HANDOUT Finance Pediatrics CAPCseminar14
Payment Reform—More Talk than Action? Developing the Financial Case for Pediatric Palliative Care Stefan J. Friedrichsdorf, MD, FAAP Associate Professor in Pediatrics, University of Minnesota Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota, Minneapolis/St. Paul, MN [email protected] ...with Thanks to Sarah Friebert, Akron, Ohio @NoNeedlessPain Minneapolis / St. Paul (Minnesota) Language background of today’s speaker… “This may surprise you...” What are you hoping for...? Attitude ✤ You are considering to run a interdisciplinary PPC service - what might you hear from leadership regarding issues of financing it...? 2 Main Objectives ✤ ✤ ✤ Describe two components of healthcare reform that support a business model for pediatric palliative care (PPC) Identify current and potential sources of revenue and reimbursement to support a PPC program List key steps in constructing a business plan to support a PPC program in the participant’s home institution How Many Children Would Benefit from PPC ✤ ✤ ✤ ✤ UK: 32/10,000 (high income country) South Africa 150/10,000 (upper middle income country) Zimbabwe 180/10,000 (low income country) No accurate figure globally: ICPCN estimates 15-20 million children worldwide (low estimate) Mortality 1-4 Year Olds worldmapper.org PPC ... 2-3 generations ago? Causes of Death in Children 0-19 years (USA, 2002) 1. Birth!! ! ! 2. Life-limiting diseases! 3. Unintentional Injury! 4. Homicide! ! 5. SIDS!! ! 6. Suicide ! ! Total! ! ! ! ! 18,487! 15,963 ! ! ! ! ! 10,952 2,604 2,050 1,900 ! ! 51,956 US Dept Health & Human Services; US Census Bureau; National Institute of Child Health & Human Development Friedrichsdorf SJ, Minneapolis, 2006 Life-Limiting Conditions (LLC) ✤ ✤ …are those for which there is no reasonable hope of cure and from which children will die before reaching adulthood. UK: Prevalence [32/10,000] Fraser LK, Miller M, Hain R, Norman P, Aldridge J, McKinney PA, Parslow RC: Rising national prevalence of life-limiting conditions in children in England. Pediatrics. 2012 Apr;129(4):e923-9 ✤ ✤ White: 27/10,000 ✤ Chinese: 32/10,000 ✤ Black: 42/10,000 ✤ South Asian: 48/10,000 USA - Age 0-17: 74.3 million children (2014) http://www.childstats.gov/americaschildren/tables/ pop1.asp ✤ ✤ Prevalence [32/10,000]:! > 237,000 with LLC Mortality [1.5-1.9/10,000]: 10,800 - 13,700 die/year ACT & Royal College of Paediatrics and Child Health, 2003 ✤ 15,000 die/year Age (0-24), who would benefit from PPC Feudtner, 2001 Boeing 747-400 416 passengers US Health Care System...? ✤ ✤ USA: > 15,000 children die each year due to life-limiting conditions 83 “Boeing 747” ✤ ✤ one crash every 10 days [every 4.4 days, when including infants] What makes funding a PPC program difficult? ✤ Financial barriers ✤ Enrolling into “Hospice” often not applicable ✤ Resource allocation Financial Barriers ✤ Reimbursement ✤ ✤ ✤ PPC outcomes not favorable in Fee-for-service environment Not an efficient, procedure-driven, money making enterprise ✤ Our “procedure” is often the family meeting ✤ Time and decision making might be our major offerings Current system forces choices between services ✤ Emphasis on duplication of services “Hospice” concept - why often not applicable in pediatrics? ✤ Unrealistic to think parents will be able to abandon aggressive therapy ✤ ✤ “leave no stone unturned” Exception, not the rule – rare family will fall into “classic hospice patient” ✤ ✤ Pediatric care is (!) more expensive ✤ ✤ Horse already needs to be out of the barn But the cost is often offset by true QoL => 2010: Concurrent Care Objective 1 Describe two components of healthcare reform that support a business model for pediatric palliative care I. Concurrent Care for Children ✤ March 23, 2010: Patient Protection and Affordable Care Act (PPACA) ✤ ✤ Section 2302 (page 202), termed “Concurrent Care for Children” Requirement (CCCR) http://www.nhpco.org/resources/concurrent-care-children Concurrent Care for Children Requirement (CCCR) ✤ Applies to children: ✤ ✤ ✤ covered by Medicaid and Children’s Health Insurance Program (CHIP) With a 6 month prognosis and eligible for hospice services Also applies to children covered under umbrella programs, such as Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, the child health component of Medicaid What Concurrent Care for Children Is... ✤ When child elects hospice care under Medicaid or CHIP: ✤ ✤ ✤ ✤ Does not waive the child’s right to be provided with, or to have payment made for, services that are related to the treatment of the child’s condition, for which a diagnosis of terminal illness has been made. Services covered and paid for separately from those provided under the child’s hospice benefit A voluntary election to have payment made for hospice care for a child (as defined by the State) shall not constitute a waiver of any rights of the child to be provided with, or to have payment made under this title for, services that are related to this treatment of the child’s condition for which a diagnosis of terminal illness has been made Retroactive to March 23, 2013 Example: California ✤ CA: 2013: 7 hospice agencies in 13/58 counties ✤ 2011-2012: 166 kids on concurrent care CA Children’s Hospice & Palliative Care Coalition What Concurrent Care for Children Is Not... Does not remove major barriers to providing more expansive PPC services ✤ Child must be within last 6 months of life (If disease follows its normal course/progression) ✤ Limited to existing Medicaid hospice and other Medicaid services ✤ Does not indicate: ✤ ✤ Who determines what is curative or palliative ✤ How the services should be billed ✤ How to handle children who have or are awaiting waiver services Free Toolkit Available ✤ Concurrent Care for Children Implementation Toolkit ✤ Free download: www.nhpco.org/pediatrics II. PPC as a Strategy in an ACO Model ✤ "Super-utillizers": 1 percent of patients consume 21 percent of all health care spending in US: $1.3 trillion in 2010 ✤ Fee for Service -> Accountable Care Organization / Bundled Billing ✤ PPC key health system strategy in re-aligning healthcare delivery ✤ Population health management includes seriously ill children (highest risk and highest cost) What is a Pediatric ACO? ✤ Providers who work together, alongside families, to provide and coordinate services for individuals under 21 years of age; and collectively take accountability for improving the lives of these children ACO Goal Outcomes ✤ In adults and pediatrics: ✤ Decreased institutional utilization ✤ ED visits ✤ Readmission (? – controversial) ✤ Hospitalizations – occurrences and LOS ✤ Increased home care utilization ✤ Increased value (V= quality x safety / costs) Authority for ACO Programs ✤ ✤ PPACA Sec. 2706: Pediatric Accountable Care Organization Demonstration Project O.R.C. 5111.161: Recognition of Pediatric Accountable Care Organizations Specific Pediatric ACO Objectives ✤ Improve health outcomes ✤ Incentivize more appropriate care ✤ ✤ ✤ Assign high risk families and children a primary support team that will coordinate services across traditional boundaries Smoother transitions Create a single care plan for high risk families and children ✤ Track performance measures ✤ ... isn’t that PPC...? To be recognized as an ACO, programs must: ✤ ✤ ✤ ✤ ✤ Explain how you will be accountable for care, share data, and collaborate with managed care providers and community-based organizations such as schools and social services. Have collaborative agreements with Primary Care Medical Homes, Pediatric Specialists (esp behavioral health), Community Pharmacies, Dentists. Explain what region of the State you will be covering. Demonstrate performance measures in place and being tracked Certain types of pediatric ACOs will be required to agree to a state’s performance measures Pediatric ACO Mandatory Elements for performance ✤ Education ✤ Social ✤ Mental Health ✤ Physical Health ✤ Transparency ✤ Community Leadership ✤ Consumer Trust Payment per member/month ✤ Insurance companies: already paying for adult home PC ✤ Now first payers in peds is paying per member/month ✤ Example: The Center of Hospice & Palliative Care www.HospiceBuffalo.com ✤ Thanks to Melanie Marien, MS, RPAC PPC: ACO is the light at the end of the tunnel...? ✤ In the new environment, payers are new natural allies! ✤ http://www.capc.org/payertoolkit/toolkit.pdf Objective 2 Identify current and potential sources of revenue and reimbursement to support a pediatric palliative care program A. Direct Reimbursement / Fee for service (FFS) Professional Billing and Coding ✤ ✤ ICD-9: diagnostic codes (soon to be ICD-10) ✤ Think beyond the primary diagnosis ✤ Signs/symptoms, psychosocial concerns ✤ BILL on TIME! Current Procedural Terminology (CPT) codes ✤ Outpatient ✤ Inpatient ✤ Home-based ✤ Prolonged service Pro Forma ✤ ✤ Depends on your payer mix… E.g. 40% Medicaid/Medicare; 60% Private payers, selfinsured ✤ Hypothetical Reimbursement: MD 53 % , NP 44% ✤ Initial Inpatient Consultation ✤ (Appendix 3.2 Table 1: CPT Codes) ✤ 992533 (55min): $ 250 ✤ 992553 (110 min): $ 500 Pro Forma ✤ New Office consultation ✤ ✤ New Outpatient ✤ ✤ 992053 (60 min) $ 250 Established Patient Follow-Up ✤ ✤ 992453 (80 min): $ 400 992153 (40 min): $ 200 Prolonged Service ✤ 993543 (30-60 min): $ 200 Pro Forma ✤ Facility Fee for Outpatient Clinic ✤ Home Visit ✤ 993453 (75 min): $ 350 Nurse Practitioner Inpatient ✤ MN (salary.com): $ 135,203 incl. benefits ✤ 44% reimbursed = Billing $ 307,300 /year ✤ 45 weeks = $ 1366 / day ✤ 1 New Consult: 992553 (110 min): $ 500 ✤ 4 Follow-Ups: 992333 (35 min): $ 200 ✤ TOTAL $ 1300 ✤ 2 New Consult & 2 Follow-Ups: ✤ TOTAL: $ 1,400 Pediatrician Inpatient ✤ US (healthcare-salaries.com) $171,467 plus 33% benefits = $ 228,000 ✤ 54% reimbursement = Billing $ 422,000 /year ✤ 45 weeks = $ 1875 / day ✤ 1 New Consult: 992553 (110 min): $ 500 ✤ 6 Follow-Ups: 992333 (35 min): $ 200 ✤ TOTAL $ 1,700 ✤ 2 New Consult & 4 Follow-Ups: ✤ TOTAL: $ 1,800 Outpatient Clinic ✤ NP = $ 1366 / day; MD = $ 1875 / day ✤ 1 New patient 135 min [992453 & 993543] = $ 600 ✤ 1 FU (75 min) [992153 & 993543] = $ 400 ✤ 1 FU (40 min) [992153] = $ 200 ✤ NP = 1 New plus 3 F/U (75min x1) = $ 1,400 ✤ MD = 1 New plus 4 F/U (75 x 2) = 1,800 Some payers... ✤ Like Regence Blue-Cross/Blue-Shield (6 US states) MI, SC ✤ reimburse for RN/SW working under MD with NPI ✤ Incident 2 billing (nurses reimbursed under MD) ✤ Torrie Fileds, MPH Cambia Health Solutions, Portland OR Professional Billing and Coding ✤ Existing codes are somewhat poorly reimbursed, even the well-established ones ✤ Peds in adult hospitals using adult MA codes ✤ Many codes are not paid for at all ✤ Prolonged service (but some are!) ✤ Telephone calls (some telehealth is) ✤ Care plan management (currently changing) ✤ Team conferences Hospice benefit ✤ Restrictions of the hospice benefit ✤ ✤ ✤ ✤ Per diem is not enough: average $142.91 in 2010, $176/ day 2013 (CA) Private insurance caps rapidly exceeded Palliative Care Waiver (CA): Expressive Art included (not in Hospice) Non-ideal reimbursement for time and non-medical services ✤ Most of the interdisciplinary team members cannot bill How do we do this better? ✤ ✤ ✤ Billing -> checklist Working with business development to interact with discharge Document time spent in the medical record ✤ ✤ ✤ ✤ Be specific about complexity necessary to justify time Bill for symptoms whenever possible – symptoms that someone else isn’t managing Learn your payer mix Temporarily, “consultations” paid better than new patients ✤ Not in Medicare; Medicaid likely soon to follow B. Philanthropy Philanthropy ✤ ✤ ✤ ✤ Clinical reimbursement will not be enough Philanthropic support is a VALID income stream and can become a stable source of funding for innovation and expansion Need to ensure that you can raise money for your program separately from your institution/organization, if possible Philanthropy = Investment from donor, often expecting program sustainability Grants ✤ Great for start-up costs/momentum ✤ Need to show sustainability ✤ Attractive if show collaboration among different agencies, systems, etc. Grants ✤ National/regional – ONLY if you have support infrastructure ✤ Memorial bequests ✤ Local granting agencies or community foundations ✤ Employee Foundations from hospitals, corporations/businesses ✤ Private local funders ✤ FAMILIES Caveats ✤ Close collaboration with Grants and Development/Foundation staff ✤ Can be fairly time-consuming – and then they are due again ✤ Avoid funding positions/people if possible, and go for program extras that will require less for ongoing maintenance ✤ Ex: database construction C. Direct Support Direct Hospital Support ✤ In-kind support ✤ Alignment with hospital mission ✤ Community Benefit ✤ Resource sharing Why should they do that…? ✤ Recognition ✤ Halo Effect: Increase in market share ✤ Decrease in complications / earlier discharge = higher patient turn over ✤ Reduced liability for iatrogenic harm ✤ Increased staff / patient / parent satisfaction ✤ ✤ ✤ HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey Reduced staff turn-over (> $ 60-100 K training 1 ICU RN) “Never Events” NOT reimbursed (PPC patients over represented) --> home care Direct Hospital Support Value = Q x S / C ✤ ✤ ✤ An early palliative care intervention (even from the point of diagnosis) = appropriate and beneficial treatments, increased quality of life and may in fact lead to prolonged (!) life. RCT, n=151; adult cancer patients receiving palliative care early in their illness lived longer (11.6 months vs. 8.9 months, P=0.02), with better quality of life, including decreased depression Results underscore the need for palliative care early in a serious illness ✤ This appears to refute the notion that palliative care means giving up ✤ Patients received palliative care alongside their curative treatment. ✤ Although this is only one study, it is an exciting one & results are not surprising: PC clinicians regularly see these outcomes in practice even in pediatric patients. Palliative Care & Cost Savings? ✤ Smith S, Brick A, O’Hara S, Normand C: Evidence on the cost and cost effectiveness of palliative care: A literature review. Palliative Medicine 2013 http://m.pmj.sagepub.com/content/early/2013/07/05/0269216313493466.long ✤ ✤ ✤ 46 papers; examining cost and/or utilization implications of PC intervention with some form of comparator; main focus was on direct costs, little focus on informal care or out-of-pocket costs overall quality of studies is mixed, although a number of cohort studies do undertake multivariate regression analysis. Palliative care is most frequently found to be less costly relative to comparator groups, and in most cases, the difference in cost is statistically significant. Palliative Care & Cost Savings? Resource utilization among individuals dying of pediatric lifethreatening diseases (British Columbia, Canada 2002-07) Chavoshi, N., T. ✤ Miller, and H. Siden, Resource utilization among individuals dying of pediatric life-threatening diseases. J Palliat Med, 2013. 16(10): p. 1210-4. ✤ ✤ required approximately 222 medical services Infants were discharged once on average, and required 21 medical services. During the fiscal year of death and the fiscal year prior to death, children/adolescents experienced ✤ ✤ 5.3 hospital discharges ✤ spent 48 days in the hospital Pediatric Palliative Care & Cost Savings? Knapp CA, Shenkman EA, Marcu MI, Madden VL, Terza JV. Pediatric palliative care: describing hospice users and identifying factors that affect hospice expenditures. J Palliative Medicine 2009;12:223-9. ✤ ✤ Death certificate data: 1527 children in Florida Medicaid program ✤ 11% used hospice services; of those 55% location of death was home Pediatric hospice users had higher inpatient, outpatient, emergency department, and pharmacy expenditures than non-hospice users ✤ Black non-Hispanic, Hispanic, and children of other races had $730 to $880 fewer hospice expenditures than Whites ✤ Pediatric Palliative Care & Cost Savings? ✤ Ward-Smith P, Korphage RM, Hutto CJ. Where health care dollars are spent when pediatric palliative care is provided. Nursing Economics 2008;26:175-8. ✤ ✤ ✤ ✤ Study comparing case controlled hospital-based charges was performed Nine exemplars: total hospital costs associated with the last 6 months of life ranged from $33,283 to $783,953 [mean $231,900]. Control: $28,970 to $803,657 [mean of $228,199]. Children receiving care coordinated by the PACCT undergo fewer radiology procedures and receive greater assistance from pharmacologic services (= greater attention and interventions provided to treat pain and provide comfort?) Pediatric Palliative Care & Cost Savings? ✤ Pascuet E, Cowin L, Vaillancourt R, et al. A comparative cost-minimization analysis of providing paediatric palliative respite care before and after the opening of services at a paediatric hospice. Healthcare Management Forum 2010;23:63-6. ✤ ✤ ✤ Costs of managing respite care for children with life-limiting illness at Children's Hospital of Eastern Ontario 12-month period both before and after services at Roger's House (RH, a pediatric hospice) was made available The opening and operation of RH for providing respite care resulted in minimization of operational costs (n = 66 patients, mean decrease of $4,251.95 per month per patient). Pediatric Palliative Care & Cost Savings? ✤ Gans D, Kominski GF, Roby DH, Diamant AL, Chen X, Lin W, Hohe N. Better outcomes, lower costs: palliative care program reduces stress, costs of care for children with life-threatening conditions. Policy Brief UCLA Cent Health Policy Res. 2012 Aug;(PB2012-3):1-8 ✤ Shifting care from a hospital setting to in-home community-based care resulted in cost savings of $1,677 per child per month on average--an 11% decrease in spending on a traditionally high-cost population. ✤ 1/3 fewer admissions/length of stay ✤ Improved comfort ✤ 24hr nursing consultation ✤ Reduced stress Pediatric Palliative Care & Cost Savings? ✤ Postier-Nugent A, Chrastek J, Nugent S, Osenga K, Leighton L, Friedrichsdorf SJ: Exposure to home-based pediatric palliative and hospice care and its impact on hospital and emergency care charges at a single institution. J Palliat Med, 2014. 17(2): p. 183-8. ✤ ✤ ✤ Children’s Hospitals and Clinics of Minnesota, Dept. Pain Medicine, Palliative Care & Integrative Medicine: 425 children 1-21 years: Home-based PPC or hospice services 2000-2010 Compare pediatric hospital resource utilization before and after enrollment Non-cancer patients: LOS decrease 38 days, decrease hospital charges $ 275,000 / patient Barking up the cost saving tree...? So…. How do we overcome these barriers? ✤ ✤ PPC program sustainability depends (approximately) in 2014/2015 on: ✤ Professional billing revenue (1/3) ✤ Philanthropy/grants (1/3) ✤ Direct support (1/3) But, things are A-Changin’... ✤ ACO ✤ Payers How do you bring this all together? - How did you overcome financial barriers? - How is your program funded? Copyright 2014 Center to Advance Palliative Care. Reproduction by permission only. Wrapping It Up... ✤ ✤ ✤ Healthcare reform supports a business model for pediatric palliative care Successful PPC programs get funded: ✤ Professional billing revenue ✤ Philanthropy/grants ✤ Direct support And...consider CAPC PCLC in Akron, OH or Minneapolis, MN! ADDENDUM (not part of presentation) Objective 3 List key steps in constructing a business plan to support a pediatric palliative care program in the participant’s home institution. A Business Plan ✤ CAPC PCLC (Akron, OH or Minneapolis, MN) ✤ The story of what you are trying to accomplish ✤ Why? What’s broken? ✤ What? Will the service provide? ✤ Where? ✤ When? ✤ Who? ✤ How much? Why is this important? ✤ Formalizes the request ✤ Links resource needs to impact ✤ Creates momentum ✤ You won’t get it if you don’t ask for it ✤ Chance to compete with other resource initiatives Parts of the Plan ✤ (1) Executive summary ✤ (2) Institutional analysis/market review ✤ (3) Operational plan for implementation ✤ (4) Marketing plan ✤ (5) Financial/Budget summary ✤ (6) Appendices (1) Executive Summary ✤ Big picture program objectives ✤ Context: why now, why here? ✤ ✤ ✤ Include 1 or 2 pertinent patient stories? What is broken that needs to be fixed? Why is it in the institution’s best interest to fix the problem? ✤ How will your plan fix the problem? ✤ Key program features (2) Operational Plan ✤ Policies and procedures ✤ Service standards ✤ Staffing model ✤ Spaces and equipment ✤ ✤ Integration with existing local/regional programs Evaluation metrics and plan (3) Marketing Plan ✤ ✤ Include resources needed in executing the plan Planned approach to market to key stakeholders (4) Financial/Budget summary ✤ Multi-year budget ✤ Expenses: usually direct ✤ ✤ PPC staff salaries, staff education, travel, marketing, office supplies, equipment Revenue ✤ Professional billing, hospital support, philanthropy, grants, contracts Further Training Center to Advance Palliative Care (CAPC) - Pediatric Palliative Care Leadership Center (PCLC) Training | Minneapolis, MN or Akron, OH | Dec 10-12, 2014 Education in Palliative & End-of-life Care [EPEC]: Become an EPEC-Pediatrics Trainer | Phoenix, AZ | May 4-5, 2015 8th Annual Pediatric Pain Master Class | Minneapolis, MN | June 20-26, 2015 Twitter: @NoNeedlessPain Blog: http://noneedlesspain.org Stefan J. Friedrichsdorf, MD, FAAP Associate Professor of Pediatrics, University of Minnesota Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota 2525 Chicago Ave S | Minneapolis, MN 55404 | USA 612.813.6450 phone | 612.813.6361 fax [email protected] http://www.childrensmn.org/services/more/pain-program-andpalliative-care
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