manager ’s exceeding the boundaries of her own scope of practice (for example, by refusing to speculate); and communicate to the client a sense of support and optimism about the future.
All this can be very difficult to do, especially because the case manager might be managing a host of her own frustrations, but it is a powerful reason why case managers must be extremely artful communicators. I return to the fact, though, that what underlies many of these trying situations are the vagaries and ambiguities of the R&N determination: that what is the “reasonable” thing to do at the moment is not necessarily what will secure the best outcome in the long run, especially as we look back on the decision-making process with the perfection of hindsight. There is, however, another source of discomfort that a case manager might feel related to R&N determinations. This occurs when she believes that the physician’s planned course of treatment or care is neither reasonable nor necessary. And that is the second issue I would like to discuss. Issue #2: The Authority to Make R&N Treatment Decisions Everyone agrees, I hope, that only physicians can make R&N medical determinations, especially because those decisions normally occur within the parameters of case management practice. Case managers can certainly question these physicians’ medical decisions, they can certainly recommend that a decision be reevaluated, and they can (and should) refer R&N decisions to the appropriate individual’s attention when they believe that those decisions are in error. But case managers are not professionally or legally authorized to make medical R&N decisions. Consequently, case managers who represent themselves in ways that make it appear that they are making medical R&N decisions may be committing a serious violation of the Code of Professional Conduct for Case Managers.1 Notice that the code contains language, such as in Standard #2, that “Certificants
will practice only within the boundaries of their competence, based on their education, training, professional experience, and other professional credentials.” Consequently, case managers should be very careful as to how they represent their professional determinations and judgments to their supervisors, clients, payer sources, and to those health professionals who manage the care of their patients. Consider, then, the case manager who writes the following in a progress report that she submits to a payer source: “Dr. Smith is requesting authorization to perform treatment X on my client, Mr. Rogers. X, however, is an unreasonable and unacceptable treatment for Mr. Rogers at this stage. I, therefore, will contact the plan and urge that Mr. Rogers be seen instead by Dr. Williams, who I believe will order a more appropriate plan of care.” At the very least, this entry makes it appear that the case manager has decided that the medical treatment is unreasonable and will have it changed. Of course, what she should do is refer her concern to the medical director of the plan for his or her determination of the reasonableness of Dr. Smith’s authorization request. And she should document it just that way: “Dr. Smith has requested authorization to perform X on Mr. Rogers. I will refer this request to the plan for determination and facilitation.” Moreover, her stated intention to change Mr. Rogers’ doctor might call into question whether she is planning to exert “undue influence” on Mr. Rogers to effect the change of his doctor (Standard S3b) or whether she is unduly imposing her values on her client (Standard 13). The point, then, is that if case managers are not authorized to make medical R&N decisions, they must not represent themselves as doing so. Furthermore, if this case manager works for a company and November/December 2005
TCM 25
continued
CM ETHICS
has a supervisor who signs off on her progress reports but who fails to correct the case manager’s R&N misrepresentations, then that supervisor might herself risk violating the code, perhaps by way of failing to be “unbiased in reporting the results of . . . professional activities to appropriate third parties, to avoid exerting undue influence upon the decision making process” (Standard 19). How should the case manager respond, however, if a plan overrides a medical determination that a particular treatment is not R&N and decides to pay for it anyway? Does this at all affect the case manager’s advocacy? Issue #3: Advocacy and Problematic R&N Determinations Notice that Standard #1 of the Code for Professional Conduct requires case managers to “serve as advocates for their clients” by providing needs assessments, options for necessary services, and access to resources. Assuming that treatments deemed R&N will usually turn out to be in the client’s best interests, a case manager naturally will advocate for her client’s accessing them. On the other hand, when the plan determines after a good faith review, which might even include an interdisciplinary team review, that a treatment is neither reasonable nor necessary, the case manager should presumably support the plan’s denial. It sometimes happens in instances of denial of benefits, though, that a client will mount an aggressive appeal (which might include the threat of legal action against the plan), such that, although the plan’s medical authorities believe that the requested treatment is not medically R&N, other authorities within the plan might authorize payment for the service anyway. Does such a situation present an ethical dilemma involving the case manager ’s continuing advocacy for this client? TCM 26
November/December 2005
I believe it does. Such a situation presents the case manager’s advocating for services that are not deemed to be in the client’s medical welfare and whose provision would constitute an unnecessary expenditure of health care dollars. Yet— and a deep organizational dilemma it is—entities within the plan unfortunately choose to be at odds with one another, because the risk management/fiscal arm of the plan overrides the clinical arm. In all probability, the decision to reimburse the treatment is not being made for the client’s benefit but rather for the plan’s benefit for fear of adverse and perhaps costly litigation arising from a denial. The plan’s authorization of such a reimbursement can thoroughly confuse the case manager’s advocacy. From a principled perspective, the case manager is being asked to advocate for a treatment or a treatment plan that not only appears to be a waste of health care dollars but might even harm the patient. From a purely practical perspective, the case manager might find herself befuddled (as well as having to wrestle with painful feelings) about coordinating care services that are not indicated in the first place. Now, I might be accused of exaggerating the seriousness of this phenomenon, because many of these kinds of treatment authorizations, where denials are internally overturned, might be fairly benign, such as when a client demands reimbursement for another magnetic resonance imaging scan. But suppose a client with a serious condition demands reimbursement for an experimental or investigational intervention whose efficacy and associated risks are not well known or studied. In such an instance, the case manager might feel that she is being asked to be complicitous in a treatment program that might pose unnecessary harm to her client and that the plan’s medical authorities believe is extremely unwise. At the very least, it is
easy to see how her patient advocacy can be immensely compromised in such a situation. Consequently, plans that occasionally overturn medical R&N denials for selfserving reasons should think deeply about how their case managers’ continuing advocacy for those clients can be negatively affected. Of course, an ethically ideal response from the plan would be to support the medical decision’s original denial because that decision is presumably made for the client’s welfare, not the plan’s. Failing that, a plan might contract with an independent case manager who can take over for the originally assigned case manager if she can no longer continue in good conscience. Given the workload that many case managers handle, it might be hard enough for them to satisfactorily manage their ethically uncomplicated cases. To place them in a position where they cannot, in good conscience, advocate for their clients is ethically and organizationally intolerable. Conclusions While the R&N construct is indispensable, it poses a host of implementation problems and will continue to do so as long as medicine remains an imperfect science. Ironically, one of the most troublesome factors that complicate our understanding of what is R&N is America’s engine of clinical research. Consider, for example, how much care that was understood as R&N 20 years ago would be considered malpractice today. And one can only surmise what R&N care will look like midway through the twenty-first century, when genetic interventions will probably be quite familiar. Case managers should make opportunities to discuss the problematic contours of R&N determinations, because they are at the core of case management continued on page 34
continued
ADA UPDATE
CM Ethics continued from page 26 activities, yet the problems they present can frequently affect the efficiency and the quality of case management services. It is easy to imagine an entire weekend conference devoted to the intersection of case management and R&N decisions, where various stakeholders can come together and share strategies for dealing with the kinds of problems R&N determinations raise. What must be borne in mind, however, is that while the R&N construct sounds categorically clinical, it admits numerous ethical moments such as the ones discussed above. That is why R&N determinations can be as provocative as they are problematic. ❏ Reference 1.
Commission for Case Manager Certification. Code of professional conduct for case managers [cited 10 Sep 2005]. Available from: URL:http://www.ccmcertification. org
John Banja, PhD is an associate professor at the Center for Ethics at Emory University. The opinions expressed in this article are the author’s and not necessarily those of any organization with which he is affiliated. You can e-mail your ethical queries, stories, or case examples to him at [email protected] or call his office at (404) 712-4804. ACKNOWLEDGMENT I am indebted to Diane Huber, PhD, RN, FAAN, CNAA, BC, and Carole Stolte Upman, RN, MA, CCM, CRC, CDMS, CPC, for their extremely helpful insights and recommendations regarding an earlier draft of this paper. Any errors or contentious observations that are present in this article are my responsibility and mine alone. Reprint orders: E-mail authorsupport@ elsevier.com or telephone (toll free) 888-834-7287; reprint no. YMCM 326 doi:10.1016/j.casemgr.2005.08.007
TCM 34
November/December 2005
“REASONABLE AND NECESSARY”: SOME CASE MANAGEMENT CONSIDERATIONS John D. Banja, PhD
A
s it pertains to treatment decisions in health care, the concept of “reasonable and necessary” (R&N) care seems utterly indispensable. It speaks directly to the standard of care, which must exist if we are going to distinguish professional practice from quackery. R&N care also informs our budgeting of health care resources. Treatments that are not reasonable or necessary do not serve a clinical purpose and presumably do not serve the patient’s welfare. Providing a treatment that is neither reasonable nor necessary constitutes a waste of health care resources and a waste of the money used to finance those resources. The purpose of this article is to discuss three aspects of the R&N concept that intersect with the work case managers do.
Issue #1: Reasonable and Necessary Care Determinations are Probabilistic Although it would be impossible to deliver health care without the notion of R&N care, there is a mountain of literature attesting to how troublesome the notion is. Case managers know this all too well. Health plan definitions of R&N that use words like “appropriate,” “beneficial,” acceptable,” and “cost effective” and that look to the decision making of a community of “reasonable and prudent” practitioners are hardly useful in difficult cases. Also, when a great deal of money hangs in the balance of R&N decisions and when one of the case manager’s roles is to secure effective care in the most cost-effective manner, additional pressures are imposed on R&N decision making that would not exist in a world of limitless resources. The first point I would like to discuss about the R&N construct, though, is how it often involves a determination of probability. Here is an example: TCM 24
November/December 2005
Mrs. Jones arrives at the emergency room of her local hospital complaining of headache and neck pain. She has no fever and the attending physician proceeds to rule out other likely suspects: muscle sprain, arthritis, migraine, and so forth. An radiograph of her neck shows nothing abnormal, and a few hours later, Mrs. Jones is discharged. Twelve hours later she returns, complaining of no relief. A more elaborate examination follows but again reveals nothing, and she is discharged. Six hours later, Mrs. Jones begins experiencing urinary incontinence and numbness, weakness, and tingling in her legs. When she returns to the emergency room with these symptoms, diagnostic tests reveal an epidural spinal abscess. Sadly, the correct diagnosis and treatment come too late, and Mrs. Jones is left with paraplegia. This case was referred to an attorney, who later had to drop it, because he could not find any experts who would testify that Mrs. Jones’ physicians did anything wrong. Everything they did, as documented in the medical records, seemed R&N, even though the professionals failed to discern a catastrophic disease process. Interestingly, the attorney told me that his theory in the case was that rather than the physicians’ ruling out the usually self-limiting causes of neck pain and headache, he believes they should have begun by asking themselves, “What is the worst thing that might be causing these symptoms?” and start the differential diagnosis process there. But, he could find no physician agreeing with his theory, perhaps because if health care was commonly practiced that way, it would become enormously time consuming and hopelessly expensive. The old adage of “whenever you hear the sound of hooves, expect horses, not zebras,” nicely captures the probabilistic dimensions of R&N treatment decisions.
But, when that rare zebra does appear, as it did with Mrs. Jones, health professionals might encounter an indescribably angry and miserable patient demanding to know why her condition was “allowed” to proceed to catastrophic proportions. Case managers doubtlessly frequently encounter these situations. In fact, I was recently involved in a malpractice case against a case management firm because it was alleged that one of the firm’s case managers did not facilitate aggressive measures to have her client diagnosed and treated in a timely fashion. In my opinion, this allegation failed to appreciate the facts that the client’s attending physician, who had been treating the patient all along, did not believe that a referral to specialty care was immediately indicated, and that a zebra-like syndrome was present that took considerable time to diagnose with confidence— namely, reflex sympathetic dystrophy. So how should the case manager respond to the utterly bewildered client who angrily asks why Dr. Smith waited so long to do X, to refer him to Dr. Y, or to change his medicines? Now, it might indeed be the case that Dr. Smith is not the brightest light in the medical firmament, or that the clinical environment in which Dr. Smith works does not permit him to spend as much time with patients as he would like, or that cost constraints force Dr. Smith to render less care or to postpone ordering expensive tests longer than he would prefer. But just as often, I believe, the answer is that health professionals do not have crystal balls that can predict the outcomes of their perfectly reasonable diagnostic and treatment strategies—that is, that doing what is perfectly R&N can nevertheless result in tragic outcomes that are not the health professional’s fault, such as what occurred with Mrs. Jones. Unfortunately, R&N decisions are inevitably imperfect
and fallible, because one can never guarantee that any health care decision rests on perfect data, or that the data, even if it is perfectly present, will be interpreted correctly, or that the individual patient will respond the way everyone else does. The point for case managers is that when they are confronted by irate patients who demand perfection in an imperfect world, the case manager should be able to call on a repertoire of communication techniques that begin with acknowledging the patient’s anger and grief, for example, “Mr. Smith, this must be bewildering for you as to why the diagnosis wasn’t made sooner. You’re terribly angry, and I’m so sorry that it took so long for your doctor to figure out what’s wrong.” With that as an empathic start, the case manager can then continue by saying something like, “I would strongly urge you to talk to your physician about your concerns. Although I can’t speculate on why your doctor chose to do what she did, she might be able to explain it in a way that would be very helpful to you. If you don’t bring any of this up, however, you might continue to be suspicious about the quality of care you’ve received. And that may not help your recovery, which we want to concentrate on now.” In these kinds of conversations, the case manager must work very hard to contain her urge to be defensive— especially if the client is blaming her as well as the doctor; acknowledge her client’s anger and attempt, through an empathic approach, to defuse it; respond to whatever unrealistic or uninformed ideas the client may have about his care up to that point, without the case manager ’s exceeding the boundaries of her own scope of practice (for example, by refusing to speculate); and communicate to the client a sense of support and optimism about the future.
All this can be very difficult to do, especially because the case manager might be managing a host of her own frustrations, but it is a powerful reason why case managers must be extremely artful communicators. I return to the fact, though, that what underlies many of these trying situations are the vagaries and ambiguities of the R&N determination: that what is the “reasonable” thing to do at the moment is not necessarily what will secure the best outcome in the long run, especially as we look back on the decision-making process with the perfection of hindsight. There is, however, another source of discomfort that a case manager might feel related to R&N determinations. This occurs when she believes that the physician’s planned course of treatment or care is neither reasonable nor necessary. And that is the second issue I would like to discuss. Issue #2: The Authority to Make R&N Treatment Decisions Everyone agrees, I hope, that only physicians can make R&N medical determinations, especially because those decisions normally occur within the parameters of case management practice. Case managers can certainly question these physicians’ medical decisions, they can certainly recommend that a decision be reevaluated, and they can (and should) refer R&N decisions to the appropriate individual’s attention when they believe that those decisions are in error. But case managers are not professionally or legally authorized to make medical R&N decisions. Consequently, case managers who represent themselves in ways that make it appear that they are making medical R&N decisions may be committing a serious violation of the Code of Professional Conduct for Case Managers.1 Notice that the code contains language, such as in Standard #2, that “Certificants
will practice only within the boundaries of their competence, based on their education, training, professional experience, and other professional credentials.” Consequently, case managers should be very careful as to how they represent their professional determinations and judgments to their supervisors, clients, payer sources, and to those health professionals who manage the care of their patients. Consider, then, the case manager who writes the following in a progress report that she submits to a payer source: “Dr. Smith is requesting authorization to perform treatment X on my client, Mr. Rogers. X, however, is an unreasonable and unacceptable treatment for Mr. Rogers at this stage. I, therefore, will contact the plan and urge that Mr. Rogers be seen instead by Dr. Williams, who I believe will order a more appropriate plan of care.” At the very least, this entry makes it appear that the case manager has decided that the medical treatment is unreasonable and will have it changed. Of course, what she should do is refer her concern to the medical director of the plan for his or her determination of the reasonableness of Dr. Smith’s authorization request. And she should document it just that way: “Dr. Smith has requested authorization to perform X on Mr. Rogers. I will refer this request to the plan for determination and facilitation.” Moreover, her stated intention to change Mr. Rogers’ doctor might call into question whether she is planning to exert “undue influence” on Mr. Rogers to effect the change of his doctor (Standard S3b) or whether she is unduly imposing her values on her client (Standard 13). The point, then, is that if case managers are not authorized to make medical R&N decisions, they must not represent themselves as doing so. Furthermore, if this case manager works for a company and November/December 2005
TCM 25
continued
CM ETHICS
has a supervisor who signs off on her progress reports but who fails to correct the case manager’s R&N misrepresentations, then that supervisor might herself risk violating the code, perhaps by way of failing to be “unbiased in reporting the results of . . . professional activities to appropriate third parties, to avoid exerting undue influence upon the decision making process” (Standard 19). How should the case manager respond, however, if a plan overrides a medical determination that a particular treatment is not R&N and decides to pay for it anyway? Does this at all affect the case manager’s advocacy? Issue #3: Advocacy and Problematic R&N Determinations Notice that Standard #1 of the Code for Professional Conduct requires case managers to “serve as advocates for their clients” by providing needs assessments, options for necessary services, and access to resources. Assuming that treatments deemed R&N will usually turn out to be in the client’s best interests, a case manager naturally will advocate for her client’s accessing them. On the other hand, when the plan determines after a good faith review, which might even include an interdisciplinary team review, that a treatment is neither reasonable nor necessary, the case manager should presumably support the plan’s denial. It sometimes happens in instances of denial of benefits, though, that a client will mount an aggressive appeal (which might include the threat of legal action against the plan), such that, although the plan’s medical authorities believe that the requested treatment is not medically R&N, other authorities within the plan might authorize payment for the service anyway. Does such a situation present an ethical dilemma involving the case manager ’s continuing advocacy for this client? TCM 26
November/December 2005
I believe it does. Such a situation presents the case manager’s advocating for services that are not deemed to be in the client’s medical welfare and whose provision would constitute an unnecessary expenditure of health care dollars. Yet— and a deep organizational dilemma it is—entities within the plan unfortunately choose to be at odds with one another, because the risk management/fiscal arm of the plan overrides the clinical arm. In all probability, the decision to reimburse the treatment is not being made for the client’s benefit but rather for the plan’s benefit for fear of adverse and perhaps costly litigation arising from a denial. The plan’s authorization of such a reimbursement can thoroughly confuse the case manager’s advocacy. From a principled perspective, the case manager is being asked to advocate for a treatment or a treatment plan that not only appears to be a waste of health care dollars but might even harm the patient. From a purely practical perspective, the case manager might find herself befuddled (as well as having to wrestle with painful feelings) about coordinating care services that are not indicated in the first place. Now, I might be accused of exaggerating the seriousness of this phenomenon, because many of these kinds of treatment authorizations, where denials are internally overturned, might be fairly benign, such as when a client demands reimbursement for another magnetic resonance imaging scan. But suppose a client with a serious condition demands reimbursement for an experimental or investigational intervention whose efficacy and associated risks are not well known or studied. In such an instance, the case manager might feel that she is being asked to be complicitous in a treatment program that might pose unnecessary harm to her client and that the plan’s medical authorities believe is extremely unwise. At the very least, it is
easy to see how her patient advocacy can be immensely compromised in such a situation. Consequently, plans that occasionally overturn medical R&N denials for selfserving reasons should think deeply about how their case managers’ continuing advocacy for those clients can be negatively affected. Of course, an ethically ideal response from the plan would be to support the medical decision’s original denial because that decision is presumably made for the client’s welfare, not the plan’s. Failing that, a plan might contract with an independent case manager who can take over for the originally assigned case manager if she can no longer continue in good conscience. Given the workload that many case managers handle, it might be hard enough for them to satisfactorily manage their ethically uncomplicated cases. To place them in a position where they cannot, in good conscience, advocate for their clients is ethically and organizationally intolerable. Conclusions While the R&N construct is indispensable, it poses a host of implementation problems and will continue to do so as long as medicine remains an imperfect science. Ironically, one of the most troublesome factors that complicate our understanding of what is R&N is America’s engine of clinical research. Consider, for example, how much care that was understood as R&N 20 years ago would be considered malpractice today. And one can only surmise what R&N care will look like midway through the twenty-first century, when genetic interventions will probably be quite familiar. Case managers should make opportunities to discuss the problematic contours of R&N determinations, because they are at the core of case management continued on page 34
continued
ADA UPDATE
CM Ethics continued from page 26 activities, yet the problems they present can frequently affect the efficiency and the quality of case management services. It is easy to imagine an entire weekend conference devoted to the intersection of case management and R&N decisions, where various stakeholders can come together and share strategies for dealing with the kinds of problems R&N determinations raise. What must be borne in mind, however, is that while the R&N construct sounds categorically clinical, it admits numerous ethical moments such as the ones discussed above. That is why R&N determinations can be as provocative as they are problematic. ❏ Reference 1.
Commission for Case Manager Certification. Code of professional conduct for case managers [cited 10 Sep 2005]. Available from: URL:http://www.ccmcertification. org
John Banja, PhD is an associate professor at the Center for Ethics at Emory University. The opinions expressed in this article are the author’s and not necessarily those of any organization with which he is affiliated. You can e-mail your ethical queries, stories, or case examples to him at [email protected] or call his office at (404) 712-4804. ACKNOWLEDGMENT I am indebted to Diane Huber, PhD, RN, FAAN, CNAA, BC, and Carole Stolte Upman, RN, MA, CCM, CRC, CDMS, CPC, for their extremely helpful insights and recommendations regarding an earlier draft of this paper. Any errors or contentious observations that are present in this article are my responsibility and mine alone. Reprint orders: E-mail authorsupport@ elsevier.com or telephone (toll free) 888-834-7287; reprint no. YMCM 326 doi:10.1016/j.casemgr.2005.08.007
TCM 34
November/December 2005