Module B: Economics, Regulations & Reimbursement

CE Credits: 1.5


This module explores the relationship between quality and cost and ensures that case managers realize that spending is highly concentrated among a relatively small portion of high-cost users. Just 5% of the population is responsible for nearly 50% of all spending.
Quality and costs are negatively affected when patients:
» Receive non-beneficial care
» Fail to receive care in the setting of their choice—usually the home
» Do not receive the care that they say they want
» Experience unnecessary suffering
Evidence has demonstrated that these patients receive care characterized by fragmentation, overuse, medical errors and poor quality of life. The patients who fall into this group are an appropriate target population for palliative care and, when eligible, for hospice services.

Learning objectives: After completing this module the case manager will be able to:
» Describe the changing landscape of palliative and EOL care delivery
» Identify the relationship between quality and value
» Discuss regulations and standards affecting palliative and hospice care programs
» Review hospice coverage options
» Identify reimbursement guidelines for Medicare and Medicaid
» Discuss commercial payer reimbursement variations

Advance your professional practice:: Case managers gain an understanding that palliative care shares characteristics with hospice care including a focus on:
» Careful pain and symptom management
» Added family support
However, palliative care differs from hospice care in that patients are allowed to simultaneously receive any and all medical treatment which is deemed to be potentially effective and is directed toward their underlying disease(s).


Improve organizational performance: Improving knowledge and hence the case manager’s ability to education patients and other transdisciplinary team members that palliative care is an emerging type of speciality care will improve quality of care, communication and coordination for seriously ill patients and their families and, through this process, reduce reliance on emergency departments and hospitals.