Competition, Organizational Change, and Conflict: The Changing Role of Case Managers in Ontario's Homecare System

Article excerpt

As health care costs climb, governments continue to seek ways of controlling expenditures and improving accountability. One approach recently used by the government of Ontario to reform the delivery of homecare services focused on the introduction of competitive market forces in conjunction with the establishment of greater managerial controls over the activities of frontline health professionals. The purpose of this article is to assess how this "managed competition" model impacted the role of homecare case managers and their relationships with frontline health professionals. Data for this case study were obtained primarily through 36 in-depth key informant interviews with representatives from homecare provider agencies and the community care access centers (CCACs), which contract with the provider agencies for client services. The managed competition reform dramatically altered the role of homecare case managers by requiring them to take on greater responsibility for monitoring budgets and rationing services. This shift from a collaborative to a competitive system promoted conflict between case managers and other health care professionals. In the presence of an increasingly bureaucratized case manager role, interprofessional conflict and a focus on cost containment seems to have left clients without any clear advocate of their interests.

Keywords: bureaucratization; health care reform; Canada; health policy

Since the 1980s, one of the most widespread approaches to improving efficiency and accountability in public administration has been the introduction of reforms that embrace market mechanisms and promote managerial control over the activities of frontline health professionals (Drake & Davis, 2006; Hoggett, 1996; Hood, 1991; Kitchener, 2000; Kitchener, Kirkpatrick, & Whipp, 2000; Scott, 1982). The primary goal behind these reforms has been to constrain the growing costs of publicly funded services. The health care sector has been a prime target of such reforms because of the speed at which health care costs have been rising. Market mechanisms promote competition while managerial controls facilitate the monitoring of care provided by health professionals and, in some instances, may include the establishment and implementation of practice guidelines or care pathways that promote the standardization of care.

Between 1997 and 2000, Ontario's Progressive Conservative government implemented a "managed competition" model as part of its province-wide reform of homecare services. The managed competition model was intended to introduce competitive market forces in conjunction with the establishment of greater managerial controls over the activities of frontline health professionals. Competition was promoted by requiring a separation between purchasers and providers of services. In order to achieve this separation, Homecare programs were replaced with community care access centers (CCACs), which were responsible for purchasing and coordinating the delivery of homecare services within Ontario rather than providing services directly.

Under this new model, for-profit homecare provider agencies were permitted to compete directly with the traditional not-for-profit provider agencies, such as the Victorian Order of Nurses and the Red Cross, for service contracts. Homecare service contracts were to be awarded based on a combination of lowest cost and highest quality. However, under this new competitive model, once contracts were awarded, the CCAC would need a method for monitoring both costs and quality and it was to be the case managers within the CCACs that were to take on this new role.

While reforming health care systems by embracing market mechanisms and managerial controls has become commonplace, research has tended to evaluate success based principally on economic criteria. The purpose of this article is to move beyond economic evaluations to assess how the organizational change resulting from the implementation of this "managed competition" model impacted the role of homecare case managers and their relationships with frontline health professionals since interprofessional relationships can have a critical impact on organizational performance. …

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