Our experience with the TCPC Program shows that it is both clinically responsible and economically feasible for MCOs to offer seriously ill patients a blended model of care that introduces palliative measures into curative practices.
The TCPC program is one of a small minority of palliative care programs in the nation that enjoys a predictable income stream because its annual budget, about $900,000, comes from the monthly fixed reimbursements that Kaiser Permanente (our parent institution) receives for each of its enrollees. In southern California, almost all of Kaiser's 296,000 members aged 65 and older, 10% of the total membership, are covered by Medicare+Choice. Under this program, Kaiser receives an inclusive, capitated rate under a managed care risk contract that covers hospital inpatient and outpatient services, including TCPC services.
Until recently, HCFA did not adjust payment rates for severity of illness, thus creating a disincentive to enroll sicker patients with higher care costs. Beginning in 2000, however, risk adjustments were being phased in, starting with a 10% adjustment. That year, Kaiser's Medicare+Choice reimbursement (with the 10% risk adjustment) averaged about $628 per member per month for a 65-year-old male with no adverse medical conditions and increased to about $661 per member per month for an 80-year-old male. By comparison, the monthly reimbursement for a single adult between the ages of 40 and 49 with no adverse medical conditions was $178, rising to $242 for a healthy single adult aged 60 to 64.
With its six-year track record, the TCPC Program has demonstrated a high degree of fiscal stability, which it expects to maintain in the years ahead. A recent program evaluation that compared service utilization for TCPC patients to a control group of home health patients who received usual care found that cost offsets make the program economically feasible to sustain. When all service costs — for both inpatient and outpatient care — were considered, total average costs for TCPC patients were 45% lower than costs for the comparison group. Although TCPC patients had more home health visits, they had fewer emergency department visits, inpatient days, skilled nursing days, and physician office visits. Kaiser directly benefits from these TCPC cost offsets because its patients receive all their health services within this capitated system. Thus, Kaiser has a financial incentive to maintain the TCPC Program.
Fiscal savings from the TCPC Program have not compromised quality of care. Our program evaluation also showed that satisfaction with services 60 days following enrollment was significantly higher among TCPC patients than a comparison group of home health patients who received usual care. Of the participants who died, 89% of the TCPC patients died at home — the expressed preference of most of these patients — compared to 57% of the control group, whose members were significantly more likely to die in the hospital.
<<< Previous Next >>> [ Go Up ]
For more information about the TriCentral Palliative Care Toolkit visit www.growthhouse.org/palliative/. All content is Copyright © 2002, 2003 by Richard D. Brumley, M.D. All rights reserved. No part of this toolkit may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publishers. This guide to developing home-based outpatient palliative care services was developed through a grant to the Kaiser Permanente TriCentral Service Area from The Project on Death In America. The Kaiser Permanente TriCentral Palliative Care Program is a Sustaining Member of the Inter-Institutional Collaborating Network On End-of-life Care (IICN) which links major organizations internationally.
