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Reimbursement attitudes may be changing
Case managers and the PACC model
Most hospices that provide pediatric palliative care must do so without reimbursement. But there are trends that suggest the days of care wholly subsidized by community support may be on its way out. Private insurers and Medicaid demonstration projects are investigating ways to integrate palliative and curative care, and to remove the reimbursement barrier that forces parents to choose between efforts to cure their sick children or to provide physical and emotional comfort.
The solution to integrating palliative and curative care is a relatively simple one, says Joyce Hagan Schifano, BSN, MBA, president of Passport Health Plan, a 120,000-member HMO that covers 15 counties surrounding the Louisville, KY, metropolitan area. Health plans can improve the quality of care for dying children by changing their reimbursement policies to allow hospices or other palliative care providers to offer support services and consultations to both the family and treating physicians without a terminal illness certification.
"It’s easily implemented and easily adaptable to most health plans," says Schifano. "It takes a two-pronged approach: Change your policy, and develop internal resources."
Those resources include networks of local hospices, physicians, volunteers, hospitals, and community organizations that can meet the diverse needs of dying children. Like most hospices around the country, Genesee Region Home Care and Hospice in Rochester, NY, formerly had to admit dying children only if their parents elected to give up aggressive treatment. Under Excellus Health Plan, a Rochester-based group that covers 1.7 million members and includes three New York State Blue Cross Blue Shield Plans, including Blue Cross Blue Shield of the Rochester Area, Genesee Hospice is allowed to accept children with potentially life-limiting illnesses even though the patient may still be undergoing treatment for the disease. This is done under Exellus’ CompassionNet program.
Like Passport, CompassionNet case managers handle patients and their families throughout the continuum of care, including social worker assessments and patient advocacy at the time of disease diagnosis.
By using a case manager, Passport and CompassionNet officials are able to introduce palliative care and other services earlier in the disease process, in recognition of the fact that many patients are in need of pain management and counseling from the point of diagnosis.
"It works because it removes not only the reimbursement barrier, but also the access barrier to the care they need," says Jeanne Chirico, MPA, director of family life services and CompassionNet at Genesee Region Home Care and Hospice in Rochester, NY.
Both Schifano and Chirico say the policy changes within their programs have benefited care, but there are financial incentives, as well, they say. "I think that one of the reasons why other health plans don’t do this is that there is a fear that the cost would be exorbitant, but we’re not seeing that," says Chirico.
In addition, Passport is studying the case manager approach in end-of-life care among adult Medicaid patients diagnosed with cancer. Through a grant funded by the Robert Wood Johnson Foundation, the health plan is measuring both quality and financial outcomes. "With better education about their options, I believe parents will choose what is best for their child, which will translate into reduced costs," Schifano says.
Ins and outs of the PACC model
The case manager model, however, is not the only model being used to revolutionize the way dying children are cared for. Children’s Hospice International, an Alexandria, VA-based patient advocacy organization, developed its own model similar to the Program for All-inclusive Care for the Elderly, which blossomed in the 1990s. Program for All-inclusive Care for Children (PACC) is now a Medicaid demonstration project in six states.
The guiding principle, says Ann Armstrong-Dailey, president of Children’s Hospice International, is that children and their parents are made aware of all their options at the time of diagnosis. "Looking at the needs of kids and their parents at the time of diagnosis is critical," she says. "Parents who have gone through the process tell us that it’s when they need us the most, and that the actual death was anticlimactic."
The beauty of the PACC model is its flexibility. Participants must adhere to a set of requirements, but are left to design their own programs.
The basic requirements of the program include:
The success of the 3-year demonstration project will depend greatly on not only improving the quality of care, but on programs’ ability to save money. Like other pediatric end-of-life care experts, Armstrong-Dailey says she is confident that reduced hospitalization, emergency room visits, and costs related to illnesses resulting from stress following the death of a child will dramatically reduce the cost of care.