The reduction of funding in healthcare and the gradual decrease in the amount of the available costs is one of the most common trends in contemporary healthcare in the United States. The trend is accompanied by the complications in the form of the tightening of the Medicaid and Medicare standards. As a result, under the newly rising pressures, healthcare organizations have to adjust and improve their services in order to avoid needless costs. There are ways to address the excessive expenditure, and the hospitals and medical centers are actively exploring them.
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When it comes to the case management, even though this specialty has been in place for several decades, the outline of its role has been rather vague for a long while (Treadwell et al., 2015). The initial guiding principles of the profession of the case manager made them functional only for the patients whose cases required certain solutions and management. However, modern realities have made adjustments to the role of the case manager. That way, every case qualifies for the management.
The main duty of the medical professionals, to this extent, is to assign the level of care that is appropriate for the patient’s condition (“ED case managers are crucial to help maximize reimbursement,” 2011). This issue refers to the obligations of the case managers who are required to make sure that the inpatient and outpatient status is assigned according to all the rules, and that the inappropriate readmissions are excluded or minimized (“ED case managers are crucial to help maximize reimbursement,” 2011). In other words, the role of the case manager is vital as it is their task to identify whether or not the medical facility is providing adequate care to a patient and minimize the change of being heavily fined for fraud or abuse.
Without the ongoing control and monitoring, the medical institutions are likely to suffer the losses of capitals as today the standardization of healthcare is conducted by means of the close collaboration between the programs such as Medicaid or Medicare and the insurance companies (“ED case managers are crucial to help maximize reimbursement,” 2011).
Private and Government Funding
When it comes to the funding of healthcare, the capitals can come from two types of sources – private and public. The programs funded publically involve the government funds that are delivered via national healthcare systems; at the same time, private services are delivered by the medical facilities who work for profit and self-employed medical professionals developing their private practices. The latter type of providers of the medical services is funded by private organizations or individual investors (Basu, Andrews, Kishore, Panjabi, & Stuckler, 2012).
The researchers disagree about the performance of publically and privately funded institutions in terms of integrity, quality, and efficiency. In some studies the professionals report that the private sector organizations tend to have a higher level of abuse and fraud which is explained by their financial interest and desire to make money pushing unnecessary procedures and tests on the patients; the other studies maintain that privately funded facilities tend to demonstrate better care and quality in order to ensure that the higher level of patient satisfaction helps them improve their reputation and attract more clients (Basu et al., 2012).
The opinions differ when it comes to government-funded organizations. One the one hand, there are studies that characterize their performance by the lower quality and a higher rates of negative patient outcomes, also, one more frequent characteristic of the government-funded facilities is the higher level of corruption that always impacts the quality of care provided and the patient satisfaction rates; and on the other hand, there are studies that argue that the public sector organizations are known for a greater level of efficiency that occurs due to the limited funding and the need to accomplish a wide variety of tasks with the scarce resources (Basu et al., 2012).
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Based on the studies and analyses, the factors that shape the organizational performance at the healthcare institutions are versatile and multiple; they may include such impacts as the level of funding, the culture of the institution, the allocation of resources, the sufficiency of staffing, even the economic situation in the region or a country (Basu et al., 2012).
In terms of the case management and the reimbursement, the new approach to funding and the standardization of the state healthcare in the US has made the government introduce new policies as to the service provision and funding (“ED case managers are crucial to help maximize reimbursement,” 2011). As a result, the payers have more chance to recoup for the treatment reimbursement in case if the requirements of the new policies were not met appropriately. That way, a professional and experienced case manager is to take part in the process of the service allocation and some aspects of the medical-decision making in order to prevent the institutions from being exposed to fines, lawsuits, and accusations of fraud, abuse, and medical malpractice.
Basu, S., Andrews, J., Kishore, S., Panjabi, R., & Stuckler, D. (2012). Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PloS Medicine, 9(6), e1001244. Web.
ED case managers are crucial to help maximize reimbursement. (2011). Hospital Case Management, 113-6.
Treadwell, J., Perez, R., Stubbs, D., McAllister, J. W., Stern, S., Buzi, R. (2015). Case Management and Care Coordination. SpringerBriefs in Child Health, 17-26. Web.