The new Medicare 2019 Hospital Outpatient Prospective Payment System final rule focuses on patient-driven healthcare, acknowledging the importance of addressing social determinants of health.

  • Changes that will affect case managers include the rule’s focus on preventive care, better communication and coordination, working with communities, and strengthening family engagement.
  • The rule has a strong focus on outpatient care facilitation.
  • Case managers should focus on improving quality of care, as well as lowering costs of care.

Case managers can expect some changes in their roles under the Medicare 2019 Hospital Outpatient Prospective Payment System (OPPS) final rule, effective Jan. 1, 2019.

Focusing on patient-driven healthcare, the rule acknowledges the importance of case managers addressing social determinants of health. It also addresses reimbursement disparities between inpatient and outpatient services.

For instance, the rule’s Meaningful Measures place the focus on preventive care, better communication and coordination of care, strengthening family engagement, and working with communities to promote health. (http://bit.ly/2S4A4CO)

“The OPPS rules will impact case managers,” says Ellen Fink-Samnick, MSW, ACSW, LCSW, CCM, CRP, principal of EFS Supervision Strategies in Burke, VA.

Under the proposed new OPPS rule, there is a greater focus on patient choice. This makes it necessary for more effective patient dialogues, Fink-Samnick says.

“There is a greater focus on mastery of technology and interoperability for consumers — and, thus, their case managers,” she says. “And there’s a strong focus on outpatient care facilitation.”

The proposed rule will require case managers to be diligent about making sure patients have what they need in their communities, says Mary McLaughlin-Davis, DNP, ACNS-BC, NEA-BC, CCM, a senior director of care management at Cleveland Clinic in Ohio. McLaughlin-Davis also is the immediate past president of the Case Management Society of America (CMSA).

“Case managers will need to be cognizant of what is and isn’t available,” McLaughlin-Davis says.

Their focus should be on improving quality of care, as well as lowering costs of care, she adds. “Look at what is available for patients and help them manage transitions.”

The focus on social determinants of health is positive, Fink-Samnick says.

“Let’s not forget that $1.7 trillion is spent on 5% of the population, and their problems mostly are related to social determinants of health,” she says.

“The new OPPS rules will ramp up case managers and their organizations to more closely align with nonclinical community resources that can address the social determinants of health,” Fink-Samnick adds. “Connecting patients with those resources reduces readmissions and saves overall costs.”

This reality is why four out of five payers have these kinds of programs in place and healthcare organizations increasingly are engaged in vertical mergers, such as CVS and Aetna. Such mergers enhance care and service access, minimize food and pharmacy insufficiency, and assure greater population health and wellness, she says.

The CMS Meaningful Measures Initiative, launched in 2017, approaches quality measures through fostering operational efficiencies and reducing costs, collecting, and reporting burden, according to the final rule. The objectives include:

  • address high-impact measure areas that safeguard public health;
  • patient-centered and meaningful to patients;
  • outcome-based where possible;
  • fulfill each program’s statutory requirements;
  • minimize the level of burden for healthcare providers;
  • significant opportunity for improvement;
  • address measure needs for population-based payment through alternative payment models;
  • align across programs and/or with other payers.

The rule’s quality reporting section notes that organizations will see the following benefits from Meaningful Measures:

  • eliminating disparities;
  • tracking measurable outcomes and impact;
  • safeguarding public health;
  • achieving cost savings;
  • improving access for rural communities;
  • reducing burden.1

The final rule is promoting a wellness model for the Medicare population, McLaughlin-Davis says.

“We don’t have all the pieces in place yet, so that’s why organizations really are focusing on social determinants and behavioral health of patients, along with medical health and integrating both,” she explains.


  1. The Centers for Medicare & Medicaid Services. Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs. Fed Reg. Nov. 21, 2018;CMS-1695-FC:1-1182. Available at: https://bit.ly/2E6oKmK.