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Here's how five health plans are successfully approaching palliative care.
Palliative care is looking more and more like hospice care, moving programs from the site of treatment-a hospital, nursing home or extended care facility-to the home. While both services provide compassionate care, what often separates them is the curative services offered in a palliative program.
Palliative care is not necessarily only for end-of-life situations but for patients at any point after diagnosis of a severe illness, says Lee Goldberg, project director, Improving End-of-Life Care, The Pew Charitable Trusts.
Under Medicare, patients with six months or fewer to live who are in hospice cannot receive concurrent care, a combination of treatment and compassionate service; however, seniors in private plans are not bound by the ruling.
The Medicare Care Choices Model, which began in January 2016, is a demonstration initiative under the Centers for Medicare & Medicaid Innovation for patients with advanced cancer, congestive heart failure, and chronic obstructive pulmonary disease who are eligible for Medicare hospice benefits.
The study is testing whether allowing concurrent care in hospice leads to additional care coordination, better quality of life, a decrease in hospitalizations and avoidance of preventable health expenditures.
Medicare is not the only insurer rethinking its approach to palliative care. Many managed care organizations are doing so with initiatives such as integrating multidisciplinary care teams-palliative care physicians and nurses, social workers and chaplains; providing home-based and concurrent care and care coordination; and developing care goals and life plans.
The hope is that these changes will reduce costs and improve care quality. For example, cost savings might be generated by taking the time to discuss patient concerns, reconciling those concerns with a family and healthcare team, and ensuring patients are better informed about care options. This in turn, could lead patients to opt against a traditional hospitalization option, or prevent a hospital admission or readmission.
Here's how five health plans are successfully approaching palliative care.
About five years ago, Priority Health, a Michigan-based nonprofit health plan, put palliative care on the front burner with a comprehensive initiative to make the public aware of the availability of services and ensure physicians could deliver them.
Using advanced analytics and clinical data, Priority identified which patients would benefit from palliative care services, including for medical and nonmedical services such as transportation. “We did not want to offer it to members who couldn’t benefit because the program is a covered benefit without a copayment,” says Greg Gadbois, MD, medical director of Priority.
Priority established the Tandem365 initiative, a consortium of long-term care facilities working together to offer home-based care. The model combines medical, behavioral and social healthcare and addresses the needs of patients that are critically ill and unable to access traditional outpatient care due to psychosocial and financial burdens. It relies on a multidisciplinary team to create a life plan for patients.
The initiative has resulted in a 38% decrease in inpatient stays, 52% decrease in emergency department visits, 35% decrease in total cost of care, 46% fewer specialty care visits, and an ROI as much as 4:1, depending on the patient and timing of intervention, Gadbois says.
Priority partners with Aspire Health, which supports patients with serious illnesses, including providing strategies to relieve symptoms and pain, assisting patients in treatment decision making, and offering emotional and spiritual support to patients and caregivers.
Regence, which offers health plans in Idaho, Washington, Oregon, and Utah, rolled out a palliative care program in 2015, including advance care planning, care coordination, team conferences among palliative care providers, in-home counseling, provider training to engage patients/families in end-of-life care planning and increased access to services.
The palliative care program tries to be inclusive, with a broad set of eligibility requirements, opening the door to anyone with a serious or complex illness without any designated time until end of life, says Bruce Smith, MD, executive medical director of the program.
The program’s services include:
A variety of providers-physicians, specialists, nonphysician providers, nurses, social workers, behavior health providers and clergy-can submit claims for advance care planning. Members pay a standard copayment for office visits without additional fees for home care.
As a result of the program, 67% of those in palliative care were in hospice when they died, indicating that it was successful in transitioning patients from palliative care to hospice at the right time, says Smith.
Blue Shield of California, Hills Physicians Medical Group (the largest independent physician association in Northern California), and Snowline Hospice (a community-based nonprofit hospice and palliative care provider), are collaborating to provide a home-based, palliative care program with an interdisciplinary group of providers-a physician, nurse, social worker, home health aide and chaplain-to deliver comprehensive care and support to seriously ill patients and their families.
Torrie Fields, senior program manager for palliative care, says that although Blue Shield of California doesn’t deliver care as an integrated healthcare system would, it can still make a contribution by:
Like Priority, Blue Shield provides its palliative care program to members as a standard benefit without a cost share.
The payer works closely with providers to identify which patients should have access to palliative care. “We want to ensure that our members receive services where and when they need them,” says Fields. “We don't want younger people with illness to feel isolated. Palliative care is not just for older adults; anything can happen at any stage of life.”
Although Fields says it is too early for program results, researchers from the University of Southern California plan to compare outcomes from patients who receive care from primary care providers trained in palliative care and those who receive home-based services provided by multidisciplinary, palliative care teams.
The Southern California Permanente Medical Group, part of Kaiser Permanente, recognized a need to engage its members in advance care planning.
“We wanted to move up the conversation and not wait until members became sicker and conditions exacerbated-make it a normal part of health maintenance,” says Susan Wang, MD, vice president of the medical group and lead for life care planning. “A palliative care program falls right in step with Kaiser Permanente’s population health approach.”
Kaiser has adapted the national Respecting Choices model, an evidence-based model of advance care planning that creates a healthcare culture of person-centered care.
Kaiser Permanente initially targeted members at high risk but more recently has developed multimodal techniques for identifying members who would benefit from advance care planning.
For example, when a woman has just had a baby, that might be the right time to discuss family planning and leverage support.
Wang says Kaiser identifies patients based on mortality risk-from members without a healthcare directive to those with chronic illness who are thinking ahead about their conditions to others with advanced illnesses who are at risk of dying. It targets each member with an appropriate, sometimes scripted, conversation; and plans to train trainers to conduct and improve discussions.
Although Kaiser Permanente’s palliative care program doesn’t differ too much from that of other insurers, its model embeds supportive services within standard care. Member copayments cover home-based care.
“Home-based care is the new frontier,” Wang says.
Sharp HealthCare, is an integrated regional health care delivery system located in San Diego and health plan. One of the primary objectives of its palliative care program is to prevent members from using a hospital as a tool for decompensation management of chronic illness, such as dementia, says Daniel Hoefer, MD, chief medical officer, Sharp HealthCare's outpatient palliative care program called Transitions.
“When these patients are recognized early, they won’t need those services,” he says.
Sharp created a program to teach providers how to identify these patients. “Although most providers know when their patient becomes ‘at risk’ of starting to use the hospital as a tool to manage chronic medical condition decompensations, we use the concept, when you think your patient will start to use the hospital to manage disease decompensations/exacerbations, as admitting criteria to our outpatient palliative care program,” Hoefer says. “We also teach evidence-based prognostication and use it to justify keeping/putting people on the program.”
Program goals include reducing emergency department visits, completing advance care planning, referring members to hospice on a timely basis, saving money and providing patient/family satisfaction.
Like Kaiser Permanente, Sharp puts a lot of stock in advance care planning, which Hoefer says improves quality of care, decreases deaths in a hospital, increases use of hospice, and reduces ICU and emergency department visits and hospital lengths of stay.
Besides advance care planning, Transitions combines comprehensive, in-home patient and caregiver education about disease processes; proactive medical, medication and lifestyle change management; and evidence-based prognostication.
“The program helps patients and their families understand what to expect-not if something is going to happen but when and how to prepare,” says Suzi Johnson, vice president, Sharp HospiceCare.
“We want to ensure patients and their families receive care that reflects their values and preferences, not paternalistic care but patient-centered care,” Johnson says. “If patients can articulate needs, that is in the best interest of doctors-more continuous, comprehensive care, not a ‘quick fix.’”
Reimbursement for palliative care is under debate. Goldberg says it is difficult to get reimbursed in a fee-for-service system, requiring physicians to patch together different CPT codes. “Palliative care requires time-intensive services and needs highly specialized physicians to be with patients, making it hard to figure out how to cover costs,” he says.
Fields recommends a per-member per-month, bundled payment for services, enabling providers to be more flexible in providing what patients need.
Wang suggests that providers could bill by time because of palliative care’s emphasis on labor rather than on service utilization. “We need meaningful metrics, such as how many days of the last six months were spent at home, admissions and readmissions, lengths of stay and ICU use.
“The current healthcare system does not pay adequately for this kind of medical expertise, but the [value-based] model allows physicians and providers to be reimbursed for their time, knowledge and expertise in care coordination, comprehensive discussions with patients about their disease, goals and preferences and helping align medical and social care with preferred care,” Hoefer says.
CMS adopted a ruling in October 2015-it began January 1, 2016-enabling any physician and nonphysician practitioner to bill for documented care goal conversations, discussions about advance care planning and help with understanding advance directives if they bill Medicare Part B for these services.
Mari Edlin, a frequent contributor to Managed Healthcare Executive, is based in Sonoma, California.