Utilization and Case Management Programs: Linchpins to Provider Success in an At-Risk Reimbursement Environment

Centers for Medicaid and Medicare Services (CMS) has taken a leading role in reforming Medicare, and by default, the entire healthcare system; i.e., Medicare is often seen as the bellwether for reimbursement change by commercial payers. Last year, on January 26, 2015, Secretary Sylvia Burwell of Health and Human Services (HHS) established a timeline for moving from volume to value: “Our first goal is for 30 percent of all Medicare provider payments to be in alternative payment models that are tied to how well providers care for their patients, instead of how much care they provide — and to do it by 2016. Our goal would then be to get to 50 percent by 2018. Our second goal is for virtually all Medicare fee-for-service payments to be tied to quality and value; at least 85 percent in 2016 and 90 percent in 2018.”1