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Case Managers Are Key To Future Reimbursement


Pursuant to the Patient Protection and Affordable Care Act of 2010 (“Health Care Reform”), commencing on October 1, 2012, hospitals’ Medicare reimbursement will decrease if the hospital has an excessive rate of readmissions. This is merely one program, among many, that is designed to change reimbursement models to focus on quality outcomes instead of the volume of services rendered.  Ultimately, the goal is to reduce the costs of the healthcare delivery system.  It has been reported that Medicare intends to cut its cost by $280 Million through this reduction in hospital payments just by reducing reimbursement for excessive readmissions.  In order to avoid this reimbursement penalty, hospitals must think outside of the box and implement innovative programs that will ensure patient compliance with the treatment plans that do not require readmission to an acute care setting.


Case managers are key to a hospital’s successful strategy to avoid readmissions.  Specifically, when a patient is in the hospital, they usually develop a relationship with a case manger or social worker who can assist them in evaluating their medical and social needs.  The case managers immediately assess the patient’s unique situation, including the individuals involved in the patients’ plan of care, social needs and medication needs.  On the first day of an inpatient stay, case managers work on the proper discharge plans to ensure the patient does not need acute care inpatient care post discharge.  Case managers focus upon what types of resources will be needed by the patient when they leave the hospital setting.  The resources may include home health care, medication delivery, durable medical equipment or nutritional assistance.  By ensuring that patients have the resources—including but not limited to community resources, home health nurses, medication delivery and remote monitoring of a patient—case managers can help assist patients to be more compliant with their treatment plan and be more accountable for their health.  


In addition to facilitating and evaluating patients’ needs in the hospital, case managers now see their roles extend beyond the four walls of the hospital.  Case managers now reach out to the patients in their home setting and engage the patients on an outpatient basis to make sure that they have received their medications, that they are taking their medications and that they are complying with their treatment plan.  Although the case manager’s time engaging the patient post-discharge is not reimbursed by payers, it is a means to prevent future losses which helps the bottom-line.  Specifically, by engaging a patient in their home, hospitals are implementing strategies to circumvent the patient being readmitted in the hospital. A patient readmission would be costly to the health care delivery system without any reimbursement by Medicare and Medicaid.  Ultimately, when readmissions occur and are not paid by the government, the cost must be spread to other health care consumers, which increases not only health care costs but insurance premiums for all individuals. 

Accordingly, case managers are a key component to the new design for the delivery of health care.  Case managers can assist patients to become more compliant, ensure resources are available outside of the hospital setting and hopefully improve patient outcomes to avoid readmissions.  In order to fully and efficiently achieve the cost savings and avoid hospital readmissions, the case managers are part of a larger interdisciplinary team with the physicians, the patient and the community to ensure the necessary resources are available for patients.  During the month of November as we acknowledge the wonderful work of case managers, it is important to remember they are part of the critical team that will help hospitals get to the next stage of health care delivery and will hopefully ultimately reduce the cost of the overall delivery of care for all recipients. 

This article was originally published in the October 2012 issue of Atlanta Hospital News.