Case Management and Funding Maximization in the US Healthcare


US Health Care is one of the largest sectors of the US economy that has enormous resources. The activities of the government and private sector in this field have a multifaceted impact on American society. The health policy affects the essential interests of all layers, groups, and classes of society. Particularly, reimbursement is a rather serious problem causing a certain fragility and relative instability of health care. One of the major causes of social failure of American health care, namely, the lack of access to it, lies in the inappropriate reimbursement system both in government-funded programs and the private sector.

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Government Funded Programs

In the US, there are various public health programs, however, the largest two of them are Medicare and Medicaid. The establishment and development of the Medicare government program consist of two parts: insurance in the case of hospital care and supplemental insurance. Medicaid is the second-largest public health program, which serves as the main source of medical support for the poor population of the US. Medicaid program differs from Medicare in two key characteristics.

Firstly, it is the public program of the charity, because the population did not pay the taxes in contrast to Medicare. Secondly, it is in the legal and administrative jurisdiction of the state authorities yet co-financed by the federal government and states’ governments. The government takes responsibility for the health sector that is either unprofitable for the private medicine or objectively needs federal support.

The activities of the state in this area are clearly expressed by the tendency to comply with the interests of society in general while the activities of the main components of health care are aimed at maximizing profits. One of the main contradictions of American health care lies herein.

Medical government programs cover a large part of the population, and its influence is not confined within these programs. 95 percents of employees pay taxes for the social insurance. In this regard, the paramount role of case managers is to maximize the reimbursement that would ensure citizens’ right to quality medicine, which is a priority component of the health care. According to the study conducted by Hines and Yu (2009), “by combining payments for an entire episode of care, the goal is to increase care collaboration and promote improved outcomes and greater efficiency of care delivery” (p. 4). Case management leadership should be proactive in assisting patients to meet the appropriate quality of the health care.

Besides, case managers’ role is in providing patients with timely and relevant information concerning their social rights and payment. Moreover, they should provide the patients’ with the cost-effective recovery conditions either at the hospital or at home. Additionally, it is also important to analyze each particular case in order to offer the most suitable measures to reduce costs. Finally, the culture of safety and accountability should be created by means of the implementation of several programs that would contribute to the maximizing reimbursement.

For example, the Affordable Care Act supposes the prognostic modeling challenges and opportunities for the case management. In particular, the predictive modeling offers innovative accountable system:

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With the rapid growth of health information technology and the high likelihood that perceived health and nursing care needs will be strong predictors of readmission, there is a growing need for nurse informaticists with advanced statistical training who can liaison between clinical information needs such as those required by PM and EHR developers. (Meek, 2012, p. 18)

Electronic health records would automate the discharge readmission of patients. The described system also would promote the early detections of at-risk patients.

Private Sector

The private health care system exists under the national legislation, which determines the incentives and directions of its development and provides the government control. The private sector covers the majority of the population, and the most common form of it is a group insurance at work. The government policy in relation to private health insurance, which provides taxes incentive for entrepreneurs, largely defined the broad development of this system. Private health care system facilitates access to health care for the private sector employees.

In general, the US system of private insurance does not guarantee the patient a full coverage of the cost of medical services and especially the growth of prices. There is also the risk of negative consequences for employees in the circumstances of the loss or change of job. In addition, the voluntary nature of medical benefits left outside the health insurance millions of employees. Therefore, an inadequate reimbursement remains a serious problem.

The situation is complicated by the difference of several reimbursement types (AHC Media LLC, 2011). However, case managers might influence the length of patients’ stay at the hospital, their treatment, and communication with family along with making sure that the hospital does not lose reimbursement or encounter extra examination from payers.


In conclusion, both government programs and private sector includes the shortage of the adequate reimbursement. Case managers should undertake various measures such as proactive leadership or predictive modeling to maximize reimbursement and ensure proper quality of the health care for patients.


AHC Media LLC. (2011). ED case managers are crucial to help maximize reimbursement. Hospital Case Management, 8(2), 113-116.

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Hines, P. A., & Yu, K. M. (2009). The Changing Reimbursement Landscape: Nurses’ Role in Quality and Operational Excellence. Nursing Economics, 27(1), 7-13.

Meek, J. A. (2012). Affordable Care Act. Professional Case Management, 17(1), 15-21.

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