Case managers face the challenge of balancing the competing priorities and pressures brought upon by the clients, providers, payers, and fellow health care team members. As coordinators and facilitators of care, they are able to acquire an understanding of the competing priorities and interests of the different parties involved in a given situation and the associated demands. This is necessary to effectively advocate for the client. The case manager’s role is executed within the context of collaborative case management approach to the delivery of health care services, keeping the client and client’s support system at the center and as a top priority.
Case managers use negotiation as a desired method to acknowledge the demands of the various parties, resolve or prevent conflict, and pursue desirable results. The main purpose of applying negotiation is the desire to “maintain a delicate balance” of the competing priorities and demands of the various involved parties. Negotiation is a useful tool in advocacy because it facilitates and supports the making of agreements among the different parties involved in the delivery of health care services. It also is most important when agreements are not freely forthcoming. The main percept of negotiation in case management advocacy is that it aims to reach an agreement/final decision where each party involved feels that the result is fair, equitable, free of bias, and satisfactory. Although such outcomes are not always possible, case managers must exert every effort and employ negotiation tactics that reach fair and equitable agreements in the end (Frankel & Gelman, 1998), and outcomes that reflect what is in the best interest of their clients/support systems.
When faced with an advocacy situation that requires negotiation such as conflict regarding treatment options, case managers conduct an evaluation of the situation. Based on the evaluation, they identify which party opposes what is in the best interest of the client/support system. Keeping the client and support system at the center of advocacy and health care delivery provides the necessary focal point and helps ensure that case managers are “doing the right thing” and protecting “what is in the best interest of the client.” From this perspective, case managers use negotiation as an advocacy tactic to resolve conflict, balance the outcomes, and enhance the chance for a win–win resolution.
To illustrate, consider a situation in which an insurance company denies treatment that a physician, hospital, and health care team feel is necessary. The case manager representing the hospital and the physician stands by the client and negotiates with the insurance company (payer) representative, attempts to influence a favorable change in position; that is, authorization of the treatment that implies reimbursement for services rendered. If the efforts fail, the case manager may seek the assistance of the physician or other members of the staff at the hospital to negotiate with the insurance company the approval of the treatment. It is necessary for case managers to know what they want to achieve (i.e., clarity of problem and purpose) and advocate for before engaging in negotiation. It is also as essential for them to understand the needs of the other parties, including the client/support system, the insurer/payer, and the other providers of care involved in the situation.
In a win–win situation, an agreement is reached and all parties-–the client, insurance company, physician, hospital, and the team-–are happy. In a win–lose situation, either the client or the insurance company loses. If the losing party were the client, the case manager and the team would not give up; rather, they negotiate further on behalf of the client to reach a satisfactory resolution with the insurance company. Throughout negotiation, case managers maintain a constant awareness of the goals of care delivery, namely, efficient and appropriate use of resources and client-focused care. They also keep mindful of the needs of the health care agency, including the potential financial impact of the outcomes (desired and actual).