Life Care Planning Projections for People with Spinal Cord

Injury: A Measure of Therapeutic Intervention Effectiveness

Sarah A Morrison, PT

Vice President Clinical Services

Shepherd Center

Objectives

• Define the life care planning process

• Describe how therapy interventions can be utilized for projecting lifetime costs for persons with spinal cord injury

• Describe other lifetime economic challenges for persons with spinal cord injury

IOM Commission Recommendations

• Cost benefit should be offset by savings elsewhere• Minimum benefits should reflect those provided

by small employers in private market• Should not cover treatments unless they

demonstrate superior outcomes to current treatments

• Only medically necessary services should be covered

The Given!

Value-Based Healthcare

Outcomes achieved = ValueCosts of achieving outcomes

How will this Effect Rehabilitation Reimbursement?

• Probably through a bundled payment system– Most likely will include entire episode of care.

How will cost be allocated?– Providers need to be prepared to take risk, but

will they? – Most likely focus on high cost episodes of care

Bundled Payments

• Advantages:– Focus on outcomes and

increased efficiency

– ??regulatory hassles??

– Force providers to become more integrated

– Consumer involvement more important

• Disadvantages:– Financial incentive for

providers to cut corners

– Who to control? Acute care?

– Elimination of small freestanding providers?

– How will unique providers be taken into account?

Life Care Planning• A dynamic document based upon published

standards of practice comprehensive assessments, data analysis and research

• Provides an organized concise map for current and future needs with associated costs for individuals

• Performed by LCP in collaboration with interdisciplinary treatment team, practice guidelines, etc

14 Common Topics• Projected evaluations

• Projected therapeutic modalities

• Diagnostic testing/education assessment

• Wheelchair mobility needs

• Aids for independent function

• Orthotics/prosthetics

• Home furnishings/accessories

• Drug/supply needs

• Home/attendant/facility care

• Future routoine medical care

• Transportation

• Health/strength maintenance

• Architectural renovations

Example of LCP Use for Outcome • Locomotor Training (LT)

– 5 days per week, 1.5 hours per day– Tx in body-weight supported environment, over

ground and in community– PT + 3 PT aides

• Participants– 4.5 yo boy; C8 AIS C;16 mos post;76 sessions– 61 yo woman; C3 AIS D; 16 mos post; 198 sessions

Morrison, SA et al. JNPT. 2012;36:144-153

Clinical Results• 61 yo

– Increased LEM by14 points

– BBS increased from 6 to 47/56

– 6MWT increased from unable to 700 ft

– 10 MWT decreased from 0.05 m/s to 0.71 m/s

– Stairs improved from unable to 12 steps independently

– ADL’s improved from mostly dependent to mostly independent

• 4.5 yo– LEM unchanged

– GMFA 45.8% to 60.2%

– Increased mobility self care and mobility PEDI scores

– improved from unable to perform to 0.29 m/s (selected) and 0.48 m/s fastest walking speed

– Dependent to independent ambulation within home

– Able to perform stairs

61 yo Pre and Post Life Time CostsLow End $PRE LT POST LT Difference

Equipment Needs $5,322 $180 $5,142

WC Needs $28,970 $0 $28,970

WC Accessories $4,140 $0 $4,140

WC Maintenance $9,775 $850 $8,925

Home Mods $50,000 $0 $50,000

Transportation $56,180 $0 $56,180

TOTAL $150,247 $2,010 $148,237

4.5 yo Pre and Post Life Time CostsLow End $PRE LT POST LT Difference

Equipment Needs $22,240 $21,485 $(4,122)

WC Needs $95,285 $42,730 $52,555

WC Accessories $$35,190 $13,440 $21,750

WC Maintenance $35,070 $18,625 $16,450

Home Mods $50,000 $0 $50,000

Transportation $306,600 $980 $305,620

TOTAL $535,050 $97,260 $437,790

Other Additional Costs

61 yo PRE LT 4.5 yo PRE LT

Annual Medical Expenses 387,345 1,370,094

Personal Care 377,370 1,039,916

Total 764,615 2,410,010

Looking at the Value Equation

• Direct Cost for Providing LT– $78.40 higher cost

(personnel)/treatment session• Total increase in cost for 61 yo =

$15,721.20

• Total increase in cost for 4.5 yo = $6,034.40

Is it worth the $?

Caution

• This was not a randomized controlled study

• LCP projections were only 1 point in time. However, outcomes were maintained at 6 months and 1 year.

• Aging process was taken into consideration with equipment needs

Annual Charges and Cost

C1-4 ABC C5-8 ABC T1-S5 ABC AIS D

Annual Chg(1st year)

953,336 688,886 464,633 311,141

Annual Chg(post year 1)

165,554 101,560 61,550 37,792

Annual Direct Cost (1st year)

423,152 293,529 191,431 122,753

Annual Direct Cost (post yr 1)

150,508 89,254 49,147 33,535

Cao Y, Chen Y, DeVivo MJ. Top Spinal Cord Inj Rehabil 2011;16(4):10-16

Primary Causes for Rehospitalizations

% Mean LOS Charges Cost

Urinary 29.5% 7.3 days $24,007 $12,617

Skin 16.5% 19.8 days $75,872 $38,866

Respiratory 12.6% 7.5 days $29,975 $15,096

DeVivo MJ, Farris V. Top Spinal Cord Inj Rehabil 2011;16(4):53-61

Rehospitalizations

• Total days within 1st yr: 24.7• Top Causes:

– Diseases of genitourinary (45%)

– Disease of the skin (17.7%)

– Diseases of the respiratory system (15.3%)

– Diseases of circulatory system (11.2%)

Cost of Care With and Without Pressure Ulcer

Stroupe KT, et al. Top Spinal Cord Inj Rehabil 2011;16(4):62-73

What About Other Interventions?