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
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✤
✤
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
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Chinese: 32/10,000
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Black: 42/10,000
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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
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Enrolling into “Hospice” often not applicable
✤
Resource allocation
Financial Barriers
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Reimbursement
✤
✤
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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
✤
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“leave no stone unturned”
Exception, not the rule – rare family will fall into “classic hospice
patient”
✤
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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:
✤
✤
✤
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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
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Improve health outcomes
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Incentivize more appropriate care
✤
✤
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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:
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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
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Social
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Mental Health
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Physical Health
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Transparency
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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!
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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
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ICD-9: diagnostic codes (soon to be ICD-10)
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Think beyond the primary diagnosis
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Signs/symptoms, psychosocial concerns
✤
BILL on TIME!
Current Procedural Terminology (CPT) codes
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Outpatient
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Inpatient
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Home-based
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Prolonged service
Pro Forma
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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)
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992533 (55min): $ 250
✤
992553 (110 min): $ 500
Pro Forma
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New Office consultation
✤
✤
New Outpatient
✤
✤
992053 (60 min) $ 250
Established Patient Follow-Up
✤
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992453 (80 min): $ 400
992153 (40 min): $ 200
Prolonged Service
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993543 (30-60 min): $ 200
Pro Forma
✤
Facility Fee for Outpatient Clinic
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Home Visit
✤
993453 (75 min): $ 350
Nurse Practitioner Inpatient
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MN (salary.com): $ 135,203 incl. benefits
✤
44% reimbursed = Billing $ 307,300 /year
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45 weeks = $ 1366 / day
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1 New Consult: 992553 (110 min): $ 500
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4 Follow-Ups: 992333 (35 min): $ 200
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TOTAL $ 1300
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2 New Consult & 2 Follow-Ups:
✤
TOTAL: $ 1,400
Pediatrician Inpatient
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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
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TOTAL $ 1,700
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2 New Consult & 4 Follow-Ups:
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TOTAL: $ 1,800
Outpatient Clinic
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NP = $ 1366 / day; MD = $ 1875 / day
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1 New patient 135 min [992453 & 993543] = $ 600
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1 FU (75 min) [992153 & 993543] = $ 400
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1 FU (40 min) [992153] = $ 200
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NP = 1 New plus 3 F/U (75min x1) = $ 1,400
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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
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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
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Many codes are not paid for at all
✤
Prolonged service (but some are!)
✤
Telephone calls (some telehealth is)
✤
Care plan management (currently changing)
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Team conferences
Hospice benefit
✤
Restrictions of the hospice benefit
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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?
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Billing -> checklist
Working with business development to interact with
discharge
Document time spent in the medical record
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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
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National/regional – ONLY if you have support infrastructure
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Memorial bequests
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Local granting agencies or community foundations
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Employee Foundations from hospitals, corporations/businesses
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Private local funders
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FAMILIES
Caveats
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Close collaboration with Grants and Development/Foundation staff
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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
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In-kind support
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Alignment with hospital mission
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Community Benefit
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Resource sharing
Why should they do that…?
✤
Recognition
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Halo Effect: Increase in market share
✤
Decrease in complications / earlier discharge = higher patient turn
over
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Reduced liability for iatrogenic harm
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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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