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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