What does the term “Cost Awareness” mean in case management?
As everyone is very much aware, costs in health care have been driven to outrageous proportions. These changes have come about as a result of rocketing costs for consumers of healthcare, outrageous costs of pharmaceuticals, radiology, and medical supplies, an aging patient population, the HIV/AIDS virus, and increasing costs of technology. Health care is complex and highly technological, an equation that spells high dollar cost. Examples are life prolonging treatments such as organ transplants and kidney dialysis. Antibiotics, computerization, and durable medical equipment all add to the spiraling costs. Many changes have brought about effort to cut costs, some of which have been criticized by society as decreasing the quality of the medical care consumers expect. Managed care is one change that has been criticized for its cost-cutting ways that have seemed at times to be less concerned with quality. Case management, however, is designed and intended to manage care, monitoring and controlling of resources. It closely monitors the products of the care it manages and their effects on the patient. Case management is not to be confused with managed care. These are not interchangeable entities. Managed care is a system of cost-containment whereas case management is a process of care delivery which is sometimes used within the managed care system. Consumers and third party payors are rightfully reluctant to pay high costs when the quality of the services is not suitable. We do not want the quality of services to decrease while the costs rise. The quality must be improved and cost contained. The ultimate goal is increased satisfaction and improved outcomes. This is the realm of what nursing case management is. Nursing case management is the means for delivering services that coordinates multi-faceted care, plans care as per the physician recommendations, identifies expected outcomes, and helps facilitate the patient toward expected achievement of positive outcomes, focusing on meeting the patient’s needs, providing care in the most cost-effective way possible. Because nursing case managers understand that coverage decisions to pay for medical care by the payor are complex with many factors to be considered, the nursing case manager always attempts to work within the client’s benefit plan. Nursing case managers try to constantly be aware of additional supplemental resources to whom they may refer a patient in an attempt to meet needs not covered in the benefit plan when the services are important to promote improved outcomes for the patient/client.