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Calculating Financial Outcomes for Hospital Palliative Care.


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Calculating Financial Outcomes for Hospital Palliative Care. Kathleen Kerr Senior Analyst Faculty, UCSF PCLC University of California, San Francisco kkerr@medicine.ucsf.edu. Steven Pantilat, MD Associate Professor of Clinical Medicine Director, Palliative Care Program and
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Computing Financial Outcomes for Hospital Palliative Care Kathleen Kerr Senior Analyst Faculty, UCSF PCLC University of California, San Francisco kkerr@medicine.ucsf.edu Steven Pantilat, MD Associate Professor of Clinical Medicine Director, Palliative Care Program and Palliative Care Leadership Center (PCLC) University of California, San Francisco stevep@medicine.ucsf.edu

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Palliative Care "… thorough, interdisciplinary consideration, concentrating basically on advancing personal satisfaction for patients living with a [serious, perpetual, or] terminal ailment and for their families… guaranteeing physical solace [and] psychosocial support. [It is given all the while all other fitting restorative treatments]" Billings, J Pall Med , 1999;1:73-81 www.CAPC.org

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What Palliative Care Teams Do Symptom administration Communication illuminate or change objectives of consideration lead family gatherings Discharge arranging Advance consideration arranging Spiritual bolster Psychosocial bolster www.CAPC.org

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What Kinds of Patients do PC Teams See? CHF, third affirmation in a year Breast growth and harmful pleural emission Brain metastases Dementia and desire pneumonia New conclusion of idiopathic aspiratory fibrosis Cirrhosis and third confirmation for modified mental status www.CAPC.org

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A Distinct Population Severe, incessant regularly terminal sicknesses Deaths and live releases Resource use High expenses per case Longer lengths of stay More affirmations Payer blend More Medicare (case rate installments) www.CAPC.org

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Evident at State Level Payer Mix for Adults Discharged from California Acute Care Facilities in 2004 "Target populace" = patients released alive who were relegated to one of the 25 most basic DRGs for patients who kicked the bucket in the doctor's facility. www.CAPC.org

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… And at Individual Hospitals 200-bed California people group doctor's facility www.CAPC.org

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Medicare Profitability and LOS High expenses and high extent of Medicare cases mean numerous mortality cases and numerous objective populace cases result in money related misfortunes UCSF Medicare passings FY 2006 www.CAPC.org

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How Palliative Care Can Help Reduced ICU usage Shorter LOS in ICUs More exchanges out of, less into, ICUs More confirmations specifically to PC (versus to ICU) Lower inpatient every day costs Reduced usage of labs, radiology, drug store, blood Better care coordination, more hospice Reduced readmissions www.CAPC.org

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Analysis Process Identify changes/contrasts in asset use that can be ascribed to PC Assign worth to those progressions/contrasts Calculate net advantages www.CAPC.org

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Calculation Challenges Savings from cost evasion, not income era Need to characterize "what might have happened" had PC group not get to be included Most perplexing, most broken down patients, and a moderately little extent of healing center populace, so correlations can be troublesome Extensive expenses in the period before PC inclusion frequently implies great result is littler misfortune, not misfortune to benefit www.CAPC.org

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Measuring Changes in Costs By days Before and after PC versus non-PC Costs & LOS By affirmation Typically just utilized if PC administration in charge of total/greater part of doctor's facility stay Generally NOT proper for conferences or late exchanges to a PC unit By patient Resource use over a characterized timeframe (i.e., the most recent six months of life) www.CAPC.org

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Total Costs FIXED COSTS Those costs that don't fluctuate specifically with the volume of patient administrations gave. Over a predefined period these expenses would be brought about paying little respect to volume. As demonstrated as follows, altered expenses have two segments. VARIABLE Costs that differ straightforwardly and proportionately with the volume of patient administrations gave. These costs may vacillate everyday and would not be brought about if no administrations were utilized. As demonstrated as follows, variable expenses have two segments. Altered DIRECT Costs that can be followed to or related to a particular item or administration however that don't fluctuate with volume. Illustrations: supervisory faculty, hardware . Settled INDIRECT Costs that can't be particularly followed to an individual division and don't differ with volume. These expenses are designated to all offices. Cases: utilities, doctor's facility organization . VARIABLE DIRECT Costs that can be followed to a particular item or administration. These costs increment or reduction as per the volume of administrations gave. Illustrations: nursing care, supplies. VARIABLE INDIRECT The expenses or costs that can't be particularly followed to an individual patient yet that do differ with volume. Cases: social administrations, medicinal records. Which Costs to Measure? www.CAPC.org

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Which Cases to Use? Would you like to include: Patient released or kicks the bucket on day of counsel (PC LOS = 0) Patient seen irregularly through release Patient closes down administration www.CAPC.org

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Tallying the "Before" Costs Need date of PC counsel/exchange Data on expenses (or charges) every day by classification (room and care, drug store and so on.) Decide which "before" days to number All? Prohibit initial two (high-cost surgeries), or pull out peri-agent costs? Just utilize day instantly preceding counsel/exchange? www.CAPC.org

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"After" Costs Can think about: All "before" to all "after" Or subset of "before" to all "after" Or can restrain number of "after" days Difficulty of estimating what might have happened past a specific point, say 5 days May prohibit day of counsel or exchange (transitional day) www.CAPC.org

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Simple Before and After Comparison Average Variable Cost every Day Before and After UCSF PCS Consult www.CAPC.org

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PC versus non-PC Comparison Possible variables to use in characterizing a correlation bunch: DRG or APR-DRG (APRs incorporate seriousness of-disease and danger of-mortality files) Major ailment sort (e.g., metastatic tumor) Number of co-morbidities and/or confusions Number of organ frameworks included Age (maybe 10-year companions) Attending or clinical administration Disposition (e.g., passing) www.CAPC.org

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PC versus non-PC Cost Comparison Decide on Comparison Period Entire stay Entire "after" period A segment of the stay, i.e. last 3-5 days Common to adjust to normal LOS on PC administration www.CAPC.org

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VCU Case Control Study 60% cost lessening for patients in PCU Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA. A high-volume expert palliative consideration unit and group may diminish in-healing center end-of-life consideration costs. J Palliat Med. 2003 Oct;6(5):699-705. www.CAPC.org

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UCSF Subsequent Day Control Group Average day by day variable expenses , pts who kicked the bucket who were alluded to PCS inside 1 day of confirmation contrasted with control gathering of low-usage patients who additionally passed on www.CAPC.org

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UCSF Last 3 Days of Stay PCS Deaths versus Others Average Daily Variable Costs www.CAPC.org

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How UCSF utilizes PC versus non-PC Calculations Savings for first day on administration: Difference between normal "before" every day cost and normal "after" day by day cost Savings for resulting days: Difference between control bunch normal day by day expense and PC "after" day by day cost www.CAPC.org

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A Different Approach for Deaths Savings for first day on administration: Difference between genuine expense of day preceding interview or exchange and real cost of day after counsel Savings for consequent days: Difference between normal day by day expense of definite three days of stay for non-PC patients who passed on and normal day by day cost for conclusive three "after" PC days www.CAPC.org

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LOS Savings More troublesome than per-day investment funds evaluates Most patients have a considerable pre-PC stay Analysis starts at time of referral to PC If avg. pre-PC LOS is 14 days, your inquiry is "Once we achieve the 2-week point, what is the distinction in LOS for the two gatherings starting there until release?" Matching to practically identical pts basic Consider variety in referral designs by administration or clinical condition www.CAPC.org

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Time to PC Referral Varies by Specialty www.CAPC.org

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The Value of Saved Days Consider constraining to case rate payers Program could be credited with: Avg. variable expenses for "after" PC day x number of spared days, or Avg. complete expenses for "after" PC day x number of spared days, or Total up spared days; isolate by healing facility ALOS; duplicate by avg. benefit per case www.CAPC.org

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Profit/Loss for PC Unit Admissions www.CAPC.org

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Savings per Patient Will PC intercession change asset use not far off? Dodge confirmations altogether Change objectives and expenses of ensuing affirmations (i.e. direct admit to PC versus ICU) www.CAPC.org

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Kaiser Permanente RCT Inpatient PC 512 pts took after for 6 months No distinctions in survival amongst cases and controls PC pts had: Significantly less ICU stays (p = 0.04) Significantly more hospice LOS's (p = 0.01) Significantly bring down expenses for doctor's facility readmissions (p =0.001) Conner D, McGrady K, Richardson R, Beane J, Venohr I, Gade G. 2005. "Results from a randomized control trial of an inpatient palliative consideration benefit." The Permanente Journal 9 (4); 7 ( http://xnet.kp.org/permanentejournal/fall05/HMOabs.html ). www.CAPC.org

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Summary of PCLCs' Cost Avoidance Analyses www.CAPC.org

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Variables that Influence Financial Performance Baseline asset use Capture rate Service case blend Influence on consideration Quality of administration Level of institutional bolster www.CAPC.org

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PC Financial Analysis Do's and Don't Do's Create clinical group organization association Present budgetary results in setting of operational, clinical, & fulfillment result information Don'ts Analyze and exhibit information rashly Quibble www.CAPC.org

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Conclusions and Questions Most PC administrations can