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What’s at the Heart
of Palliative Care?
Financial Implications and Funding Sources
Alva S. Baker, MD
Hospice of Washington County
May 2, 2014
Disclosure
• Dr. Baker has indicated that he has no financial
relationships related to the content of this
presentation
Objectives
• Define funding sources for Hospice
• Define funding sources for Palliative Care
• Discuss funding implications of health care
reform evolving under the American Recovery
and Reinvestment Act (ARRA)
Objective #1
FUNDING FOR HOSPICE
Hospice Funding
• Origins in charity care
• 1982: entitlement (Medicare Part A)
• Following: major insurers provide hospice
benefit
Hospice Funding
• Capitated managed care (Medicare)
– Hospice gets per diem rate to provide all care and
services, including medications, related to the
Hospice service diagnosis (the illness from which
the person is expected to die in six months or less)
– Benefit periods: 90, 90, 60’s until death
– Higher per diem rate for higher intensity of service
categories
• Respite
• Continuous Care
• GIP
Hospice Funding
• Capitated managed care model is fairly
universal
– Certification frequency may vary
– Prior authorization may be required
Objective #2
FUNDING FOR PALLIATIVE CARE
Palliative Care Funding
• There isn’t any!
Palliative Care Funding
• Not funded by Medicare, Medicaid, and
generally not by private insurance
– coverage for standard provider care available
– may get support from Long Term Care policy
• Inpatient
• Outpatient
– ACO
– Major insurers
– Self-insured employers
Objective #3
HEALTH CARE REFORM
Health Care Reform
• Getting more bang for the buck
• Spending less bucks
• Accountability for quality of care
Health Care Reform
• Per diems are being/will be ratcheted down
• Possible case-mix adjustment for hospice per
diem
• CMS Demonstration Project
– Medicare Care Choices Model
• “Hospice-care” while receiving curative treatment
• cancer, COPD, CHF, HIV/Aids
• goal: improve QOL while receiving both palliative and
curative care
Health Care Reform
• Hospice Quality Reporting Program
(Affordable Care Act, 2010)
– Will be publically available (date ??)
• Seven quality measures (reporting starts 2014)
– Opioid Rx with bowel regimen
– Pain screening
- Tx preferences
– Pain assessment
- Beliefs/values addressed
– Dyspnea treatment
– Dyspnea Screening
Health Care Reform
• Family caregiver survey (2015)
– post-death
– assess patient and family experiences with
hospice care
Summary
• Hospice, for the most part, is a capitated
managed care product
• Hospice care is well funded
– Federal programs
– Private health insurance
– Long Term Care insurance
• Federal dollars are being ratcheted down
Summary
• Palliative Care – well-defined concept, variable
implementation
• Palliative Care is not universally funded
– No Federal funding except for provider services
• Funding of major Palliative Care programs is
from major insurance or risk-sharing entities
• Movement is underway to increase public
support for Palliative Care
Summary
• Health Care Reform
– Increase in risk-sharing products
– Traditional managed care not in favor (reduction
in Medicare Plan C funding)
– Dollars will flow to most cost-effective model
• Can Palliative Care fulfill its promise of reducing acute
care costs?
What’s at the Heart
of Palliative Care?
Financial Implications and Funding Sources