The following disguished information describes the case management of a complex family health care situation. Read about this situation and compare the points of view of the patient, family, and the health care organization.
Medical Information
Patient is a young mother with progressive biliary liver chorsis due to very rare autoimmune disease. She is at home but can't function due to fatigue, malnutrition.
Patient Preferences
Patient is depressed and tells the family she's not sure she wants transplant. Refuses to leave town to have procedure at another hospital.
Managed Health Care
This Managed Care Plan (an Australian Health Care Organization) contracts a Center for Excellence in Liver Transplant that is in a distant territory. Local nurse case manager reports that family and patient call her 150 to 200 times a month.
Family System
Husband, parents and her siblings push her to have transplant in the neighboring Excellence Center, however, family can't afford to pay for family travel/motel/costs to other area. Patient does not want to travel out of town for a transplant.
Community
Members of patient's church come to the Managed Care board meetings to protest. They articulate that she needs the support of family and local church members to manage and survive the surgery. Thus transplant must be locally done.
Media Involvement
Family makes calls to local T.V. news, church, etc. to complain and raise money to travel with her. Newspaper reports her situation as a denial of care.
Politics
This patient's grandfather is a personal friend of territory governor; Grandfather uses local newspapers and political influence to arrange for patient to stay in town for transplant by a less experienced surgical team.
Internal Managed Care Utilization Review Committee
Formal review committee of nurses, M.D.'s, ethicist (consultant from Health Care Bioethics Center). The committee concludes that transplant necessary for life and patient desires support by her family in town.
Coverage/Cost Issues
Paying for medical care outside this managed care organization is unaffordable for the family and expensive for the organization… But patient agrees she would go to another area for transplant where her sister lives so family can afford to stay with her during the surgery. Managed the care organization had an already established policy to pay for out of area. But family and newspaper request experimental transplant.
Legal Issues
Family will not allow patient to go out of the hometown thus will not follow medical advice unless managed care organization would pay for an in-town transplant. Research data indicates the greater success for surgery is at the Excellence Center.
Experimental Treatment/Technology
New experimental transplant procedure, only 2 or 3 had been done before and many M.D.s writing to family willing to use their experimental protocol. Surgeon from local area telephones patient saying he would waive fee and agrees to experimental trial surgery.
Patient agrees to local transplant but does not survive the experimental procedure. Using the clinical Ethical Guidelines analyze this case situation, from the organization's point of view.
Using the Clinical Ethical Guidelines analyze this case situation from the managed health care organization's point of view.
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