Vivek Garg Discusses Palliative Home-Based Care and the Effects of COVID-19 (PODCAST)

May 8, 2020

Dr. Vivek Garg, CareMore and Aspire chief medical officer, discusses palliative home-based care and its effects of COVID-19.

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Here is an exerpt from the interview:

MHE: Can you discuss the home-based palliative care program that Medicare beneficiaries can now receive?

Garg: Absolutely. I think the Centers for Medicare and Medicaid services, really the government agency that supports the services and benefits of Medicare and Medicaid, have been on a journey of enhancing the supplemental benefits that Medicare Advantage plans can offer: meals ride sharing other social services, respite care, over the counter medications and therapies that people need for their health. And so the latest slew of benefit enhancements and supplemental programs includes: home based palliative care services, services under palliative care where there's a reasonable expectation of improving health or maintaining health, and that those could be covered by Medicare Advantage plans, which are private entities that have to meet these standards of benefits and services.

And this also allows Medicare Advantage plans to tailor the programs to specific populations. And that's really from a resource stewardship perspective so that people with the means that are aligned can receive those services like home-based palliative care, and really to help target the resources where they're most needed. So people with serious or advanced illness now who were pre-hospice, meaning they're not thought to be in the last six months of life, have access to palliative care services under supplemental benefits for Medicare Advantage plans that have chosen to take that on. Many of the plans are now choosing to add that as a supplemental benefit. Duke University released a recent study that said now 61 different Medicare Advantage providers are offering palliative care as a supplemental benefit. And that's up from 15 in 2019, just the year before, so really a multiplication of support and resources of accessibility for seniors around a very critical domain of health. So I think it's a really fantastic evolution in terms of how we can support our seniors in the needs that they have.

MHE: What are some possible barriers or complications to receiving this program.

Garg: I think the core challenge in palliative care is really around awareness. You know, people who are experiencing serious illness, know they have a serious illness or getting care from multiple groups and providers, you know, our team oncologist, specialists, hospital-based teams. And yet somehow in the moment that unfolds, you may not be aware of what palliative care is or that it could be accessible to them. So I think that's one key opportunity, let's call it, for these programs, as they engage as a supplemental benefit under Medicare Advantage or other supports as patient education, patient awareness, proactive conversations that even this is something that might be useful for you and to have a conversation about it. I think there's not a lot of access to palliative care overall, so many services are hospital-based. This will clearly open the envelope up more. but it's still difficult to always access it in the way that's most convenient. That's where we believe home-based palliative care is a huge opportunity.

Related: Krista Drobac Discusses the Rise of Telemedicine Due to COVID-19 (VIDEO)

MHE: What is your view on the best way to integrate a palliative care into the patient's overall health plan?

Garg: I think that palliative care needs to be integral to all of healthcare. And I think that starts with patient education. Really, the ability to keep people informed about what serious illness means for them, the full spectrum of options, and really the important perspective that palliative care specialists have developed about symptom relief. And making choices that are deeply personal as people advance through their care. They're confronted with new information about what their healthcare trajectory might be. So first, I think critically, patient education, public awareness, accessibility of these programs is really important. We'll fold them in the fabric of all of our care in general, overall. The second is really to take the responsibility in our general care as primary care practitioners. I'm a practicing primary care physician with CareMore and previously I've had patients who've come to me in very severe stages of illness, even getting to the hospice stage where their life expectation was less than six months. And we've handled it all on the outpatient side.

We've had clinic visits, they've gotten the right services as in outpatient blood transfusions, different kinds of services that help their symptoms decrease and help their functionality improve; driven by their preferences and choices. And so as primary care physicians and clinicians in general care practices, I think there's a huge opportunity for us to reintegrate palliative care expertise into our daily practice, really, again, to serve that first point, which is patients have access and awareness. The last point I'd say is a lot of our care in this country is driven by specialty perspective. It's a great part of all the innovation in healthcare that's happened. We have therapies, diagnostics, interventional services, all of that has really occurred in the last 50 years to 70 years, within some of our seniors lifetimes, it's dramatically evolved. Our specialists have important expertise about what diseases mean and what people can expect in their healthcare. But I would suggest that specialty groups which really define the clinical protocols about how we should care for different types of cancer, or different stages of heart failure, integrate palliative care as an important component in consideration at the right moments in a patient's health care trajectory.

MHE: Is there anything up-and-coming in palliative care?

Garg: Palliative care, I think is really about to explode in a good way. And if you take a step back, there's multiple studies that showed that effective and timely palliative care support actually improves survival and definitely decreases symptoms and improves functionality. So it relieves suffering and actually saves unnecessary costs. And again, all of that comes from decisions and choices and services that are entirely aligned with people's conception of what they want in their health. That has to be the starting and end point. If palliative care was a pill (it'd be a) $100 billion pill, but it's not a pill. And so I do think that people are recognizing the importance of value for patients and populations around palliative care. I think we'll see growth in hospital-based palliative care services. There's a lot more job postings, many more training programs, I think we'll see a convergence of home-based care.

There's other programs from CMS and the Center for Medicare and Medicaid Innovation, where primary care practices could actually shift more into the home and receive a capitation payment to care for high needs patients. There's a serious illness population program as well, which is specifically focused on probably a palliative care eligible population with advanced in chronic illness. And you have hospice companies that do a lot of palliative care as well: pre-hospice. So there's a convergence and growth of home based care in general. I think one thing that will happen for palliative care is integration and expansion from other home-based care entities to include the scope of palliative care, which I think will be very helpful for people going through these experiences and choices. The last year aid site is really around analytics. Our team has spent a lot of time over the course of Aspire being developed and grown to analyze data to create predictive insights about who might benefit from palliative care services. When you think about all the data that exists now in healthcare systems or health insurers and all the connectivity happening, we really do have an ability to not just wait for somebody to bring up the conversation, but to use the data to trigger a moment or consideration where a primary care physician, an oncologist, a home based palliative care team could have a conversation with a patient and family so that they know their full options set and they know all the services available to them. I think that's really exciting,  we found that to be very useful.

MHE: Lastly, obviously with everything going on right now, I wanted to get your thoughts around COVID-19 and how it's affecting administer home care and technology.

Garg: Well, first in terms of palliative care, you know, one thing I think that's happening in COVID, which I don't know if we've seen reconciled yet, and I haven't personally yet as a physician, is just the large amount of suffering that's happening and the confrontation of our own mortality that's happening through the consequences of COVID. And it's happening across a broader each range, that's usual, people in their 30s adults in their 50s. It's not just seniors. And so it's different than what we experienced in seasonal flu, even very bad, seasonal flu seasons. And I don't know what that means. I don't think we've had time to process that but many more people across broader age ranges have confronted an experience where a loved one has passed away unexpectedly or where they had the risk of that or the concern of that. And I think that will change things. I don't know how.

Home-based care has been fantastic and I think that you see that many laggards in terms of moving care forward have now fully operationalized home visit services. We're very fortunate to run a large housecalls practice in many of our markets through care more and Aspire. And we've made full use of it. We've built a hospital at home program, that programs (in) Europe right now, so we bring services to people where they're comfortable, or frankly right now, they can't really leave, it's not best for them unless they're protected. We can come there and give them the services they need the care, the oversight the attention. And so we've accelerated home based care ourselves and I imagine that other healthcare entities that have done the same will keep that over time, and that will become a more permanent fixture. Within that as remote monitoring, you know, many patients with COVID have very low oxygenation levels. It's very concerning because it doesn't always manifest the shortness of breath. So we have patients going home are being served with oxygen monitors that they can put on and they can be in contact with case management and clinical teams about their oxygen levels. And in doing so, we preserve hospital access and ER access for folks with more severe versions of the condition. 

So, I think remote monitoring is another area from a technology perspective that there's really being a light shown on, there's really important needs around and the whole ecosystem of home-based care in the surveillance that you can provide on patient's behalf in the home is really having a moment and I think that will persist. There are many significant conversations happening now through technology-based means as doctors and nurses and other practitioners. We have physicians and nurses having video visits with patients and families where they discuss end-of-life goals, or they talk about a change in status. And sometimes those conversations end with a decision from the patient with their family support, to choose a non curative path or to choose added palliative care services or to choose something else, and that's happening by video, more and more, and it's very effective. I think what we've learned is, it's about the people. It's about what they care about. It's about people bringing them perspective. It doesn't always matter whether it's in person or not. Clearly, we would all prefer that, that human touch that human presence. And on a final note about this point, you know, we have a great palliative care team of specialists through Aspire.

One of the great joys I've had in the last month or two is actually seeing them mobilized to support or impatient physicians or hospitals that we call extensiveness who care for inpatients are senior patients in the hospital every day in five different states. They developed a virtual palliative care console program where they're accessible by video as experts in palliative care to our hospitals, physicians, so that they can be counseled and supported in their care of their patients in a different state. And so today that just kind of symbolizes some of the lessons that are being learned, some of which you might have predicted, some of which you might not have predicted and, you know, how we might all come together to support each other and support patients through this through technology.