Financing and Payment Strategies to Support High-Quality Care for People with Serious Illness Proceedings of a Workshop (2018) / Chapter Skim
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Proceedings of a Workshop
Proceedings of a Workshop
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In an effort to address the complex needs of people with serious illness, public and private health care payers are testing innovative financing strategies and alternative payment models. These innovative approaches signal a gradual transition from the traditional fee-for-service system that pays providers based on the quantity of services to a system based on the value of care provided and a heightened focus on improved quality of care at lower cost.
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.2 A key challenge, however, is developing financing and payment strategies to support those models nationwide. Compounding that challenge is the fact that many comprehensive approaches to serious illness care include services that often fall outside of those reimbursed by public and private plans, such as supportive services in the home or the community.
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. Ganz added that it was a natural progression for this workshop to discuss finance and payment strategies to support high-quality care for people with serious illness.
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The speakers, panelists, and workshop participants presented a broad range of views and ideas. Box 1 provides a summary of suggestions BOX 1 Suggestions Made by Individual Workshop Participants Related to Finance and Payment Strategies for High-Quality Care for People with Serious Illness Developing Innovative Financing and Policy Approaches to Support Comprehensive and Integrated Serious Illness Care • onsider financing plans that incorporate more social ser C vices and allow for a more integrated approach that encom passes a patient's physical, psychological, supportive, and spiritual needs.
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• evelop specific payment models focused on serious illness D care. (Conway)
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(Ling) • evelop quality measures that are appropriate for assessing D care of older seriously ill individuals that do not add new report ing burdens on clinicians and that are appropriate for holding providers accountable for serious illness care.
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• sk CMS to consider guidance to allow Medicare hospice pro A viders to offer 24-hour home health aide services to patients at home, rather than requiring them to be transferred to a skilled nursing facility or acute care hospital.
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The workshop speakers' presentations have been archived online (as PDF and audio files) .4 PATIENT–CAREGIVER–CLINICIAN PERSPECTIVE ON MANAGING AND PAYING FOR SERIOUS ILLNESS CARE Ralph Bencivenga, a 66-year-old two-time cancer survivor, proud father of three adult children, and caregiver for Patricia, his wife of 45 years who passed away in June 2017, opened the first session by describing the health challenges his wife had faced.
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At that point, Scarborough arranged for home hospice, but Patricia died that same day. When Bomba asked Ralph to describe his experience caring for his wife, he started by describing her as a very shy yet proud and independent woman.
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Further compounding the situation, the Bencivengas did not have coverage for home health care. "Without that, there was no ability to get somebody into the home to help with things without having to have the family privately hire someone, which is expensive and just not possible for many families," said Scarborough.
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Bomba asked Ralph if Patricia's physicians had let him know that her appetite might not be normal given how ill she was, and Ralph replied that Patricia's physicians never talked to him about what to expect as her health continued to deteriorate. "I have to tell you, I thought I would have her for another couple of years," said Ralph.
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Given that the large share of individuals with serious illness are more than 65 years old, Medicare plays a substantial role in shaping serious illness care in the United States through its coverage of a range of inpatient, outpatient, post-acute home health services, skilled nurse facility care, and so on, said Stevenson. Medicare's hospice benefit, the primary mechanism
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Despite this increased role, approximately two-thirds of Medicare beneficiaries are hospitalized in the last month of their lives, often spending time in the intensive care unit. Stevenson added that many of the same challenges affecting end-of-life care, such as siloed financing and fragmented service delivery, also affect serious illness care (Teno et al., 2013)
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. Nursing home care accounts for a large portion of those outof-pocket expenses, even though most people in nursing homes are there because they need assistance with daily life activities and not necessarily traditional medical care, Stevenson explained.
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Stevenson noted that efforts are under way to experiment with innovative, value-based financing and delivery strategies that aim to rationalize and improve care for people with serious illness. These include primary care and care management models, bundled payment demonstrations, accountable
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." This results in substantial out-of-pocket costs, especially for those living with serious illness over an extended period. Furthermore, Stevenson asserts that the scrutiny placed on ensuring that hospice and home health benefits do not become 6 ACOs are groups of doctors, hospitals, and other health care providers who come together voluntarily to provide coordinated care to their Medicare patients.
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Although this "carve out" ensures access to an individual's hospice provider of choice, it reduces the incentives for Medicare Advantage plans to bolster their own expertise and creates incentives for plans to cede responsibility for end-of-life care. The fourth financing challenge highlighted by Stevenson arises from the fact that as the health care system increasingly focuses on value, there are few established quality measures to hold providers accountable for serious illness care.
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Stevenson concluded his remarks by noting that in the context of the heightened focus on value and efforts to develop incentives for a more comprehensive approach to providing care for people with serious illness, "it is important not only to have financial incentives that push in that direction, but also accountability standards to make sure providers are delivering" high-quality care. Taking Care of a Seriously Ill Patient in the Context of the Current Health Care Financing System Diane Meier, director of the Center to Advance Palliative Care, agreed with Scarborough's earlier comment on how, when faced with the inability to help patients get the care they need because of gaps in the current system, a clinician can be led to feel like a failure.
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Jones knows about the problems, his office arranges for a home health agency to conduct a safety evaluation, install grab bars and an elevated toilet, provide a hospital bed and a chair that assist in standing, and arranges for Meals on Wheels. With Bernard and Martha's permission, the house calls team contacts their church and arranges for a friendly visitor program, something most faith communities provide, and for someone to bring them to church and back home on Sundays.
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There were no 911 calls, emergency department visits, or hospitalizations, and Martha passed away peacefully at home after receiving 5 months of hospice care. What made it possible to provide more appropriate and better care for Martha and Bernard was a value-based payment model enabled by a riskbearing entity, which in this case was a Medicare ACO, explained Meier.
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She said she suspects strongly that many of these programs would cut health care costs for caregivers as well as the beneficiary. Amy Berman from The John A
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Kelly Vontran, who works at CMS on payment policy for home health and hospice, said that getting data from providers on the impact of social determinants of health on how and if patients access health care can be challenging, and it is difficult to determine whether the information is accurate and not "just an artifact of a payment incentive." She asked about effective ways to get critical information about social determinants of health, for example, so that high-quality comprehensive care can be provided to patients with serious illness. Judith Peres from the Social Work Hospice and Palliative Care Network asked the panelists for their thoughts on how it might be possible to coordinate services provided by the health system with the types of 12 The Health and Retirement Survey is a longitudinal project sponsored by the National Institute on Aging and the Social Security Administration and was conducted at the University of Michigan's Institute for Social Research.
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She said that CMS has approved one social ACO and would like to see more work in this area.14 EXPLORING FINANCING AND PAYMENT INNOVATIONS: CHALLENGES, IMPACTS, AND LESSONS FROM FEE-FOR SERVICE AND VALUE-BASED PAYMENT ARRANGEMENTS In his introduction to the workshop's second session, Harold Paz, executive vice president and chief medical officer at Aetna, explained that quality care for people with serious illness is a high-priority area for Aetna and is the focus of its Compassionate Care program. This program identifies Aetna members with serious illness, coordinates their care, and provides 13 The Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act (CHRONIC)
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"As we move toward patient-centered personalized health, care management -- along with interoperability of patient-centered data and information and value-based contracting -- offers the opportunity to create a new way of delivering services for individuals at the end of life, and frankly, I think, across the entire life span," said Paz. Financing Serious Illness Care at Cambia Health Solutions For Cambia Health Solutions, creating a personalized health care solution for every person under their care is a cause, not a mission, said Richard Popiel, Cambia's executive vice president and chief medical officer.
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In addition to providing caregiver support, Cambia's health benefit plan for serious illness care now includes advance care planning -- with no limits on the number of discussions between the patient and the provider. Cambia also funds home health medical and psychosocial services and, recognizing that "providers who have been caring for their patients for a long time also grieve," Cambia provides support for health care providers as well.
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CompassionNet: Community-Based Pediatric Palliative Care Jeanne Chirico, vice president for community services for Lifetime Care and director of the Excellus BlueCross BlueShield CompassionNet program, explained that CompassionNet is a community-based pediatric palliative care program covering some 300 square miles in upstate New York, including low-income rural areas as well as urban centers such as Buffalo, Rochester, and Syracuse. As a wrap-around program, it supports the entire family as a unit and provides for all of their needs -- psychosocial, financial, medical, or environmental.
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Citing data from the National Hospice and Palliative Care Organization, Chirico pointed out that fewer than 20 percent of children with serious illness die at home (CMS, 2017c) (see Figure 2)
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Anthem's Enhanced Personal Health Care When the leadership at Anthem studied how its members with serious illness were receiving care, they found fragmented care between primary care providers and specialists characterized by limited advance care planning, inadequate symptom control, aggressive care near the end of life (including in-patient hospitalizations and chemotherapy) , and limited hospice usage.
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TABLE 1 Cost and Location of Death at Five Moments in the Last Year of Life Median Total Costs Year 6 Months 3 Months 1 Month Last Week Children/Adolescents Hospital (n = 84)
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This will include changing the prognosis requirement to 12 months and allow for disease-modifying therapy to continue along with hospice care. Debono said that Anthem anticipates there will be quality improvements on measures such as advance care planning, less aggressive care near the end of life, lower emergency department utilization, and fewer hospitalizations.16 In considering ways to optimize palliative care for its members, Debono explained that Anthem examined the barriers to palliative care from a number of perspectives.
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Primary palliative care also requires resources to develop and staff a primary care team that many practices may not have. Nonetheless, primary palliative care would be a good fit with alternative payment models for care coordination if a practice achieves quality metrics.
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17 provide the opportunity to develop and test alternative payment models. The challenge here, said Ling, is to think about how those models will improve outcomes for beneficiaries with serious illness.
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,21 is that shared savings is not a sufficient incentive by itself to improve patient-centered care and that quality of care metrics also must be included 18 For more information, see https://innovation.cms.gov/initiatives/independence-at-home (accessed January 22, 2018)
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What would be helpful going forward, said Ling, is to have the ability to define what qualifies as having a serious illness better, perhaps in terms of function and functional limitations, so that practices and systems could better target those indi viduals who need more than routine care. BSWH's Journey Toward Value in Serious Illness Care Robert Fine, clinical director in the Baylor Scott & White Health's (BSWH's)
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He explained that by entering each hospital's data into the Center to Advance Palliative Care's Impact Calculator,22 the direct cost savings can be identified and used to remind hospital administrators that cost savings are the same as generating income from procedures. BSWH's palliative care journey has taught them that hospice is the gold standard for end-of-life care, and is essential, but not sufficient by itself to achieve all of the needed improvements in serious illness care.
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He emphasized that value-based payment by itself will not address all of the challenges of expanding palliative care. Discussion After the second session's presentations on financing and payment innovations, Paz opened the discussion by asking the panel what they would describe as the key outcome measures needed to define the quality of the serious illness programs and align that care with value-based reimbursement.
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In working with the Medicare Care Choices Model, Lee noted that the program's largest challenge was that payment was not sufficient to provide hospice and all curative treatments comprehensively. Allison Silvers from the Center to Advance Palliative Care explained that her organization is working to ensure sufficient compensation for the time providers need to attend to the seriously ill.
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Ten years ago, Wyden explained, passage of the CHRONIC Care Act would have been on the front page of every newspaper in the United States because it is a truly transformative policy. The reason why this bill is so important, Wyden noted, is that both parties -- and he emphasized both parties -- had not fully grasped what Medicare has become, which is insurance to cover chronic illness.
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For him, improving end-of-life care is not about saving money, but about caring for patients, and improving care for patients with serious illness, and is about spending more time with the patient and less time entering data into an electronic health record (EHR)
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EXPLORING FINANCING AND PAYMENT INNOVATIONS: CHALLENGES, IMPACTS, AND LESSONS FROM GLOBAL BUDGETING ARRANGEMENTS In her introduction to the workshop's third session, Cheryl Phillips, president and chief executive officer of SNP Alliance, pointed out that new financing and payment strategies are needed because the volumebased, fee-for-service model has not worked well for individuals with complex care needs, including those with serious illness. She described SNPs as a type of Medicare and Medicaid managed care targeting highrisk, high-cost, vulnerable populations.
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scores by an average of 13 percent across 51 HEDIS measures and save millions of dollars in the process, said Wang. One successful component of Complete Care is its online personal action plan, an email-based outreach tool that links to a personalized plan for members and targets a member's pre-office encounter to prepare them for their upcoming visit.
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According to Wang, a pilot project contacted 3,000 Kaiser members who were predicted to be in the top 1 percent of high users and assessed and addressed various social needs. Arakelian said a preliminary analysis found a potential impact on cost and usage from addressing social needs.26 The final program Wang discussed was Kaiser's Life Care Planning System, which she called a systematic approach to advance care planning based on respecting choices.
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Global Payment Arrangements for Serious Illness Care in Massachusetts Massachusetts has seen high rates of adoption of global payment arrangements across payers and programs, said Anna Gosline, senior director of health policy and strategic initiatives at Blue Cross Blue Shield of Massachusetts (BCBSMA) (see Figure 3)
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SOURCES: As presented by Anna Gosline and Vicki Jackson, November 29, 2017; Center for Health Information and Analysis, 2017. FIGURE 4 Share of members whose care was paid for under a global payment arrangement.
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To answer that question, BCBSMA worked with Ariadne Labs to implement a primary palliative care program in two different systems in the state. This effort, said Gosline, works hand in hand with her organization's policy and community efforts, which established a statewide coalition of approximately 85 organizations working together to improve care for those with serious illness.
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The program grew out of the realization that many individuals who could benefit from palliative care, such as Patricia Bencivenga, are too ill to engage in a longitudinal medical relationship with their provider and are not eligible for hospice. The pilot is embedded in the organization's ACO and, like all seriously ill patients in the Partners system, individuals in the pilot are assigned a nurse care manager who identifies patients with unmet palliative needs that would be better served by a home-based program.
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Complex Care Management at OptumHealth One area of OptumHealth's strategy to establish sustainable financing for serious illness care is to focus on transitions as a means of reducing readmissions, explained Gregory James, senior medical director at OptumCare, a division of OptumHealth. Readmissions cost Medicare more than $17 billion annually in avoidable costs, said James.
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In addition to saving money, this program improves quality measures by closing gaps in care and improving patient and family satisfaction. This is largely due to the increased attention that patients get from their nurse practitioner or physician assistant, and the time they spend on advance care planning.
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According to James, more than half of SNF-based Medicare beneficiaries had one or more emergency department visits, compared with 28 percent for non-SNF-based beneficiaries, and 33 percent had at least one hospitalization, compared with 19 percent for non-SNF-based beneficiaries. Currently, only about 3 percent of these SNF residents are enrolled in an institutional special needs Medicare Advantage program.30 A broken clinical model, explained James, is what drives the high costs associated with these individuals.
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Phillips said that while HEDIS measures are viewed as important for commercial plans and younger populations, they have virtually no meaning for those with serious illness, which goes back to the issue that Gosline raised earlier about the need for quality measures for these types of programs. Gosline pointed out that having measures of patient and family experience would be a good start.
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To NCQA's credit, when officials from OptumCare explained that risks of doing a colonoscopy on a 75-year-old nursing home resident outweigh the benefits, NCQA removed the 66- to 75-year-old group in long-term care nursing facilities from that quality measure. Jackson pointed out that as her organization has been rolling out its serious illness conversation program, it has relieved its physicians, and particularly its primary care providers, of needing to check the box on certain measures.
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work for them." EXPLORING POTENTIAL REGULATORY AND POLICY CHANGES TO ENSURE HIGH-QUALITY CARE FOR PEOPLE OF ALL AGES WITH SERIOUS ILLNESS When his father died of cancer in Indiana about a decade ago, Patrick Conway, president and chief executive officer of BCBSNC,34 was helping to manage his care from hundreds of miles away, even with incredibly wellmeaning providers and care teams in place. At one point, he explained, he 32 The questionnaire was launched in January 2016.
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He acknowledged that training and education of staff will be critical to the organization's success because many clinicians and care teams are at different stages of understanding the importance of serious illness care and how best to provide that care. He applauded the decision of CMS to pay for advance care planning and pointed out that while there is room for improving how the agency pays for serious illness care, the idea of delivering hospice and palliative care services concurrent with so-called curative care is a step in the right direction.
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That story, explained Conway, underscores the importance of ensuring that care teams have a level of training that enables them to have those conversations and provide the kind of care everyone wants for their families. Policy Opportunities Edo Banach, president and chief executive officer of the National Hospice and Palliative Care Organization, began his remarks with the observation that "despite all our innovations and all the great work at CMS,35 most people are still getting care from either a 1965 or a 1983 version of Medicare, where the question is whether the care you are getting is medically necessary, or if you are talking about home health, the question is whether there is a skilled need or whether you are homebound, or if you are talking about hospice, the question is whether you have less than 6 months to live." That is the reality, he said, regardless of the discussion about value and person-centered care, and the fact is that most providers still fight those battles every day as they try to deliver the right care for their patients.
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Department of Agriculture and helped raise five children, decided his life mission was to care for his wife. Fortunately, his grandmother was one of the rare individuals who had purchased long-term care insurance when she had been an elementary school teacher, so they were able to have a home health aide come twice per day to help with some of his wife's activities of daily living.
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What he found particularly interesting was that many of these advocates had already thought about how to coordinate medical care and services and, as a result, were able to provide an understanding about the disconnect between medical services and the long-term services and supports that those with serious illness need to life full lives. As a result, according to Harris, the demonstration project created a staff position specifically to help ensure that the spectrum of long-term services and supports were not disconnected from medical services and to make sure people -- including those in the health care system -- knew these services and supports were available.
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One group believes that by emphasizing universal coverage and ensuring the quality of care is as high as possible, the cost issue will solve itself eventually. The other group looks at the same issue and believes that cost is paramount and must be controlled by any means necessary, which will eventually lead to universal coverage that may include the highest-quality care possible.
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Panel Discussion Following their brief remarks, Banach, Conway, Harris, and Whitlock had a lively discussion about policy changes that could incentivize higher quality care for people with serious illness. Banach said he would like to see policies that remove some of the barriers to getting palliative and hospice care, such as eliminating the 6-month limit on hospice and the need to demonstrate on a case-by-case basis that a given service is needed for a Medicare beneficiary.
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Banach pointed out that the silos involved in providing fee-for-service care -- hospice in one silo, home health in another, and so on -- often lead to significantly greater Medicare spending. CMS is aware of this problem, but is constrained by the way Congress wrote the Medicare law, added Banach.
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He also said Whitlock's example raised what he considers a big issue, which is that the system does not think of a husband and wife as a unit when it comes to Medicare, providing services, and keeping them both healthy and at home. That idea, he said, ties into the notion of providing caregiver support as part of the care plan for the person with serious illness.
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Conway added that some states, including North Carolina, are using their waiver authorities to begin experiments at blending financing streams for medical and social services and perhaps demonstrate what is possible in that realm. Allison Silvers from the Center to Advance Palliative Care pointed out one problem with that type of approach: there will be budgetary winners and losers, assuming the total pot of money will not grow.
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Huskamp noted the range of issues from workforce to quality measurement challenges faced by those who work to develop and implement financing approaches to support improved care for people facing serious illness. In closing, Huskamp reminded participants of Senator Wyden's observation that they may currently be at an inflection point.
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https://www.kff.org/ medicare/issue-brief/medicare-spending-at-the-end-of-life (accessed January 11, 2018)
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2017a. Integrating the patient and caregiver voice into serious illness care: Proceedings of a workshop.
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2017. Providing early palliative care interventions for patients with serious illness.
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