by Betsy Keesler, RN, BSN, CLCP
There are different ideas about what a Life Care Plan consists of and the purpose it serves. The International Association of Rehabilitation Professionals (IARP) and the International Academy of Life Care Planners (IALCP) have collectively and succinctly defined the essence of the Life Care Plan through this definition:
“The life care plan is a dynamic document based upon published standards of practice, comprehensive assessment, data analysis, and research, which provides an organized, concise plan for current and future needs with associated costs for individuals who have experienced catastrophic injury or have chronic health care needs.”
This article will focus on the key concepts of “consensus” and “standards of practice” as the foundational framework for the life care planning professional to build credible and accurate costing research and analysis upon.
The life care plan, as developed for the catastrophically injured person, called the evaluee, is expected to be individualized, comprehensive, and professionally collaborative in nature. We can think of the life care plan as a road map, to assist the evaluee in obtaining optimal outcomes and preventing/reducing complications. Importantly, the life care plan should reflect identifiable input from multiple healthcare professionals, regardless of the life care planner’s professional scope of practice.
As such, the foundationally secure and valid life care plan will be transparent, reproducible, implementable, and evidence based. Each of these characteristics is applicable to every aspect of the life care plan, including the process of researching costs for the myriad of items which will inevitably be presented in the plan.
The life care plan is, in fact, a marriage of sorts between Economics and Rehabilitation Practice.
“In the 1970s, the specialty practice of life care planning emerged from the disciplines of economics and rehabilitation as a methodology to determine future medical care needs and associated costs. The first textbook publication of this method appeared by 1982 (Deutsch& Raffa, 1982). Over the next two decades, the specialty practice evolved. By 1996, a lifecare planning professional association, a nationwide training program, and a life care plan certification program were established” (Weed & Berens, 2018).
The International Association for Rehabilitation Professionals (IARP) and the International Academy of Life Care Planners (IALCP) have collectively published peer-reviewed and agreed upon Consensus Statements, as found in the Journal of Life Care Planning, and are applicable to all life care planners, regardless of their professional background and education.
The Consensus Statements represent the collective expertise of the life care planning community. The current edition of Consensus Statements was published in 2018, following a Delphi Methodology study.
The Delphi research methodology is utilized to establish consensus among subject matter experts. It is important to note, the study included consensus information derived from 17 years of life care planning summits and received endorsements from multiple professional organizations. The initial stages of the study included members of the International Commission of Health Care Certification (ICHCC), as well as practicing life care planners from sixteen states. The professional fields represented include Rehabilitation Counseling, Case Management, Nursing, Medicine, Psychology, and Social Work. The resulting information was then provided to the life care planning community for analysis through rounds of sample surveying. The Consensus Statements developed from this Delphi study constitute peer-reviewed and conclusive findings from the life care planning community at large that outline the developmental requirements for the life care plan.
Pertinent Consensus Statements to the arena of costing include the following:
Consensus #45: “Life Care Plans shall be individualized.”
Consensus #54: “Life Care Planners shall research condition, resources, services, and costs.”
Consensus #61: “Life Care Plans shall include an annotated list of requested and reviewed data/sources.”
Consensus #69: “Life Care Planners shall utilize protocols for cost research.”
(Consensus Statements and standards of practice represent such protocols.)
Consensus #70: “Life Care Planners shall gather geographically relevant and representative prices.”
Consensus #85: “Best Practices for identifying costs in life care plans include:
a. Verifiable data from appropriately referenced sources.
b. Costs identified are geographically specific when appropriate and available.
c. Non-discounted/market rate prices.
d. More than one cost estimate when appropriate.”
Consensus Statements have, in turn, informed the construction of life care planning Standards of Practice, Fourth Edition, as published by IARP/IALCP in the Journal of Life Care Planning (2022).
When delineating costs for the evidence-based life care plan, the following methodology should be adhered to:
“Standard 14: The life care planner uses a consistent, valid, and reliable approach to costs.
Practice competencies include:
a. Uses a consistent method to determine costs for various categories of available/needed services.
b. Uses geographically relevant and representative costs.
c. Identifies services and products from reliable sources.
d. Follows a consistent method for organizing and interpreting data for projecting costs.
e. Explains the life care planning process to involved parties to obtain needed information.
f. Cites verifiable cost data.”
“Standard 15: The life care planner communicates their opinions.
Practice competencies include:
a. Follows a consistent method for creating the narrative component of the life care plan report.
b. Develops and uses documentation tools for reports and cost projections.
c. Considers classification systems (e.g., International Classification of Diseases [ICD], Current Procedural Terminology [CPT], Healthcare Common Procedure Coding System [HCPCS], International Classification of Functioning, Disability, and Health [ICF]) to provide clarity regarding care recommendations and costs.
d. Records lack of access to pertinent information.”
In sum, the life care plan should answer questions, not raise more of them.
To create accurate life care plan costing tables, there are several important concepts to consider: usual, customary, and reasonable, probability vs. possibility, CPT® codes, total present value, and life expectancy.
Usual, Customary, and Reasonable
The American Medical Association (AMA), Policy H-385.923, formally defines usual, customary, and reasonable, relative to service fees, as follows:
1. “‘usual’ fee means that fee usually charged, for a given service, by an individual physician to his private patient (i.e., his own usual fee)
2. a fee is ‘customary’ when it is within the range of usual fees currently charged by physicians of similar training and experience, for the same service within the same specific and limited geographical area, and
3. a fee is ‘reasonable’ when it meets the above two criteria and is justifiable, considering the special circumstance of the particular case in question, without regard to payments that have been discounted under governmental or private plans.”
Probability vs. Possibility/Potential of Care Recommendations
Dr. Joseph Guileyardo published an article in 2015 titled, “Probability and uncertainty in clinical and forensic medicine,” in which he outlines the following concepts:
A reasonable degree of medical probability is a conclusion defined as “having a probability greater, but not significantly higher than 50%.”
A reasonable degree of medical certainty is defined as an opinion “generally considered as significantly exceeding 50% likelihood.”
The Life Care Planning and Case Management Handbook (Fourth Edition) explains that life care plans frequently include projected future complications. This professional treatise also notes, “complications that only rise to the level of ‘potential’ do not meet the criterion of ‘probable’ as defined in the legal sense.” Recommended care items, included within the life care planning cost tables, must have a reasonable degree of medical or rehabilitative probability and/or certainty to associate the items, with costs, in a life care plan.
CPT® Codes
The Current Procedural Terminology (CPT®), as developed by the American Medical Association (AMA), provides health care professionals with a uniform language for coding medical services and procedures across all venues of service operation. In other words, the universal CPT® code creates an avenue to compare costs from one health care provider to another, and from one region to another, in an “apples to apples” fashion. As mentioned in Standard of Practice 15c, the utilization of CPT® codes in the cost development process of the life care plan enables the life care planner to establish usual, customary, and reasonable costs for an evaluee in a specific zip code/geographical region. Relative to the necessity of professional collaboration, the establishment of medical foundation from a health care professional acting within his or her scope of practice, should lead to more accurate costing research by utilizing the most appropriate CPT® codes.
Total Present Value vs. Total Lifetime Cost
The only important total cost of consideration in a life care plan is the total present value. This is the number the trier of fact will be asked to consider providing for a lifetime of medical and care needs for the evaluee. Often, a life care planner will choose to include a lifetime calculation of costs based on his or her costing research. This presentation of total lifetime cost may result in confusing, or even misleading, information to the trier of fact. Most life care planners lack the qualifications and the expertise to perform the economic analysis of factoring in inflation and interest required to determine total present value. Because the life care plan will document the need for future care over an evaluee’s entire life, this future care must be presented in today’s dollars, making necessary the retention of an economic expert to perform this complex calculation.
Life Expectancy
As described in the Journal of Life Care Planning, the overall methodological processes necessary to determine life expectancy for purposes of a life care plan are quite extensive and complex (Caruso et al., 2021; Rosen et al., 2013; Kush et al., 2013; & Krause et al., 2013). From an evidence-based life care planning perspective, it would be inappropriate to assume and utilize an average life expectancy for an evaluee, absent necessary and qualified expert foundation for the same.
In summary, to build a foundationally solid cost table based on the recommendations of the life care plan, it is essential the life care planner follow the Standards of Practice and Consensus Statements put forth by the International Association of Rehabilitation Professionals (IARP) and the International Academy of Life Care Planners (IALCP), as these are the protocols which guide the cost developmental process of the life care plan. Standards of Practice and Consensus Statements are the peer-reviewed culmination of solid practice foundation developed by subject matter experts. As such, these guidelines show the criteria necessary to establish credible, reproducible, and transparent data needed for the robust life care plan cost projection.
REFERENCES:
American Medical Association. (2013). “Definition of Usual, Customary and Reasonable.” From: www.ama-assn.org. H-385.923 Definition of "Usual, Customary and Reasonable" (UCR) | AMA (ama-assn.org)
Caruso, G et al. (2021). “Life Expectancy Issues in Life Care Planning.” Journal of Life Care Planning, 19 (1), 19-58.
Guileyardo J. M. (2015) “Probability and uncertainty in clinical and forensic medicine.” Proceedings (Baylor University Medical Center),28(2). 247-249
International Association of Rehabilitation Professional & International Academy of Life Care Planners (2022), Fourth Edition. Standards of Practice for Life Care Planners.
Johnson, C; Pomeranz, J. & Stetten, N. 2018. “Life Care Planning Consensus and Majority Statements 2000-2008: Are They Still Relevant and Reliable? A Delphi Study.” Journal of Life Care Planning, 16 (4), 5-13.
Johnson, C; Pomeranz, J. & Stetten, N. 2018. “Consensus and Majority Statements Derived from Life Care Planning Summits Held in 2000, 2002, 2004, 2006, 2008, 2010, 2012, 2015 and 2017 and updated via Delphi Study in 2018.” Journal of Life Care Planning, 16 (4), 15-18.
Krause, J. et al. (2013). “Utilizing Research to Determine Life Expectancy: Applications for Life Care Planning.” Journal of Life Care Planning, 12(1), 51-60.
Kush, S. J., Day, S., & Reynolds, R. (2013). “Life Expectancy for Life Care Planners.” Journal of Life Care Planning, 12(1), 31–49. Journal of Life Care Planning, 12(1), 31-50.
Preston, Karen, et al. “Standards of Practice for Life Care Planners, Fourth Edition.” Journal of Life Care Planning, 20 (3), 5-24.
Rosen, B. et al. (2013). “Estimating Life Expectancy: A Physiatric Perspective.” Journal of Life Care Planning, 12 (1), 3-14.
Weed R. & Berens D.E., (editors). 2018. Life Care Planning and Case Management Handbook. (4th ed.). New York, NY: Routledge.
