Health policy and case management.

The purpose of this article is to analyze the performance of and support for case management using a policy framework in order to increase case managers' awareness of policy making and facilitate successful planning for future policy initiatives. Feldstein's (1996) theory of opposing legislative outcomes indicates that legislation can be viewed on a continuum, ranging from legislation that meets the needs of the public to legislation considered to be in the self-interest of the participants and legislators. The current health care system requires that case managers working for publicly funded health care organizations balance the need for stewardship of U.S. tax dollars and the health care needs of consumers. It is apparent from the literature that case managers are successfully achieving this balance. However, certain conditions should exist that allow for case manager decision-making that promotes effective and efficient utilization of health care resources. Case managers must work within the context of the health care policy environment. Realizing that it is more likely that the conflicts between stewardship and the provision of health care services will continue, case managers' knowledge and influence regarding policy making becomes imperative in order to ensure that these conflicting goals do not become mutually exclusive. The responsibilities of publicly funded health care organizations conflict; stewardship of U.S. tax dollars must be balanced with the desire to provide an extensive health care benefit package. Case managers are instrumental in assuring that these conflicting goals do not become mutually exclusive. However, the prevailing benefit package policies have the potential to unnecessarily curtail the case manager's ability to maintain that balance between cost-efficiency and effectiveness of care; policies meant to curtail costs may create unnecessary and inefficient barriers. Therefore, it is in the best interest of the health care organization and the beneficiaries that case managers not only understand health care policy, but influence policy decisions. The purpose of this article is to analyze the case management program of uniquely publicly funded health care organizations in order to increase case managers' awareness of policy making and facilitate successful planning and implementation of future policy initiatives. The analysis includes a discussion of the theoretical framework, the identification of the problem and its significance, the delineation of the various objectives of the parties involved, the identification of political issues and influences, the impact on case managers, and recommendations for future action. THEORETICAL FRAMEWORK Feldstein (1996) believes that policy is developed under the rubric of public interest, but more truthfully, by way of self-interest. Public interest theories have an underlying assumption that the basic objectives of policy making are to improve efficiencies and to redistribute resources more equitably. Conversely, the self-interest paradigm redistributes wealth or benefits toward those who can offer political support, thereby imposing costs on those who cannot. Self-interest legislation redistributes wealth, but at the sacrifice of political support. Redistribution is classified into two major types: charitable programs and universal programs (Feldstein, 1996). Charitable programs are designed to assist the poor by requiring that income be redistributed from those with higher incomes. These programs are means tested; eligibility for participation is based on strict interpretations of income. Certain publicly funded health care organizations are considered universal programs because they apply to everyone in a particular category regardless of income, that is, Medicare. Universal programs are based on the claim that the poor will benefit and be treated the same as others. The actual effect results in net benefits to groups other than the poor, substantiating the claim that publicly funded health care organizations and other universal programs are based on self-interest. …