Partnership HealthPlan s Implementation of SB Robert Moore, MD MPH MBA. Chief Medical Officer, Partnership HealthPlan of California

Transcription

1 Partnership HealthPlan s Implementation of SB 1004 Robert Moore, MD MPH MBA Chief Medical Officer, Partnership HealthPlan of California

2 Medi-Cal Managed Care Model: County Organized Health System Mission: To help our members, and the communities we serve, be healthy Membership: 555,000 in 14 counties, including many frontier counties Primary Care: 77% at FQHC, RHC, Tribal HC 2

3 Outpatient Palliative Care Offering and Honoring Choices (OHC): PHC Initiative focused on improving advance care planning and palliative care. Partnership HealthPlan piloted an outpatient palliative care program, called Partners In Palliative Care (PIPC), starting in SB 1004 (2015) Required DHCS to set up an intensive outpatient, pre-hospice palliative care benefit for Medi- Cal. Implemented January The lessons learned from PIPC pilot informed the regulatory framework for implementation of SB 1004, and the structure of the outpatient palliative benefit in PHC counties. 3

4 Partners In Palliative Care (PIP-C) pilot Funded by California Healthcare Foundation Only Medi-Cal Managed Care Plan that participated 4 Provider organizations 6 medical conditions 4

5 PIPC Provider Partners September 1, 2015 to February 29, 2016 Four practice sites: ResolutionCare Eureka Collabria Care Napa Interim Healthcare Redding Yolo Hospice Davis 5

6 PIPC - Covered Diagnoses Cancer Cirrhosis Congestive Heart Failure COPD Frailty Syndrome Dementia 6

7 PIP-C Pilot: General Criteria General Criteria: Hospitalizations or ED visits in the late stage of illness Two years or less to live Intolerant or declines further therapy Willing to do advance care planning 7

8 PIPC - Service Model 8

9 PIPC - Payment Model Global Payment Per enrolled member, per month Lower rate if resident of SNF Bonus Payments: Quality: bonus per month once POLST is completed Shared Savings: Bonus per month if no Emergency Department visits or Hospitalizations during the month 9

10 Outcomes of PIPC Member satisfaction: Overall, I received the best possible care from my Palliative Care team Always 95% Usually 5% I would recommend my Palliative Care team to others Always 95% Usually 5% 10

11 Financial Evaluation Based on this and another method of analysis, approximately $3 of hospital costs are avoided for each $1 spent on all costs associated with the PIPC pilot. --Cassel and McClish

12 What Did We Learn? Early Findings: Identifying and enrolling members was the major challenge Intensity of psychosocial needs surprised the care teams High frequency of patients with cirrhosis was not expected POLST took a lot more work and time than anticipated 12

13 Implementation of SB 1004 Implementation of SB

14 Types of Palliative Care Type of Palliative Care Provider Types Time period Location PHC Billing Mechanism Primary Palliative Care PCPs, specialists minutes Office or hospital or SNF Fee for service: Use office visit codes and/or advance care planning codes Episodic specialty palliative care (Inpatient or outpatient) Palliative care specialists (contracted) minutes Office or home or SNF or hospital Fee for service: Use office visit codes and/or advance care planning codes or complex case management codes (latter by contracted multispecialty teams only) Inpatient Specialty Palliative Care Multidisciplinary Inpatient Palliative Care Team (contracted) One hospitalization Inpatient acute care hospital Fee for service Short term specialty palliative care (engagement) Multidisciplinary Palliative Care Team (contracted) Up to 7 calendar days Home or SNF Engagement fee Intensive Outpatient Palliative Care Multidisciplinary Palliative Care Team (contracted) 1-12 months Home or SNF Biweekly fee (14 days each), plus potential quality incentives. Hospice Licensed and contracted Hospice Organizations 1-6 months Home or SNF or hospice facility Daily rate (see Medi-Cal regulations) 14

15 Eligibility: Insurance Coverage Excluded from intensive home based global coverage: Medicare coverage Other primary insurance coverage besides Medi-Cal or Medicare Program for the All Inclusive Care for the Elderly (PACE program) 15

16 ENGAGEMENT Treatment Authorization Request (TAR) Requirements General Criteria PHC Primary Insurance 18 years of age or older Covered Diagnosis Cancer CHF COPD Advanced Liver Disease TAR Requirements (no prior authorization required) Progress or Consultation Note including documentation of: One of the four covered diagnosis Date of face to face or telemedicine visit Advanced care discussion with goals of care document Care Plan addressing medical, social, emotional and spiritual needs 16

17 Enrollment: Intensive Based Palliative Care Each unit is 14 days Prior authorization required every 3 months. Required components: 1. Multidisciplinary plan of care 2. Advance Care Planning 3. Mental Health and Medical Social Services 4. Care Coordination 5. Palliative Care Team 6. Spiritual Care Services 7. 24/7 Telephonic Palliative Care Support 17

18 ENROLLMENT Treatment Authorization Request (TAR) Requirements General Criteria: PHC primary insurance 18 years of age or older Life expectancy of one year or less Palliative performance score <=70 Two hospital or ED admission in last 6 months Covered Diagnoses with specific criteria: Stage III of IV cancer Congestive heart failure Chronic obstructive pulmonary disease Advanced liver disease 18

19 Disease Specific Criteria Cancer Stage III or IV AND Failed 2 lines of chemotherapy OR Congestive Heart Failure Hospitalized in last 6 months OR New York Heart Assn (NYHA) class III or IV AND Left ventricular ejection fraction (LVEF) < 30% OR Comorbidities (renal, diabetes, dementia, coronary artery disease) COPD FEV1 < 35% and 24 hour oxygen < 3 LPM OR 24 hour oxygen 3 LPM or more End Stage Liver Disease Model for End Stage Liver Disease (MELD) > 19 OR Albumin < 3.0 and INR > 1.3 AND Complications such as ascites, subacute bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome or recurrent esophageal bleeds. 19

20 Payment Methodology For Intensive Home Based Palliative Care 1. ENGAGEMENT (T2024): (no TAR required) Set fee, for up to 7 days of services during comprehensive assessment 1. INTENSIVE OUTPATIENT PALLIATIVE CARE (T2025): 1. If at home: Set fee per 14 days of services 2. If in LTC/SNF: Lower fee per 14 days 2. QUALITY BONUS PAYMENTS(enrolled members only) 1. POLST and use of PCQN: monthly bonus 2. No ED visits or inpatient admissions: monthly bonus 3. Bonuses paid every 6 months 20

21 Palliative Care Quality Network Palliative Care Quality Network (PCQN), started as inpatient quality reporting system, now includes outpatient palliative care reporting. Built by palliative care program at UCSF. PHC covers the cost for PCQN for all sites that are contracted. PCQN requires a separate agreement with UCSF. 21

22 Challenges with Implementing SB1004 Penetration Rates by County Who drives referrals Oncologists Hospital Discharge Planners Patient self-referral Primary care providers Building Relationships Tumor board Hospital rounding Meeting with specialists/hospital discharge planners Local press 22

23 Questions Robert Moore, MD MPH MBA 23