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Changes in healthcare reimbursement have occurred with lightning speed over the last two decades. Earlier, reimbursement had been stagnant for many years and functioned on a “no questions asked” basis. Providers billed for services rendered and were reimbursed — with no checks, balances, or control over costs of care. Case management, as a care delivery model, followed a similar course. It was a community-based model dating to the 1920s. But as reimbursement changed, so did case management. This month we will begin our discussion of reimbursement, including the changes to case management as it evolved with reimbursement.
Reimbursement Inspired Change in Healthcare
Evolution in reimbursement motivated change in healthcare delivery, moving case management into the limelight in the mid-1980s. Before the 1980s, most reimbursement schemes were fee-for-service (FFS), with little concern for length of stay or cost of care. Overuse was common — the more that was spent, the greater the reimbursement. This could be viewed as an overuse reward system. With no checks and balances on the system, costs continued to increase. At the same time, the costs of pharmaceuticals, radiology, and supplies escalated with minimal management. It became apparent to hospitals and healthcare systems that greater accountability was needed.
Forces driving the move toward case management:
• 1970s: Escalating healthcare costs;• 1980s: Prospective payment system in acute care settings;• 1990s: Managed care infiltration;• 2000s: Prospectivfve payment in home care, outpatient care, rehabilitation services, and long-term care;• 2010: Healthcare reform.
Eventually, these spiraling and unchecked costs brought pushback from patients and third-party payers. No longer were they willing to pay these high costs. It also was becoming apparent that healthcare quality was not keeping pace with the increased expenditures. Were these higher costs necessary or were they simply a result of an unchecked healthcare system? Some patients were concerned they were paying more and getting less. This concern was not unfounded. Care quality did not improve simply by throwing more resources into the process. In fact, in some instances, resource misuse and overtreatment exacerbated the problem.
By the mid-1980s, many pilot projects were underway to develop changes in delivery that might reduce costs while improving care quality. Since value in healthcare is the equation that reduces costs and improves patient outcomes, these changes were...