The cost effectiveness of palliative care in a fee-for-service or value setting

Erika Grotto: The growth and expansion of palliative care, today on HFMA’s Voices in Healthcare Finance podcast. Hello, and welcome to the podcast. I’m your host, Erika Grotto. Today, our president and CEO Joe Fifer is talking with Brynn Bowman from the Center to Advance Palliative Care. Whether you have experience in palliative care or only a passing familiarity, I think you’ll find this interview enlightening. Here’s Joe.

Joe Fifer: Alright, well, I’m really excited for today’s guest. Today we have Brynn Bowman, MPA, who is the chief executive officer for the Center to Advance Palliative Care. CAPC provides tools, training and technical assistance to more than 1,750 healthcare organizations to improve the quality of care for patients with serious illness. And Brynn, I love your simple but profound vision statement for CAPC. It says, “Palliative care everywhere.” Brynn is assistant professor for Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai. She’s a member of the National Academy of Medicine’s roundtable on quality care for people with serious illness and a former health and aging policy fellow where she served in the U.S. Senate committee on finance in 2020 and 2021. So Brynn, welcome to the podcast.

Brynn Bowman: Thanks so much. Thanks for having me. Really grateful for the chance to talk to you today and with HFMA listeners about palliative care.

Fifer: Yeah, this is going to be fun. And our listeners should know that over the last couple of years, we’ve struck a pretty good working relationship with CAPC and shared some content and who knows where that’s going to go. And there’s some reasons for that that hopefully we’ll get into during the podcast here. But just for clarity, could you just define palliative care and perhaps even compare and contrast that to, say, hospice care or other care along those lines?

Bowman: Yeah, absolutely. It’s the right starting place. So palliative care is a medical specialty for people living with a serious illness. And really, it’s focused on providing relief from the symptoms and the stressors of that serious illness. So that can mean managing pain and other symptoms, finding out what matters to patients in the context of that disease and helping to align treatment decisions with those patient goals, supporting family caregivers and helping to coordinate care and communicate across clinical teams. So it is provided by a specialty trained interdisciplinary team, so that means medicine and nursing and social work and spiritual care. And that team will work alongside a patient’s other clinicians, usually as a consult service and at the same time as disease treatment. So unlike hospice, which you brought up, which really is about the end of a patient’s life, palliative care we think of as being appropriate based on patient need at any point in the prognosis. And the goal really is to relieve suffering and improve quality of life for patients and for families.

Fifer: Sure, and it could apply to all kinds of different conditions as opposed to just end of life—not just end of life but the end-of-life environment. So a little background. I was first exposed to palliative care over 12 years ago when I worked at Spectrum Health. I remember learning about it and thought the investment in palliative care made perfect sense, but honestly, that opinion was not uniform across our executive team as we grappled with those really difficult budget tradeoffs in a competitive budgeting world. So with that as my background, can you just tell me what’s transpired over the last 10, 12 years or so about care, how many systems are investing in palliative care. Is it standard practice? How does it fit now? Bring me up to date from where it was when I looked at it.

Bowman: It’s a great question because a lot has changed in that time, and it’s changed really fast. So palliative care really is one of the most growth trends in healthcare over the last couple of decades. And if you look at U.S. hospitals with more than 50 beds, 15 years ago, you would’ve seen around 45% of those hospitals had a palliative care program, whereas today, more than 83% of hospitals have a program, and that includes almost all of the large hospitals and all, 100% of the top-ranked U.S. News & World Report hospitals. If you flip it and put it the other way in terms of patient access, more than 90% of patients go to a hospital today that has a palliative care program. This applies in the world of pediatrics too. So infants, children, adolescents that are dealing with a serious medical illness, most freestanding children’s hospitals now have a palliative care service. So we really have seen a lot of rapid growth. And what’s also true there is that the size of hospital teams and therefore the number of patients that they’re seeing every year, those numbers have grown steadily over the last 15 years as well. And I think that’s a result of hospitals having seen the benefits of palliative care and also of palliative care being more integrated into the culture of care during that time. The other trend that I want to just make a note of is, where we see health systems being earlier in the adoption curve is community-based palliative care. And that’s really important when we think about patients’ post-acute care needs and needs along the trajectory of a disease in between a crisis that may land them in the hospital. But here, too, and especially in the last five years, we’ve seen a lot of growth. So there’s a growing number of health systems that now provide palliative care in outpatient clinics or through home visiting programs. And we see kind of the need for stabilization for patients following a hospital admission, and those palliative care services can really help avoid a crisis and a readmission.

Fifer: That’s really interesting. I want to get back to the community element in a second, but first I want to talk—you can hardly talk about any healthcare issue these days without talking about the pandemic, and one can feel that palliative care maybe got its moment in the sun because of the pandemic. And honestly, I still can’t imagine what it must have been like for families with loved ones in the hospital and they couldn’t visit, and it must have been a real challenge for the palliative care world. I know you’ve provided us some statistics on the growth of palliative care over the pandemic, but maybe you just delve into that a little bit. What did the pandemic do to palliative care and caregivers?

Bowman: Yeah, it’s important, as you say, there’s no conversation now except a conversation about the pandemic, and what we saw in the palliative care field over the last two years, I think, is pretty telling. And just to start thinking about heading into the pandemic in 2020, when you think about what palliative care teams are expert in, it is taking care of very sick patients with complex needs in conditions of uncertainty, and that is expertise that was certainly called for during Covid. So one interesting thing that we saw, CAPC surveyed the palliative care field at intervals during the pandemic. More than 65% of the palliative care program leaders working in hospitals and health systems that reported back to us said that they had been called in to be part of their organization’s crisis response planning teams because of that expertise in caring for sick patients who were at risk for bad outcomes. We also saw that palliative care teams were often among the earliest telehealth adopters, and there were a couple of reasons for that. Inside of the hospital, it might have been about spreading palliative care capacity just so those team members could be when and where they were needed across the hospital, also to help connect hospitalized patients with loved ones who could not come to visit. Palliative care teams were also caring for people who had a pre-existing serious illness before the pandemic, so managing cancer or heart failure or dementia outside of the hospital, very much wanting to stay outside of the hospital during Covid and getting care telephonically or through telehealth from palliative care teams. The other things that we saw palliative care teams do during the pandemic which I think will be interesting as we start to come out of this time is really having the role of having difficult conversations with patients and families about care goals, whether that was in the emergency department, if the decision was be admitted with your Covid or try to stay home and shelter in place, when that was about treatment decisions when patients were hospitalized. And because those are conversations that palliative care teams are expert in, their colleagues were stressed, overstretched, could rely on them to have that conversation with patients and families and communicate back to the treating team. And of course, palliative care teams are managing shortness of breath and other symptoms. So trying to be when and where they could to relieve suffering. To your question about what do we take away from all of this story from the pandemic, where we are now is, I think, both at the administrative level and the level of referring clinicians, palliative care teams really were valued for the work that they did during the pandemic. Those clinical relationships between referrers and palliative care teams strengthened over that time. Consult volumes went up, and they have stayed up. And that is really good for patients and really good for referring providers, but the risk, I worry, is that palliative care teams aren’t always staffed to meet that demand from within the organization. So back to your question about how do we mainstream palliative care, I think it’s the right time to think about what do we make of what we’ve seen during the pandemic, what does it mean for strategies, for stabilization coming out of the pandemic, in what way does the work of palliative care teams support productivity and effectiveness in the ICU or the emergency department or for hospitalists for example. And what does that mean in terms of allocation of resources?

Fifer: I hear that and I think about those environments and I think of those conversations. Those conversations are so important, and I think those caregivers have a direct ticket to heaven to be able to have those conversations in the way that they do. For finance people like myself, it’s hard to put ourselves in that moment, but how truly important that really is. And I see the movement and the change as you described it, what happened during the pandemic. I think that’s amazing, and it’s really cool. I’m just wondering, are there barriers to making these in the mainstream? Are there barriers to making it stick? How can we help make it be more mainstream and permanently?

Bowman: I think you actually referenced the two biggest barriers when you talked about your experience at Spectrum. The first I believe really is an awareness of how palliative care teams do their work, and that idea that access to palliative care should be based on what the patient needs, at whatever point in a serious illness from diagnosis on. But we see a lot of conflation of the idea of palliative care and end of life, and what that can mean is missed opportunities to integrate palliative care services earlier in the disease trajectory when patients and clinicians in your organization could really realize those benefits the most. So I think that’s one issue that gets in the way. And another issue is financing. A barrier has been the fits and starts and the shift toward value-based care. Palliative care is a high value proposition. It improves quality for high-need patients and in so doing reduces cost to the hospital or the health system. And the data are very clear on this, but under fee for service payment, palliative care teams, especially because they’re interdisciplinary in nature, cannot bill to cover the staffing costs. So it really does require up-front support from the hospital for palliative care staffing, with that cost savings realized on the basis of the work of that team. So one thing that CAPC has for example is an impact calculator that hospitals can use to project what would be those cost savings based on different palliative care staffing levels and numbers of admissions seen by that service. And those calculations are based on the most up to date published outcomes data from the field so that you can kind of plan for staged growth over time. But I do think it gets back to this question of how health systems can best leverage the work of those palliative care specialists. So for example, one place I think that might be a phase for growth inside of health systems and how we think about palliative care is standardization. So do hospitals and health systems have systems in place to identify the patients that would benefit most from palliative care in a timely and reliable way so that palliative care services can ensure the highest impact and quality while operating efficiently. And there’s some health systems that have been ahead of the curve here, that have implemented standardized triggers to identify those patients without relying on clinicians proactively identifying patients for palliative care referral, and then make sure that the palliative care team is staffed appropriately to meet the need. So I think there are strategies for kind of leveraging your palliative care resources and making sure that those specialists really are seeing the right patients who will realize the benefit.

Fifer: CAPC has done some studies on the financial impact of palliative care. We don’t have time in this podcast to get into a lot of those details, but it would be worth the time and effort of our listeners to delve into that, especially if they’re already in some sort of a value-based care arrangement. I think of palliative care as one more thing that people that are tied to fee for service might see as problematic, but people that are embracing value-based care models would fit, which kind of leads into this last question that I wanted to get back to. You talked about involving the community and things outside of the health system. I’m curious about that. HFMA has been focused on cost effectiveness of health—not healthcare, but health—and I know that palliative care fits nicely into that concept, but I’m just wondering, talk a little bit more about that community involvement and then also talk a little bit about those organizations that either haven’t invested or maybe could invest more. What are reasons that they should reconsider if they either have it or just invested a little bit?

Bowman: The questions are linked. Why invest in community-based palliative care services is related to the outcomes that we see particularly under value-based payment incentives. Maybe I’ll start with the outcomes and then think about what are the community-based palliative care models. And the outcomes really are that high-quality palliative care has been shown in the hospital to reduce ICU utilization, bring down the cost per day for hospitalized patients and decrease 30-day readmissions.

Fifer: Which, by the way, fits into a fee for service model, right?

Bowman: Absolutely, absolutely. And then in the outpatient setting, palliative care reduces emergency visits and again has impact on readmission rates, and home visiting palliative care programs in particular have been shown to reduce the total cost of care. So you think about a health system, for example, that’s participating or has an accountable care organization, that starts to be a really important strategy for the proportion of patients who are sick, at risk for poor outcomes and need to have those conditions managed over time. And actually, one example that comes to mind as we talk came from an HFMA webinar last year. CFO Jim Wentz from Ochsner Medical Center showed an analysis in his presentation that for patients who are seen by palliative care within three days of hospital admission, average length of stay decreased, direct cost of care per day went down, and the hospital saw a significant return on its investment for having subsidized staffing for the program. Really interesting, I thought, from his presentation was they also realized they were leaving savings on the table if the palliative care team saw patients too late in the stay. And so that had implications for their staffing and their workflow strategies. His summary statement, which I just loved was, the numbers make sense for us in the fee-for-service world, and we’re even more excited about how they’ll look in a value-based world when we’re going to be ready. So I think that was a powerful example of the business case and of course the human case for palliative care in either financial context. And on the quality side, palliative care has been demonstrated again and again to improve quality of life for patients, improve patient and family satisfaction and decrease symptom burden. And so there are health systems now thinking about how to braid those outpatient and community-based services and inpatient services to make sure that as patients’ needs change over the course of a disease, that they have access to services when and where they need them.

Fifer: You kind of mentioned how I was going to put a wrap on this. You made it very clear, and you’ve gotten much more data than you’ve even mentioned here about being the right thing financially, that it’s a financially sound thing to do. But when you bring in the powerful human element to this, it’s a classic example of, it’s the right thing to do, it’s so powerful for patients and their families, and oh, by the way, it makes sense financially. So I just love the way that comes together, and I just really appreciate you sharing your thoughts and your insight with our members today. I still think there might be a number of members that don’t know what palliative care is, and what a great introduction to it for those or encouragement to those to continue to invest in palliative care. So thank you, Brynn, for joining us this morning.

Bowman: Thanks so much, Joe. You know, I think you put it best. We know we can do better at caring for the person while we treat their disease, and we know that doing so is cost effective. So I tell you what, that’s the healthcare experience that I will want when I need it someday.

Fifer: I’ll be right there with you. Well, thanks again, Brynn.

Bowman: Thank you, Joe. Have a great day.

Grotto: Voices in Healthcare Finance is a production of the Healthcare Financial Management Association and written and hosted by me, Erika Grotto. Sound editing is by Linda Chandler. Brad Dennison is the director of content strategy. Our president and CEO is Joe Fifer. If you’d like to reach out to our team, we’d love to hear from you. Our email address is [email protected].

On a recent episode of HFMA’s “Voices in Healthcare Finance” podcast, HFMA President and CEO Joe Fifer talked with Brynn Bowman, CEO of the Center to Advance Palliative Care (CAPC), about how palliative care can contribute to the cost effectiveness of health.

Palliative care defined

Although palliative care programs have grown in popularity in recent years, many people get confused about what it entails, Bowman said. Unlike hospice care, to which it is often compared, palliative care can take place at any point in a patient’s prognosis, she said.

“[Palliative care] is focused on providing relief from symptoms and the stressors of serious illness,” she said. Besides pain and symptom management, such care can include support for caregivers and care coordination across clinical teams.

The growth of palliative care

More than 83% of hospitals have a palliative care program today, up from about 45% 15 years ago, Bowman said. The size of hospital palliative care teams also are growing, as are programs in outpatient clinics and other non-hospital settings.

“Those palliative care services can really help avoid a crisis and a readmission,” she said.

The pandemic has pushed palliative care to the forefront, largely because of the expertise of the teams, Bowman said. In a survey, CAPC found that many palliative care leaders had been called in to help in their organizations’ crisis response. Palliative care teams also helped push telehealth forward during the pandemic, according to Bowman.

“Inside the hospital, it might have been about spreading palliative care capacity just so those team members could be [available] when and where they were needed,” she said.

Outside the hospital, palliative care teams could help patients who had serious illnesses before the pandemic stay out of the hospital by providing care via telehealth, she said.

Pushing palliative care forward

Palliative care has been shown to reduce the cost of care across the continuum, Bowman said.

“High-quality palliative care has been shown in the hospital to reduce ICU utilization, bring down the cost per day for hospitalized patients and decrease 30-day readmissions,” she said. “In the outpatient setting, palliative care reduces emergency visits and again has an impact on readmission rates. Home visiting palliative care programs in particular have been shown to reduce the total cost of care.”

An even more important thing to note, Bowman said, is the human element of palliative care.

“Palliative care has demonstrated again and again to improve quality of life for patients, improve patient and family satisfaction and decrease symptom burden,” she said.