Community-Based Palliative Care Results in Positive Fiscal Impact for Providers and Payers

At one healthcare organization, a palliative care program contributed to a 34 percent reduction in healthcare expenditures.

The fact that healthcare spending skyrockets at the end of life might suggest that policymakers and those with hospital fiduciary responsibilities should target the last few months of life to control costs. However, healthcare leaders also should be aware that high spending persists over multiple years for many patients ( The Concentration of Health Care Spending , National Institute for Healthcare Management, July 2012). In addition, older patients or those who have one or more chronic medical conditions or functional limitations are significantly more likely to be among the costliest patients.

A study of Medicare claims data found that healthcare costs at the end of life are markers of general spending patterns often set in motion long before death (Davis, M.A., Nallamothu, B.K., Banerjee, M., et al., “Identification Of Four Unique Spending Patterns Among Older Adults In The Last Year Of Life Challenges Standard Assumptions,” Health Affairs, June 2016):

• 48.7 percent of older Medicare beneficiaries were classified as “high persistent,” meaning that they maintain high spending throughout the year.
• 10.2 percent showed a progressive pattern, starting low but increasing steeply.
• 29 percent of decedents were moderate persistent, mimicking the high persistent pattern except for a spending dip a few months prior to death.
• 12.1 percent of the sample exhibited a late rise in the final four months of life after very low spending in the earlier months of that final year.

These expense patterns are magnified by the extraordinary growth of the senior population. By 2050, the senior population is projected to grow by 135 percent, according to a study published in the International Journal of Epidemiology, and the segment of people ages 85 and older, the group most likely to need health and long-term care services, is projected to increase by 350 percent.

These data show that almost half of all seniors start out as high cost and remain high cost as they near end of life. In the last year of life, this cost is typically tied to multiple chronic conditions rather than single diseases. In fact, the Department of Health and Human Services reports that care for the one-quarter of Americans with multiple chronic conditions accounts for about 66 percent of U.S. healthcare spending.

In this challenging environment, healthcare payers and providers are looking at innovative approaches to better manage their members and patients. Today, they are discovering the impact of population health approaches that include community-based palliative care, which aligns care with patients’ wishes to reduce economic burdens, improve outcomes, and enhance quality of life for patients and their caregivers.

This approach allows hospitals to identify patients with poor prognoses earlier and help them manage their care at lower costs as appropriate. It also prevents non-beneficial inpatient costs from driving up total costs. The goal is to ensure that patients, especially the chronically ill, receive the right care at the right time while avoiding unnecessary service duplication and preventing medical errors.

A Scalable Solution

These findings were tested and validated in a one-year program at Mount Carmel Hospice and Palliative Care. That program included a structured deployment of community-based palliative care for Medicare Advantage members and resulted in a 34 percent reduction in healthcare costs for those enrolled in the program. The 208 members enrolled in the program, compared with 800 control members, experienced the following positive results:

• Lower hospitalizations: 32 percent
• Reduced readmissions: 61 percent
• Reduced intensive care unit days: 37 percent
• Earlier and appropriate election of the hospice Medicare benefit

Results from the program also demonstrated the following clinical results:

• 98 percent goals of care completion
• 97 percent symptom satisfaction
• 4.8/5 stars satisfaction rating

Similar results were achieved in a home-based palliative care study, comparing costs of care and resource utilization during the final year of life for patients who were enrolled in the program, and those who received usual care (Lustbader, D., Mudra, M., Romano, C., et al., “The Impact of a Home-Based Palliative Care Program in an Accountable Care Organization,” Journal of Palliative Medicine, January 2017).

Existing Population Health Solutions

Community-based palliative care allows providers and payers to address non-beneficial treatment frequently provided to those with advanced illnesses. While shifting away from episodic to longitudinal care is a step in the right direction, more is needed, including the deployment of a specialized care approach to address the needs of the sickest patients. The focus must move beyond disease process toward the following areas:

• Emphasizing person-centered care
• Shifting from late reactionary approaches to predictive early identification
• Acknowledging the unique nature of the last year of life
• Delivering care aligned with patient and family goals
• Treating the end stage of life with 
specialized solutions

Care provided to patients as they near the end of life should address the unique challenges associated with advanced illnesses. Goals of care should encompass comfort and quality of life and place greater emphasis on addressing the needs of the whole person and the family, including the reduction of financial stresses.

Care that Aligns Personal Wishes

For community-based palliative care to function within a population health framework, it must be data-driven and move beyond in-patient hospital settings to community-focused engagement strategies that ideally reach patients in their homes, before their conditions seriously deteriorate. By adhering to structured processes and consistent ways to measure outcomes, the results are care that is better aligned with personal wishes and that reduces economic burdens for all.

Currently, physicians and nurse practitioners often provide community-based palliative care and bill Medicare Part B for visits. However, new population health arrangements with payers and ACOs allow interdisciplinary teams led by nurses and clinical social workers who perform home visits and visits by telephone.

Requirements

Successful community-based palliative care programs require clinically driven models with the proper infrastructure, staffing, and resources to intervene prior to exacerbations in advanced illness. When supported by predictive identification of patients and a standardized platform to guide, capture, and monitor interventions, this approach can be extremely effective. Moreover, it can be a bridge to medical homes, addressing medical, emotional, and social factors.

Some community-based palliative care models deploy local nurses and clinical social workers who are typically employed within local hospice and palliative care organizations. These teams document palliative assessments and follow risk-based care pathways and care management protocols to better match care delivery.

These clinicians review symptoms, perform medication reconciliation, discuss and document goals of care, guide advanced care planning, provide psychosocial support, and identify caregiver needs. They then create a palliative plan of care based on patient goals, with ongoing home-based support, and provide patient education and assistance with medical decision-making.

When issues arise related to symptoms, prescriptions, safety, or changes in goals of care, nurses or social workers directly contact patients’ physicians. The program arranges social support services and addresses other nonmedical needs. The team continues to follow patients through the course of their illnesses unless they stabilize and no longer require services.

A Quality Oversight Process

Community-based palliative care documentation can be fed into population health management platforms, ensuring fidelity to its risk-based care pathways and care management protocols, regardless of program deployment locations. In addition, the platform should track all information gathered during clinical assessments, as well as information related to patients’ enrollments and outcomes. It should then gather, report, and benchmark key metrics related to enrollments, clinical assessments, interventions, satisfaction, and outcomes to support continual quality improvement and care model refinement. Actuarial teams could then be used to analyze utilization and cost outcomes based upon claims data.

This structured clinical programming, in combination with community-based palliative care quality monitoring and oversight, are keys to success.

Key Advantages

Through care coordination and reduction of unwanted and avoidable medical utilization, community-based palliative care enhances fiscal plan performance and improves patient and caregiver satisfaction. The focus is on the person—not the disease process—and puts quality over quantity.