When I was crafting my first book on case management in the late 1980s to early 1990s I feared that case management was another passing fad in health care. This bothered me because I saw how much it was needed and how critically the patients required our expertise. Because I was so passionate about helping patients, all I could do was write a book, hoping that it would exponentially touch more patients (even if the "fad" did pass).
Not only were my fears unfounded, but as the decades passed, the evolution of case management and the commitment of thousands of dedicated individuals proved the fundamental fact that, as health care changes, case management competence and skill is ever more fundamental to patient safety. Two enormous steps validating what we all know is the value of case management were taken with the passage of the Patient Protection and Affordable Care Act (ACA) in 2010 and the advocacy of case management as a component of the medical loss ratio (MLR) (Watson, 2010).
Patient Protection and Affordable Care Act
Whether we agree with all 1,000 pages of the ACA or not, one area is prominent. The ACA specifies or alludes to case management and care coordination as a necessary ingredient in the recipe required to improve patient safety and health care quality. In many areas of the ACA, but especially Title III: Improving the Quality and Efficiency of Health Care, the work we do is highlighted and even prescribed (Office of the Legislative Counsel, 2010).
By no later than January 2011, the ACA directs the Secretary of Health and Human Services to develop a national strategy to improve the delivery of health care services, patient health outcomes, and population health (U.S. Department of Health and Human Services, 2007). The Secretary must identify priorities that include the following goals, in each of which one can "read" in the qualities and work of case management and care coordination:
* Address the health care provided to patients with high-cost chronic diseases.
* Identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care.
* Identify areas that have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations.
* Address gaps in quality, efficiency, comparative effectiveness information, and health outcomes measures and data aggregation techniques.
* Improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable hospital admissions and readmissions, and health care-associated infections.
* Reduce health disparities across populations and geographic areas.
Reading further into the ACA, we find that new patient care models are discussed, again providing opportunities for case management and care coordination to shine. This section, encouraging the development of new patient care models, mandates the creation of a new section of the Centers for Medicare & Medicaid Services (CMS) entitled the Center for Medicare and Medicaid Innovation (CMI). By January 1, 2011, the CMI must begin testing innovative service delivery models (and payment models) to reduce program expenditures while preserving or enhancing the quality of care. Preference must be given to models that improve coordination, quality, and efficiency of health care services.
Professional Case Management has published information on several of the cited patient care models, such as accountable care organizations, medical homes, and various care transition models that also reduce inappropriate readmissions. Funding for this CMI effort is substantial. For fiscal year (FY) 2010, $5 million is appropriated for the design, implementation, and evaluation of patient care models. In FYs 2011 through 2019, $10 million per year is allocated for these activities.
The Medical Loss Ratio
Several groups, including the Case Management Society of America (CMSA) and the Commission for Case Manager Certification (CCMC), submitted statements to the National Association of Insurance Commissioners (NAIC) explaining why case management and related services such as care coordination should be included in the MLR. The NAIC was tasked to decide this issue and make recommendations to the Secretary of Health and Human Services [see Watson (2010) for more detail on this issue]. In August 2010, the NAIC issued its decision on MLR, specifying that effective case management, care coordination, and chronic disease management will be included in the ratio, thus elevating the importance of case management/care coordination in the pursuit of quality, efficient, and effective health care in the United States.
The ramifications for case management are huge, and even bigger will be questions about the actual rollout of the regulations in the coming years. Professional Case Management will be available as a resource for these issues. In particular, we have added a new department entitled Legal and Regulatory Issues, headed by Lynn S. Muller. Lynn is a nurse, a case manager, and an attorney whose practice includes defense of health care professionals before state licensing boards, personal injury, family law matters, wills, and estates; she has also provided consulting representation for medical practitioners, facilities, and health service corporations on such issues as regulatory compliance. She wrote the legal chapters for the third edition of Case Management: A Practical Guide for Education and Practice and the second edition of the CMSA Core Curriculum for Case Management. Lynn has also served her community as public defender, judge, and councilwoman. She encourages Professional Case Management readers to submit manuscripts and/or questions and concerns to [email protected].
Another development you will notice in this issue is that the journal has changed the Inside Case Management (ICM) department to become more specific to the return-to-work theme. We are fortunate to continue to have Fran Snowden as Editor in this evolution of ICM.
The new changes in health care are yet to be defined. One thing is certain: case managers are prominent in those changes and will be in the coming years. Our expertise provides the value that is being sought; our touch provides the humanity in health care that is and will continue to be fundamental.
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