Funding Case Management: In the Past Few

Funding Case Management:

In the past few years, case management has developed to become a major part of patient-centered health homes and responsible care facilities. Through this process, case managers coordinate care and offer patient education regarding the management of diseases and the symptoms that show the need for a physician. While case management is a vital component of treatment service, its inclusion into the funding structure is dependent on the guidance and direction by key decision-makers. As a result, the decision to include case management in the spectrum of treatment services is usually dependent on the primary source of funding or the program level ("Funding Case Management," n.d.).

Based on this analysis, there are various strategies for getting case management funded within the existing health plans. The first strategy is to recognize the significance of case management as a major element for effective treatment and share it with the source of funding. The care providers should transform their delivery systems to incorporate case management as a vital component of effective treatment and communicate to the primary source of funding, which is usually a State agency. However, these providers must develop means for measuring outcomes if the primary funding source requires or anticipates specific outcomes that are above cost containment ("Funding Case Management," n.d.).

Secondly, case management can be funded within health plans is through measuring everything that assists the client to manage other aspects of their lives and maintain moderation. This measure enables providers to enhance the chances of having the activities of case management reimbursed. The third strategy is through integration of funding streams, which has emerged as an initiative to join services and offer continuity of care. This helps care providers to avoid the disparate mandates of various funders with system and service fragmentation.

Service Strategy v. Reimbursement Strategy:

While there are various payers for particular healthcare services, only a small number of payment methods are utilized to reimburse providers. However, the existing payment methods in the healthcare system are mainly divided into two broad categories i.e. fee-for-service and pay-for-performance. These payment methods can be referred to as service or reimbursement strategies that have significant variations. The service or fee-for-service strategy is a payment method that is classified into cost-based, prospective-based, and charge-based methods. However, the main basis of a service strategy is that it's based on a charge-based payment method in which payers are billed charges. Through the billed charges, the payers pay for the care services based on a rate schedule or chargemaster developed by the care provider ("Paying for Health Services," n.d.).

In contrast, a reimbursement strategy is also known as pay for performance strategy, which is a payment method established by insurers to reimburse the provider for the costs incurred while providing services to the insured population. In most cases, the reimbursement strategy is based on the past since the insurer pays the provider depending on what has occurred in the past. This strategy is usually restricted to allowable costs i.e. costs that are directly associated with the provision of healthcare services.

The main difference between the two is that a service strategy is charge-based while a reimbursement strategy is cost-based. The service payment method is usually dependent on the rate schedule developed by provider, which implies that the payers are at the mercy of providers. Consequently, the service strategy is most commonly used in markets where competition among providers is limited. In contrast, a reimbursement strategy is cost-based, which guarantees that a provider's cost will be catered for by revenue.

Linking Hospital Reimbursement to Performance Outcomes:

Many insurers are currently developing reimbursement systems that clearly reward providers for accomplishing certain things. These systems are commonly known as pay for performance strategies since they are modified fee-for-service and capitation systems. The pay for performance strategy rewards providers for accomplishing specific treatment goals like patient satisfaction. Notably, insurers pay the care providers an extra fee if standards that are usually linked to quality of care are achieved ("Paying for Health Services," n.d.).

The creation of these systems has contributed to the increased tendency of linking hospital reimbursement to performance outcomes. The main concept behind these systems is to develop incentives for improved quality of care that will be costly for insurers in the short-term but will result in lower medical costs in the long-term. Actually, in certain pay for performance systems, insurers force providers to bear the cost of the plan through lessening payments to poor performers and using these savings to improve payments to good performers.