Taking away the reimbursement barrier

Imagine providing hospice services to a cancer patient who is still trying to beat the disease. Under today’s current reimbursement regulations, it’s difficult to fathom. But a small HMO in Kentucky is hoping it has found a solution to the financial barrier placed by payers that prevent access to palliative care and other services.

It’s called coordinated reimbursement. At the heart of its design is a nurse case manager who watches over patients diagnosed with potential terminal illness and coordinates care from the curative stage to death, if necessary. The pilot program, the Continuum of Care Program (CCP), is part of the Journey’s End project in Kentucky and is being undertaken by Passport Health plan, a 100,000 Medicaid-only member plan in Louisville.

By using a case manager, Passport officials hope to introduce palliative care and other services earlier in the disease process, recognizing that many patients are need of pain management from the point of diagnosis. Because many of the services are provided by hospice, including pain management, are governed by six-months-or-less-to-live diagnoses, those services are most often not given.

"It seems to be the opinion of providers that the tail wags the dog, that reimbursement dictates care," says Joyce Hagan Schifano, BSN, MBA, president of Passport Health Plan, which covers 15 counties surrounding the Louisville metropolitan area.

According to Schifano, CCP will focus on two major clinical initiatives: urging supportive care for patients earlier in their disease course and coordinating the care of diverse providers and caretakers.

A patient liaison

Case managers are nothing new to managed care, but Passport intends to use them as advocates for the patient and family. Often vilified for guarding the financial interests of their HMO, health plan case managers are often at odds with doctors and patients. Passport’s version of a case manager is more of a patient liaison, who will meet with the patient and family to discuss care goals and explain services that are available throughout each stage of treatment.

This will allow patients to access pain management or spiritual care, for example, while still undergoing curative treatment, such as chemotherapy. It also will help patients and family prepare for the inevitable when curative efforts fail.

"It’s my contention that if you provide the patient and family with support and care and when it comes time for the family to make a choice about continuing with curative care to the very end or choosing hospice, nine times out of 10 they will choose hospice sooner," Schifano says. "Having worked with families in this position, I think all families are looking for is permission."

In the end, the patient has been given access — without the constraints of reimbursement rules — to quality end-of-life care and the health plan, Schifano says, will have spent less on inappropriate curative efforts.

Journey’s End officials have high hopes for their reimbursement experiment. "I believe the reimbursement piece will be huge," says Cynthia Ellis Keeney, project director.

If successful, they hope to use the model on a larger scale. Keeney estimates that to get a true indication of whether it is applicable on a large scale, they would need apply the model to five other states.