Dying in America Improving Quality and Honoring Individual Preferences Near the End of Life (2015) / Chapter Skim
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5 Policies and Payment Systems to Support High-Quality End-of-Life Care
5 Policies and Payment Systems to Support High-Quality End-of-Life Care
Pages 263-344
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From page 263... ...
Meanwhile, the practical but essential day-to-day support services, such as caregiver training, nutrition services, and medication management, that would allow people near the end of life to live in safety and comfort at home -- where most prefer to be -- are not easily arranged or paid for.
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From page 264... ...
Evidence suggests that palliative care, hospice, and various care models that integrate health care and social services may provide highquality end-of-life care that can reduce the use of expensive hospital- and institution-based services, and have the potential to help stabilize and even reduce health care costs for people near the end of life. The resulting savings could be used to fund highly targeted and carefully tailored social services for both children and adults (Komisar and Feder, 2011; Unroe and Meier, 2013)
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It then provides background information on the most important programs responsible for financing and organizing U.S. health care and the perverse incentives in those programs that affect people near the end of life.
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People with advanced serious illnesses and multiple chronic conditions share certain needs independent of their diagnosis, stage of illness, or age. They have a high prevalence of pain and other distressing symptoms that adversely affect function and quality of life.
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From page 267... ...
; designing services to address those causes (such as round-the-clock access to advice by telephone) ; reallocating funding away from preventable or unwanted acute/specialist/emergency care to support more appropriate services; and reducing the financial incentives that drive reliance on the riskiest, least suitable, and most costly care settings -- the emergency department, the hospital, and the intensive care unit.
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From page 268... ...
. Older people are the population group most likely to have chronic conditions leading to functional dependency, and spending on patients of all ages with chronic conditions ac counts for 84 percent of health care costs (Moses et al., 2013)
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6 he 13 cost contributors are fee-for-service reimbursement; fragmentation in care delivery; T administrative burden; population aging, rising rates of chronic disease, and comorbidities; advances in medical technology; tax treatment of health insurance; insurance benefit design; lack of transparency about cost and quality to inform consumer choice; cultural biases that influence care utilization; changing trends in market consolidation; high unit prices of medical services; the legal and regulatory environment; and the structure and supply of the health professional workforce.
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From page 270... ...
health care spending.7 Although the top 5 percent of health care spenders account for 60 percent of all health care costs, almost 90 percent of that costliest 5 percent are not in their last year of life. Since 1978, expenditures for Medicare beneficiaries in the last year of life -- many of whom have multiple chronic conditions and dementia -- have held steady at just over one-quarter of all Medicare expenditures (see Appendix E)
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From page 271... ...
The federal government allows the states wide administrative latitude, which results in great variability in benefits and eligibility among states. • The nearly 10 million Americans who receive both Medicare and Medicaid benefits are termed "dual-eligible." A recent study of 10 years of data on the extent and causes of people "spending down" 8 tates S that have "medically needy" programs allow people whose income exceeds usual Medicaid eligibility thresholds to enroll if their income minus medical expenses meets the eligibility standard (http://www.medicare.gov/your-medicare-costs/help-paying-costs/medicaid/ medicaid.html [accessed December 16, 2014]
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Primarily acute inpatient $139 billion hospital care (90 days per illness episode) , skilled nursing facility stays, and other services Medicare Part B 44 million (2010)
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with disabilities and other professional (2013) services, and laboratory and radiology; all states except Oklahoma cover hospice care Long-Term Care 4.4 million adults Nursing home and home $125 billion Assistance (2011)
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From page 274... ...
c Medical Care 5.6 million veteran Medical care, including $46 billion patients long-term care, home (2012) care, respite care, and hospice/palliative care Private Insurance Usually through 149 million Wide variation in $917 billion Employment- nonelderly coverage; almost Related Plans for 8 percent of hospice Employees and patients' care is paid for Retirees by private insurance, compared with 84 percent paid for by the Medicare Hospice Benefit Medicare 10.2 million Mostly costs not covered Information not Supplemental by Medicare, such as available Insurance deductibles, co-insurance, and co-payments Long-Term Care 10 percent of the Nursing home and other 4 percent of Insurance elderly long-term care services, long-term care depending on the policy expenses NOTES: aDoes not include some services, administration, public health, and investment.
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From page 275... ...
. Medicaid is the most significant payer for care of low-income children with life-limiting conditions, and it paid more than two-fifths of the nation's total bill for nursing home and other long-term care services in 2010 (KFF, 2013a,b)
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From page 276... ...
Table 5-2 summarizes how the financial incentives of public programs affect people with serious advanced illnesses. Absent incentives and mechanisms for true integration across program eligibility, benefits, and financing, it will be impossible to achieve an effectively functioning continuum of care for people with advanced serious illnesses.
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and does appear to be the best not take into account option unless patients variable needs over also have Medicaid time (which pays for nursing homes) continued
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Individuals Nursing Home resident incentives to avoid discharged from the Care people with costly hospital back to the conditions; (2) nursing home under Medicaid's lower the skilled nursing reimbursement for benefit cannot nursing home care receive hospice care is an incentive to concurrently for hospitalize dual- the same condition; eligible residents a 2011 analysis and return them to suggested one-quarter the facility under of the hospitalizations the higher-paying for dual-eligible Medicare skilled beneficiaries in the nursing benefit year studied (2005)
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From page 279... ...
. The National Commission on Physician Payment Reform, established by the Society of General Internal Medicine in 2012, concluded that fee-for-service reimbursement is the most important cause of high health care costs and expenditures.
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Yet it is hospital care, not community- or home-based care, that consumes the largest share of Medicare spending for patients in the final phase of life: fully 82 percent of all 2006 Medicare spending during the last 3 months of life was for hospital
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From page 281... ...
Unnecessary and burdensome EMS transports represent poor-quality care for people with advanced serious illnesses. When they present at the emergency department, they may be admitted to inpatient care because of an unclear diagnosis; the severity of symptom distress; caregiver concerns; and, most important, a lack of prior clarification of achievable goals for care.
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Parents of uninsured or publicly insured children with serious illnesses often face delays in obtaining physician appointments and end up seeking care in the emergency department, or they may be referred there by their primary care clinician (Rhodes et al., 2013)
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. Physicians' end-of-life care often fails to meet the needs of patients and families because some clinicians may • provide care that is overly specialized and does not address the multiplicity of a patient's diseases or the emotional, spiritual, family, practical, and support service needs of patients and their caregivers; • continue disease treatments beyond the point when they are likely to be effective; • fail to adequately address pain and other discomfort that often ac companies serious chronic illnesses and the dying process; and • fail to have compassionate and caring communication with patients and family members about what to expect and how to respond as disease progresses (Weiner and Cole, 2004; Yabroff et al., 2004)
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Other Services Although Medicare does not cap beneficiaries' hospital admissions or medical and surgical procedures, it does cap payments for ancillary services that might substantially benefit certain people nearing the end of life -- often more so than acute care and procedures. Such services may forestall hospitalizations, help people better manage daily activities, and improve both health status and quality of life (Eva and Wee, 2010; Farragher and Jassal, 2012)
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From page 285... ...
Such initiatives require careful risk stratification and monitoring to ensure adequate access and protection for these beneficiaries. Just as Medicare, through Medicare Advantage, has embraced managed care partly as a way to avoid the costs of unnecessary hospitalizations, Medicaid has embraced managed care partly to avoid unnecessary nursing home admissions.
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From page 286... ...
Services included customized care planning, coordination, and delivery. Evercare paid nursing homes an extra fee for "intensive service days" to handle cases that might otherwise have required hospitalization; this measure contributed to a 50 percent reduction in the hospitalization rate for enrollees compared with the usual care group.
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From page 287... ...
This section addresses the costs of palliative care and hospice compared with usual care and the policies that regulate the organization and provision of palliative care and hospice services. Palliative Care Palliative care programs focus on relieving the medical, emotional, social, practical, and spiritual problems that arise in the course of a serious
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From page 288... ...
Although identifying which treatments are of marginal benefit may be subjective, a study conducted in one academic medical center found that critical care clinicians themselves believed almost 20 percent of their patients received care that was definitely (10.8 percent) or probably (8.6 percent)
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Hospitals with specialty palliative care services have been able to reduce their expenditures through shorter lengths of stay in the hospital and in intensive care and lower expenditures on imaging, laboratory tests, and costly pharmaceuticals. In addition, patients receiving hospital-based palliative care have been shown to have longer median hospice stays than patients receiving usual care (Gade et al., 2008; Morrison et al., 2008; Starks et al., 2013)
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received in-home usual care group times more likely than palliative care member (p = 0.03) usual care recipients versus 152 who to die at home and received usual care had fewer emergency in two group-model department visits health maintenance and hospitalizations; organizations in two survival differences states between the two groups disappeared after data were adjusted for diagnosis, demographics, and severity of illness (Personal communication, S
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From page 291... ...
geographically and who died in the structurally diverse hospital hospitals (p = 0.001) Morrison 475 patients who Excess costs of Patients receiving et al., 2011 received palliative $4,098 for each palliative care (observational care consultations usual care patient consultation were study using and 1,576 who discharged alive more likely than usual propensity received usual care (p <0.05)
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From page 292... ...
Additional research is needed before firm conclusions can be drawn on the impact of palliative care delivery on total health care spending. Hospice Care The Medicare Hospice Benefit is the one public insurance program intended specifically to serve beneficiaries within the last few months of life.
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Still, the number of Medicare beneficiaries enrolling in the Medicare Hospice Benefit more than doubled between 2000 and 2011, from 0.5 million to more than 1.2 million (MedPAC, 2013)
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See Appendix C Payment policies The flat daily rate allowed for by the Medicare Hospice Benefit -- which means the hospice receives the same amount regardless of how many, or how few, services it provides on a given day -- is coming under scrutiny.
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reviews several potential or proposed changes to the Medicare Hospice Benefit that would affect hospice-related financial incentives and realign hospice services. Some of these changes were included in the ACA (see also Huskamp et al., 2010)
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Only one-third of elderly Americans have sufficient assets to pay for 1 year of nursing home care, which in 2012 averaged $81,030 for a semiprivate room and $90,520 for a private room (National Health Policy Forum, 2013)
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. Medicare's sole contribution to nursing home care is in paying for shortterm skilled nursing services aimed at rehabilitation following hospitalization and for short-term home health care for the homebound with a "skilled need." Post-acute care accounts for about 21 percent of all spending on long-term services and supports (KFF, 2013b)
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From page 298... ...
Indeed, there is some evidence of disproportionately high rates of potentially avoidable hospitalizations among dual-eligible residents in skilled nursing facilities and nursing homes (942 per 1,000 person years for skilled nursing facility residents and 338 per 1,000 person years for nursing home residents)
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. demonstrations to test the cost-effectiveness of home and community-based services as a substitute for nursing home care" (ASPE, 2000, p.
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. However, many states cap the number of people who can enroll in the Home and Community Based Services program, and some states maintain waiting lists for the program; testimony to the Senate Commission on Long-Term Care suggests that nearly half a million people are on these lists (Senate Commission on Long-Term Care, 2013, p.
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Movement toward alternatives to nursing homes is also supported by federal policy makers. In its 2013 report, the Senate Commission on LongTerm Care, established in 2012, urged a shift away from nursing homes and toward home care (Senate Commission on Long-Term Care, 2013)
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From page 302... ...
. Finally, if efforts to rebalance nursing home and home- and communitybased care are to succeed and more seriously ill people are to be cared for in their homes, home- and community-based care will need to encompass certain medical and quasi-medical services.
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From page 303... ...
. These findings suggest that dual-eligible individuals living in nursing homes might be good candidates for palliative care and care management intended to prevent avoidable hospitalizations, while others, living in the community, would be good candidates for a medical home or other entity that coordinates and integrates social and medical supports.
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From page 304... ...
Additional key program features are assessment of and support for family caregiver needs; round-the-clock access by phone; consistent relationships and communication among the care coordination team staff, patients, families, and medical providers; integrated assessment and delivery of both medical and social services; and generation and mobilization of needed long-term services and sup
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From page 305... ...
A 15-program randomized controlled trial of the Medicare Coordinated Care Demonstration identified six features that appeared to be central to the limited number of coordination efforts that saved money: • frequent face-to-face contact between the patient and the care coordinator; • occasional face-to-face contact between the patient's physicians and the care coordinator; • the care coordinator's functioning as the "communications hub" for the patient's practitioners; • use of evidence-based patient education interventions; • comprehensive medication management; and • a timely, comprehensive response to transitions between care set tings, such as discharge from a hospital to post-acute care (Brown et al., 2012)
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From page 306... ...
. An IOM committee recently determined that variation in Medicare spending across and within geographic areas is explained mainly by differences in spending for post-acute care, including subacute rehabilitation in skilled nursing facilities, long-term acute care facilities for ventilatordependent Medicare beneficiaries, and home health agencies.
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. Financial incentives for nursing homes to hospitalize dually eligible residents (and then to obtain Medicare's higher post-acute care skilled nursing benefit)
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. And while the United States is roughly in the middle relative to other OECD countries in total health and social services spending as a percentage of GDP,23 the ratio of social services spending to health services spending is markedly lower relative to other nations.
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. Adequate and relatively inexpensive social services could lower demand for expensive health care services for some people nearing the end of life.
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In addition, some social services themselves might produce net savings. For example, providing an elderly person daily meals is much less costly than the medical crisis and nursing home placement that result from the consequences of malnutrition (Thomas and Mor, 2013)
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Training in the responsibilities of caregiving can help. In a large online survey of a nationally representative sample of almost 1,700 people caring for family members with multiple health problems, almost half of respondents said the training they received had positive effects on the care recipient, including avoiding nursing home placement (p <0.05)
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From page 312... ...
. As a striking example of the impact of social services, results of a recent study suggest that among ostensibly "low-need" people aged 60 and older, home-delivered meals could mean the difference between living at home and needing nursing home placement (Thomas and Mor, 2013)
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From page 313... ...
An analysis of factors affecting that decision, conducted within the Connecticut Home Care Program for Elders (which serves approximately 14,000 state residents aged 65 and older) , identified a lack of transportation for both medical and nonmedical purposes as one of these factors (Robison et al., 2012)
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From page 314... ...
Specific opportunities arise from the new arrangements that involve risk sharing by Medicare providers, including ACOs, patientcentered medical homes, and bundled payments, as well as recently instituted penalties for 30-day readmissions, hospital mortality, and poor patient experience scores. These and other innovations under the ACA have spurred interest, discussed earlier, in meeting the needs of the nation's sickest and most vulnerable patients in their own homes and communities as an alternative to costly emergency department visits, hospital stays, and institutional care.29 In addition, the new CMS Innovation Center has the broad goal of working toward better care for patients, healthier communities, and lower costs through improvements in the system of care.
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. This merging of funding streams creates an opportunity and an incentive for state Medicaid programs to seek efficiencies in care delivery for dual-eligible individuals, as opposed to the problematic cost and care shifting that currently occurs.
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At present, CMS's Bundled Payments for Care Improvement Initiative specifically excludes hospice services (CMS, 2013d)
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ACOs update the original health maintenance organization concept and could prove extremely helpful to people with advanced serious illnesses given the importance of effective care coordination to high-quality care, as discussed earlier (Berwick, 2011)
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. A specific problem for people with advanced serious illnesses is that beneficiaries placed in postacute care or institutional settings following hospitalization may no longer
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From page 319... ...
Gaps in the Affordable Care Act From the standpoint of care of patients with advanced serious illnesses, the ACA has several noteworthy gaps: 30 his cut is in addition to a phase-out of the Budget Neutrality Adjustment Factor used T to calculate the Medicare hospice wage index, and will result in an additional reduction in hospice reimbursement of approximately 4.2 percent (NHPCO, undated)
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• The act is not required to include home-based palliative care as a covered service. • The act does not improve prospects for a more effective or finan cially stable long-term care system that better matches patient and family needs with social services.
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• Blue Cross Blue Shield of Michigan expanded hospice eligibility to patients with a life expectancy of up to 12 months rather than the usual 6, and permits concurrent care (BCBSM, 2009)
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From page 322... ...
, potentially attributable to undetected problems with randomization between the palliative care and usual care groups, how patient preferences may have changed over time, or closer adherence to patient preferences in the palliative care group. This result is in conflict with other research indicating longer survival in palliative care programs (Temel et al., 2010; see Chapter 2)
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From page 323... ...
. Other examples of state policies that can have a significant effect on end-of-life care include • rules affecting Medicaid eligibility and benefits; • rules governing state Medicaid managed care programs; • low Medicaid reimbursements that make it difficult for recipients to obtain physician care; • regulation and oversight of health facilities (for example, nursing homes, hospice, home health programs, and hospitals)
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From page 324... ...
and is high cost. In the current context, it is clear that recurrent hospitalizations for nursing home residents with advanced dementia are of low value.
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From page 325... ...
. In the context of value and the desire of policy makers, professionals, and the public to close the gap between the health system's potential performance and its current shortcomings, "accurate, reliable, and valid measurements are a prerequisite for achieving and assessing progress in areas such as improving the quality of health care delivered to patients, reporting on the status of the health care system, and developing payment policies and financial incentives that reward improvement" (IOM, 2013c, p.
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From page 326... ...
Improving the quality of care for Americans nearing the end of life, then, will require the development and implementation of new measures that, for example, • are more patient-oriented and include population groups with multiple conditions receiving care across multiple settings; • include demographic groups that are typically underserved; • measure quality for a broader spectrum of patients, including peo ple enrolled in Medicare Advantage, Medicaid managed care, and hospice and those residing in nursing homes; • take into account a broader array of patient and family needs, particularly those related to the social services discussed in this chapter; • measure the adequacy of support for informed choice by patients and families; • enable assessment of system performance with respect to advance care planning, shared decision making, and provision of spiritual support, all now defined variably across programs and research efforts; • track whether care provided accords with patients' values, goals, and informed preferences; and • capture the full array of costs of care near the end of life, includ ing out-of-pocket expenditures and those associated with informal caregiving. Prioritization among existing and new quality measures and indicators is likely to be an important future endeavor (Meltzer and Chung, 2014)
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From page 327... ...
• What are the experiences of patients with advanced serious ill nesses enrolled in Medicare Advantage and Medicaid managed care programs, and how do they compare with those of patients having fee-for-service coverage? • What meaningful-use criteria relating to end-of-life care need to be developed so that emerging electronic health records will collect adequate data on this care?
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From page 328... ...
For example, it would be useful to determine the relative contribution of financial incentives, communication gaps, and resource shortages to the care provided to nursing home residents with dementia and to the causes of multiple hospitalizations for preventable conditions. Other areas worthy of serious investigation that would directly benefit health care organizations, as suggested by the discussion in this chapter, would document the contribution of social services to quality care, and reimbursement approaches that support palliative care at home and in the hospital with full continuity between them.
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From page 329... ...
. Integration of Health Care and Social Services Evaluations of programs that integrate health care and long-term social services indicate that the additional supports may reduce hospitalizations and health care costs while improving enrollees' quality of life.
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From page 330... ...
From a system perspective, fragmented, uncoordinated care and unwanted and unnecessary acute care services -- which in the current system constitute "default care" -- are extremely costly. At the same time, many of the practical, day-to-day social services that would allow people near the end of life to live in safety and comfort at home, where most prefer to be -- such as caregiver training and support, meals and nutrition services, and family respite -- are not easily arranged or paid for.
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From page 331... ...
High-quality, comprehensive, person-centered, and family-oriented care will help reduce preventable crises that lead to repeated use of 911 calls, emergency department visits, and hospital admissions, and if implemented appropriately, should contribute to sta bilizing aggregate societal expenditures for medical and related social services and potentially lowering them over time. REFERENCES AARP Public Policy Institute.
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From page 332... ...
Health Affairs 31(12)
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From page 333... ...
2012. Best bets for reducing Medicare costs for dual eligible beneficiaries: Assessing the evidence.
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From page 334... ...
2013. Potentially avoidable hospital admissions among vulnerable Medicare beneficiaries.
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2012. Effects of nursing home stays on household portfolios.
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2013. Health insurance status and the care of nursing home residents with advanced dementia.
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2010. A new Medicare end-of-life benefit for nursing home residents.
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2004. Effect of an innovative Medicare managed care program on the quality of care for nursing home residents.
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Health Affairs 33(1)
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Health Affairs 30(3)
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Health Affairs 31(7)
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From page 342... ...
2012. Transition from home care to nursing home: Unmet needs in a home-and community-based program for older adults.
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2013. Providing more home-delivered meals is one way to keep older adults with low care needs out of nursing homes.
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Health Affairs 33(1)
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