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Related Experiment Videos

Finding meaning in medical necessity.

Jeffrey Schwartz1, Michael B Weiner

  • 1Managed Health Network, New York, NY 10005, USA. Jeffrey.Schwartzmhn.com

Social Work
|August 6, 2003
PubMed
Summary
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Care managers face professional conflicts balancing medical necessity criteria and educating on efficient treatments. This impacts relationships with colleagues and ensuring treatment quality.

Area of Science:

  • Healthcare Management
  • Clinical Practice
  • Patient Advocacy

Background:

  • Managed care organizations (MCOs) increasingly utilize care managers as liaisons.
  • Care managers play a crucial role in bridging MCOs and patient care.
  • The evolving healthcare landscape presents unique challenges for care managers.

Purpose of the Study:

  • To highlight the professional conflicts encountered by care managers.
  • To examine the dual clinical functions of determining medical necessity and educating stakeholders.
  • To explore the impact of these functions on professional relationships and treatment quality.

Main Methods:

  • The study synthesizes personal experiences of care managers.
  • Relevant literature on care management and healthcare policy is reviewed.

Related Experiment Videos

  • Qualitative analysis of professional conflicts is presented.

    • Main Results:

    • Care managers experience significant conflict in applying medical necessity criteria.
    • Educating practitioners and patients on effective treatments presents challenges.
    • Maintaining collegial relationships while enforcing MCO policies is difficult.

    Conclusions:

    • Care managers navigate complex professional conflicts in their dual roles.
    • Balancing cost-efficiency with optimal patient care is a primary challenge.
    • Further support and clearer guidelines are needed for care managers to ensure treatment excellence.