When Children Die Improving Palliative and End-of-Life Care for Children and Their Families (2003) / Chapter Skim
Currently Skimming:
7. Financing of Palliative and End-of-Life Care for Children and Their Families
7. Financing of Palliative and End-of-Life Care for Children and Their Families
Pages 234-292
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 234... ...
Smith (Lyckholm et al., 2001) Health insurance whether public or private has traditionally focused on acute care services intended to cure disease, prolong life, or restore functioning lost due to illness or injury.
|
From page 235... ...
but, instead, by thousands of private insurers and a multitude of state Medicaid and other public programs that have differing eligibility and coverage policies. These policies are poorly or not conveniently documented and constantly changing, so such information as is available on private health plans and Medicaid programs may be incomplete or out of dated Further, because death in childhood is relatively uncommon, data from surveys (e.g., of hospice and home care services)
|
From page 236... ...
Most children (and adults) are, however, covered by private health plans sponsored by employers.
|
From page 237... ...
SOURCE: Compiled from data from Center for Cost and Financing Studies, Agency for Healthcare Research and Quality: Medical Expenditure Panel Survey Household Component, 2000. of children were covered by private insurance, 6 percent by Medicaid, and 16 percent had no insurance (Tang et al., 2000~.
|
From page 238... ...
Variability in Coverage of Palliative, End-of-Life, and Bereavement Care Coverage of end-of-life and palliative care services for children who die and their families varies tremendously, both across payer types (e.g., private insurance, Medicaid) and among payers of the same type.
|
From page 239... ...
Provider payment methods and levels and other important financing issues are discussed in subsequent sections. Employment-Based and Other Private Insurance General As noted above, almost two-thirds of children in the United States are covered by private health insurance, mostly through plans sponsored by employers that also offer usually for an additional charge coverage for an employee's family.
|
From page 240... ...
Most large and many middle-sized employers are self-insured. Private Insurance Coverage of Home Hospice Care As an insurance benefit, hospice coverage normally includes homebased nursing care, physician services, physical or occupational therapy, respiratory therapy, medical social services, medical supplies and certain equipment, and prescription drugs.
|
From page 241... ...
Private Insurance Coverage of Home Health Care Health plan rules, licensure regulations, and physician and family reluctance to accept hospice can make home hospice coverage less helpful than it might otherwise be for children who die and their families. For these children and families, home health care providers, including those affiliated with hospices, may offer an array of supportive medical and other services including home nursing care.
|
From page 242... ...
. Health plans that pay for home health care may, however, exclude certain services that are often or sometimes included in hospice benefits (e.g., physical therapy, bereavement care)
|
From page 243... ...
Such consultative services for a patient receiving home health care would not ordinarily be covered by private health insurance (unless the health plan waived coverage restric
|
From page 244... ...
Private Insurance Coverage of Inpatient Hospital Care The centerpiece of most private health insurance has traclitionally been coverage for inpatient hospital services, which continue to be generously covered compared to other services. Thus, much of the emergency, intensive, and palliative care inclucling nursing care, diagnostic tests, meclications, and many other services that is provicleci to children with life-threat.
|
From page 245... ...
Formulary provisions could also lead parents and physicians to select less costly drugs that are also less effective for a particular child given, for example, his or her ability to metabolize certain opioids or other drugs.6 A separate and often controversial issue with employment-based health plans is the introduction of therapeutic substitution policies. Such policies 6Not all persons are created equal in the enzymes needed to metabolize medications.
|
From page 246... ...
One disadvantage of COverage contingent on these diagnoses is that bereaved family members may receive a diagnostic label that could jeopardize their future ability to qualify for health insurance, especially inclivicluai~y purchased insurance. Even as part of their hospice benefits, private health plans do not universally cover 7The Food and Drug Administration (FDA)
|
From page 247... ...
When a child has a severe chronic condition, families may bear extraordinary physical, emotional, and financial burdens because neither regular paid assistance nor occasional respite care is covered. Innovations in Coverage Some private health plans have developed or are testing innovative programs of coverage for palliative and end-of-life care focused on adults.
|
From page 248... ...
Challenges identified by the two health plans included early identification of children and families who might benefit from hospice care and changing the relationship with hospices from adversarial to cooperative. Cost and satisfaction data are still being collected and analyzed.
|
From page 249... ...
The family "spends down" to eligibility because the child's medical expenses reduce the family's income below the state Medicaid maximum. If a state has a medically needy program, it must include certain children under age 18 and pregnant women who would otherwise be eligible as "categorically needy" under the optional coverage requirements.
|
From page 250... ...
, establish methods and rates of payment for services, and administer the program. Federal law requires, however, that state Medicaid programs cover a generally broader array of services for children than for adults.
|
From page 251... ...
. This category includes PCCMs and those prepaid health plans that act as PCCMs.
|
From page 252... ...
, states can undertake demonstration projects to test innovative program ideas or service concepts. As noted in Chapter 1 and discussed further below, Congress has authorized several state demonstration projects to test innovative approaches to providing comprehensive palliative and end-of-life care for i4When developed for children with disabilities, Section 1915(c)
|
From page 253... ...
. As discussed in a later section on professional and provider payment, Medicaid coverage for specific services is less an issue for many physicians, hospitals, and Medicaid enrollees than is the level and predictability of payments.
|
From page 254... ...
Although Medicaid beneficiaries have to forgo curative care to receive hospice benefits, federal law no longer requires that Medicaid beneficiaries receiving hospice care give up other supportive Medicaid services. Specifically, the Omnibus Budget Reconciliation Act of 1990 (P.L.101-508)
|
From page 255... ...
Medicaid Coverage of Home Health Care A child's eligibility for home care services under Medicaid can be difficult to determine given the complexity of federal Medicaid provisions and the variability in state Medicaid policies (see, e.g., Smith et al., 2000~. Under federal law, required home health services for eligible beneficiaries include nursing care, home health aides, and medical supplies and equipment.16 Optional home health services include physical and occupational therapy.
|
From page 256... ...
. Medicaid Coverage of Inpatient Hospital Care As is the case for private insurance, much of the emergency, intensive, and palliative care provided to children who die is covered as an inpatient service.
|
From page 257... ...
recently announced an intention to implement a closed formulary (Bruen, 2002~. As is true for private health plans, one goal of formulary implementation is to negotiate lower drug prices or aciclitional services (e.g., chronic disease management programs in Floricla)
|
From page 258... ...
A parent or sibling covered by Medicaid in his or her own right might, however, be able to receive supportive mental health services upon referral for a diagnosis of depression or certain other emotional problems. As Box 7.1 indicates, state Medicaid programs are not required under federal law to provide respite care, which offers family members rest and relief from the demands of caring at home for a child with major health care needs.
|
From page 259... ...
regulatory limits on the array of services that a child may need, including skilled, intermittent, and 24-hour nursing care, respite care, music and other therapies designed to meet children's developmental needs, and bereavement care; payment limits that discourage hospices from accepting children w" to require expensive care; · waiver program provisions (e.g., requirements that a child needs an institutional level of care) that are not fitted to the needs of children who could benefit from hospice care; and .
|
From page 260... ...
State S CHIP programs are, like state Medicaid programs, highly variable. Separate S CHIP programs may or may not provide the same covered benefits as the state Medicaid program and may or may not use stateapproved Medicaid managed care plans to provide services.
|
From page 261... ...
. One long-standing positive feature of state programs for children with special health care needs is their concern with the organization, coordination, and availability of services (Ireys, 1996~.
|
From page 262... ...
Congress has, however, required state programs to provide and promote family-centered, community-based, coordinated care. A major recent emphasis of Title V programs has been on Promoting enrollment of children with special health care needs in managed care plans, monitoring results, and encouraging program and plan adjustments to better serve these children and their families.
|
From page 263... ...
Nonetheless, given its un22In decades past, public and private insurance payments subsidized care to the uninsured. Today, the opportunities for such cross-subsidies are limited or nonexistent in a world of competitive markets, health plan contracts, discounts from charges, global per-case payments related to diagnosis, and other cost-control strategies (see, e.g., IOM, 2000a; MedPAC, 2000a)
|
From page 264... ...
targeted community events to raise funcis for palliative and hospice services for chilciren and families, inclusion of pediatric hospices in United Way campaigns, foundation grants to support pediatric palliative care programs in chilciren's hospitals, or siblings, and organization of community-baseci and on-line support groups.
|
From page 265... ...
Some private insurers have agreed to pay for certain trials or for routine care associated with trials, although many today and in the past have undoubtedly paid for such care without knowing it (IOM, 2000d; NCI, 2001b) .23 In Tune of 2000, the President directed that Medicare explicitly authorize payment for routine patient care costs and costs to treat complications associated with participation in clinical trials.24 A recent study found that nearly 90 percent of Blue Cross Blue Shield plans already pay for routine care in clinical trials, and some encourage the creation of clinical trials to test certain therapies (IOM, 2000d)
|
From page 266... ...
into which the discharge is classified. The Balanced Budget Act of 1997 mandated the adoption of PPSs for other services, including home health care and skilled nursing facility care.
|
From page 267... ...
Such payments may also threaten the survival of physician practices and hospitals, especially in low-income areas where few patients are covered by better-paying health plans. Hospital Payment Hospitals are paid by a variety of methods.
|
From page 268... ...
Because hospital care is generally better insured than other care, shifting care to nonhospital settings often increases the financial burden on patients and families. The pressure for quick discharges may make it difficult to mobilize appropriate hospice care or other alternatives promptly 26Medicare uses an outlier payment mechanism to reimburse hospitals for particularly high-cost inpatient hospital stays.
|
From page 269... ...
accounted for by Medicaid programs and other payers using DRG-based payments. For children not covered by a payer using some form of DRG-based payment, hospitals face an array of other Medicaid, private insurer, and other payment methods and rates.
|
From page 270... ...
This project expanded the seven initial neonatal DRGs to 46 DRGs that took into account birth weight and use of surgery or mechanical ventilation. The Department of Defense adopted these modified neonatal DRGs for its civilian health insurance program, which uses its own DRG-based payment method (DOD, 1999~.
|
From page 271... ...
The commission's analysis indicates that such a change, combined with other recommended changes related to calculation of DRG weights and outlier payments, would raise payments for hospitals that treat more seriously ill patients. In response, HCFA agreed that the change could reduce distortions in the current system.
|
From page 272... ...
and lower for respite care.29 One study found at least 20 percent of Medicare hospice beneficiaries who used the benefit in 1996 had at least one day of inpatient hospital care covered by the hospice benefit (Gage and Dao, 2000~. The committee identified no equivalent information for Medicaid programs or private payers or for those children receiving inpatient hospice care.
|
From page 273... ...
Some hospitals report tapping foundation grants and philanthropy to fund adult inpatient palliative care programs. For example, Diane Meier, M.D., the director of Palliative Medicine at Mt.
|
From page 274... ...
A number of Medicaid and private payers have also moved to pay physicians based on elements of the RBRVS. A 1995 study reported that about 40 percent of Medicaid programs and 25 percent of managed care plans used some elements of the RBRVS to pay physicians and that onequarter of managed care plans did (PPRC, 1995; see also Reisinger et al., 1994~.
|
From page 275... ...
The survey did not cover payments from private health plans. Other Professionals Separate, direct reimbursement for inpatient services provided by pediatric nurse practitioners, clinical psychologists, clinical social workers, and other professionals is limited, although it has been expanding.
|
From page 276... ...
276 Payments to Pediatricians and Others Who Care for Children WHEN CHILDREN DIE RBRVS and Pediatric Care As was the case for DRGs, the research and data analyses for the Medicare RBRVS emphasized services provided to adults by generalist and specialist physicians who care primarily or entirely for adults. Pediatrics was one of the 32 specialties studied, but relatively few services were examined in each specialty.
|
From page 277... ...
In 1994, a government commission concluded that Medicaid fees were still less than 75 percent of Medicare fees and less than half of what private insurers paid (PPRC, 1994~. In 2001, the federal government's General Accounting Office reported to Congress that Medicaid fees in the states surveyed were only 29 to 61 percent of Medicare levels for the same services (U.S.
|
From page 278... ...
Among pediatricians, two frequently mentioned omissions are telephone calls and team conferences. A few Medicaid programs cover telephone consultations, and some cover team conferences (CPT code 99361)
|
From page 279... ...
To cite another example of coverage for physician services when the patient is not physically present, Medicare began paying in 1995 for physicians (and recently nurse practitioners) to provide "care plan oversight" under certain circumstances for beneficiaries receiving home health or hospice services who require complex multidisciplinary care.
|
From page 280... ...
Documentation issues are not well described for Medicaid programs and private payers, but these payers may follow claims administration procedures established for Medicare. The committee understood that claims for the EPSDT services that are covered for children but not adults sometimes cause confusion for Medicaid claims administrators.
|
From page 281... ...
, the physician of record can bill Medicare, Meclicaici, or private insurance for services provicleci to that patient subject to certain conditions. Most hospice care is, however, provicleci and managed by nurses and other nonphysicians.
|
From page 282... ...
Different per diem rates apply for four categories of hospice service: routine home care, continuous home care (for patients requiring eight or more hours of hospice care during a day) , general inpatient care, and inpatient respite care.37 In addition, hospices face caps on overall payments and on total payments for inpatient care (HCFA/CMS, 2001a)
|
From page 283... ...
By 1999, 91 percent of individuals with employer-sponsored private insurance were enrolled in managed care, including HMOs, PPOs, and multiple variants on these structures. As indicated above, the use of managed care by state Medicaid programs has also become widespread, with more than half of the children covered by Medicaid now enrolled in managed care plans.
|
From page 284... ...
The committee found no systematic documentation of the extent to which children with life-threatening medical conditions and their families encounter serious problems with review requirements for hospice, home care, or other services to meet their needs for palliative or end-of-life care. Provider Networks Most managed care plans select a subset of providers in the area to be members of their provider network.
|
From page 285... ...
Medicaid Payment to Managed Care Plans States initially found managed care plans receptive to enrolling Medicaid beneficiaries. More recently, like Medicare, state Medicaid programs have found less enthusiasm, particularly from plans with large private enroliments.
|
From page 286... ...
With new programs and voluntary programs, managed care plans may benefit from enrolling healthier beneficiaries, including those without established physician relationships (see, e.g., Freund et al., 1989; Leibowitz et al., 1992~. With mandatory enrollment and more mature programs, the lack of satisfactory risk adjustment for the health status or riskiness of populations served becomes a serious concern for health plans (see, e.g., Buntin and Newhouse, 1998; MeUPAC, 1998a)
|
From page 287... ...
Children whose parents are covered by health plans sponsored by large employers often have excellent access to care to cure or prolong life. Coverage for palliative and supportive care often to supplement curative and life-prolonging care may also be generous.
|
From page 288... ...
In some cases, they may refuse to serve patients covered by a lowpaying plan or program, notably state Medicaid programs, which typically pay providers considerably less than other public and private programs. Although all of these problems affect seriously ill children and families, most can be addressed only by broad policy changes for example, policies that extend public or private insurance to all that are beyond the charge to this committee.
|
From page 289... ...
Hospice Several factors contribute to low use of hospice care by children who die, including physician and parent attitudes or lack of knowledge and the large proportion of child deaths that are sudden and unexpected. Coverage limitations also constitute a barrier in state Medicaid programs and some private insurance plans.
|
From page 290... ...
No child should die in pain or other distress because health plans fail to cover specialized expertise in symptom management. Families should also not have to face a choice between expert palliative care for their child and publicly funded home health assistance for children with special needs.
|
From page 291... ...
Implementation To implement the recommendations related to improved benefits for palliative, end-of-life, and bereavement care, eligibility criteria must be defined. Federal officials should work with state Medicaid officials, pediatric organizations, and private insurers to define diagnosis and severity criteria to establish children's eligibility for pediatric palliative care and hospice services and family members' eligibility for bereavement services.
|
From page 292... ...
Although providers faced with claims denials and hassles may sometimes render services without billing for them, they may also opt not to provide the services or to avoid patients that need such services. Recommendation: Federal and state Medicaid agencies, pediatric organizations, and private insurers should cooperate to (1)
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.