Scaling Palliative Care to
Improve
p
Quality,
y Reduce Cost
Academy
cade y Health
ea t Annual
ua Research
esea c Meeting
eet g
June 2010
Diane E. Meier, MD
Director,
Center to Advance Palliative Care
Mount Sinai School of Medicine
www.capc.org
www.getpalliativecare.org
di
diane.meier@mssm.edu
i @
d
Objectives
1. Wh
1
Whatt is
i palliative
lli ti care?
?
2 How does it differ from hospice?
2.
3. Impact of palliative care on
quality and costs
4. Policy priorities for going to scale
CMS Definition of Palliative Care
Does Not Mention Prognosis
Palliative care means p
patient and family-centered
y
care that optimizes quality of life by anticipating,
preventing,
p
g, and treating
g suffering.
g Palliative care
throughout the continuum of illness involves
gp
physical,
y
intellectual, emotional,
addressing
social, and spiritual needs and to facilitate patient
y access to information, and choice.
autonomy,
73 FR 32204, June 5, 2008
Medicare Hospice Conditions of Participation – Final Rule
How Does Palliative Care Differ from
Hospice?
•N
Non-hospice
h
i palliative
lli ti care is
i
appropriate at any point in a serious
illness. It is provided at the same time
as life-prolonging
e p o o g g ttreatment.
eat e t
• Hospice palliative care provides
palliative care for those in the last
p
weeks-months of life under a Federal
Medicare Benefit
Benefit.
Conceptual Shift for Palliative Care
Life Prolonging Care
Life Prolonging
g g
Care
Medicare
Hospice
Benefit
H
Hospice
i C
Care
Palliative Care
Dx
Death
Old
New
The 10% of Medicare Beneficiaries Driving 2/3rds of Medicare
Spending are Those with >= 5 Chronic Conditions
No chronic
conditions
1%
1-2 chronic
conditions
10%
Palliative care
patient popn:
3 chronic
5+ chronic
conditions
conditions
10%
66%
4 chronic
conditions
13%
Source: G. Anderson and J. Horvath, Chronic Conditions: Making the Case for Ongoing Care. Baltimore, MD:
Partnership for Solutions, December 2002.
Key components of the strategy
P lli ti Care
Palliative
C
Teams
T
Improve
I
Care
C
in 3 Domains
1 Relieves physical and emotional distress
1.
2 IImproves patient-professional
2.
ti t
f
i
l communication
i ti
and decision-making
3. Coordinates and assures continuity of care
across settings
tti
Evidence of Impact
Palliative Care Improves Quality
•
Mortality follow back survey palliative care vs. usual care
•
N=524 family survivors
• Overall satisfaction markedly superior in palliative care group,
p<.001
• Palliative care superior for:
 emotional/spiritual support
o at o /co
u cat o
 information/communication
 care at time of death
 access to services in community
 well-being/dignity
 care + setting concordant with patient preference
 pain
 PTSD symptoms
Casarett et al
al. J Am Geriatr Soc 2008;56:593-99
2008;56:593 99.
Temel et al NEJM in press; Bakitas et al JAMA 2009; Jordhay et al Lancet 2000; Higginson et al, JPSM,
2003; Finlay et al, Ann Oncol 2002; Higginson et al, JPSM 2002.
Potential to Impact Costs
Palliative Care Reduces Costs
Costt avoidance
C
id
d
demonstrated
t t d across
settings, region, institutional, and delivery
model.
• How?
– Talking with patients, families, and treating
physicians
h i i
about
b t what
h t iis h
happening
i and
d th
the
achievable options leads to more conservative
choices.
choices
– Allows provision of higher quality care in
appropriate, often less costly, settings.
Cost Drivers Targeted
Palliative care:
• Counters financial disincentives preventing
communication about achievable goals
g
• Counters fragmentation, multi-specialty care
p
for,, and remediates,, lack of training
g
• Compensates
on needs of seriously ill, including symptoms,
communication, coordinated transitions
• Compensates
C
t for
f lack
l k off primary
i
(coordinated)
(
di t d)
care for the patient with advanced illness
• Addresses lack of communication
• Steps up to compensate for the fact that no-one is
in charge
How Hospital Palliative Care
Reduces Cost
•
•
•
IImproved
d resource use
g cost units
Reduced bottlenecks in high
Improved throughput and consistency
The Conceptual Model:
Dedicated team =
Focus + Time =
g / Clarity
y / Follow
Decision Making
through
Conversations about Goals
demonstrably improve quality
quality, reduce
costs
In a prospective multicenter study of 332 seriously
ill cancer patients, family
f
recall off occurrence off
a prognostic/goals conversation was associated
with:
– Better quality of dying and death
– Lower risk of complicated grief + bereavement
– Lower costs of care
– Less ‘aggressive’ care
Zhang et al. Arch Int Med 2009;169:480-8.
Wright et al. JAMA 2008;300:1665-73.
Palliative Care Shifts Care Out of
H
Hospital
it l to
t Home
H
Service Use Among Patients Who Died from CHF, COPD, or Cancer
Palliative Home Care versus Usual Home Care,, 1999–2000
Usual Medicare home care
Palliative homecare intervention
40
35.0
30
20
13 2
13.2
11.1
9.4
10
5.3
2.3
0.9
2.4
4.6
0.9
0
Home health
visits
Physician
office visits
Brumley, R.D. et al. 2007. J Am Geriatr Soc.
ER visits
Hospital days
SNF days
Cost Impact
p
of Hospital
p
Palliative Care
Estimated Benefits
Low
Medium
High
Patient cases ((% of discharges)
g )
2%
4%
6%
Patient cases (cases/year)
405
809
1214
Savings due to reductions in direct
costs/case
t /
$1,196,216
$2,392,432 $3,588,648
Intervention cost/case
($550)
($356)
($356)
Costs of intervention net of revenues
($222,571)
($288,128)
($432,192)
Increase in net income
$973,645
$2,104,304 $3,156,457
300 Bed Hospital Example Using CAPC-PCLC Study Results. Higher estimates for
the low scenario represent less efficiency due to scale and also variations in revenue
Source: Siu et al. Health Affairs, 2009
Estimating National Cost Impact
Assumptions
A
ti
1. 2% of all hospitalizations end in death.
2 Palliative
2.
Palliati e care programs sho
should
ld be seeing most patients who
ho
die in hospital.
3 At scale,
3.
scale palliative care programs should be seeing >5-8%
5 8% of
all hospital discharges (patients who die + very sick patients
discharged alive).
4. Estimates limited to hospital direct cost avoidance; reduction
in downstream costs, readmissions, and improved system
capacity/throughput not included.
included
5. Average direct cost avoided/palliative care patient = $2,659
(assumes 70% live discharges, 30% deaths).
6. Assume 30,181,406 hospital discharges/yr (all payers).
7. If penetration = 1.5% of discharges x 30,181,406 annual
di h
discharges
= 452
452,721
721 patients
ti t seen x $2
$2,659
659 saved
d per case
= $1.2 billion costs avoided now annually.
Goldsmith et al. JPM 2008; Morrison et al. Arch Intern Med 2008; Siu et al. Health Affairs 2009; AHA Annual Survey 2008
Estimated National Cost Impact
Estimated savings now based on palliative care services at 50% of U.S.
hospitals (>50 beds):
 Penetration of services to approximately 1.5% of all hospitalized
patients
ti t
-Direct cost savings = $1.2 b/yr
Estimated future savings based on palliative care services at >90% U.S.
h
hospitals:
it l
 Penetration of services to approximately 5% of all hospitalized patients
-Direct cost savings = $4 b/yr
Penetration of services to approximately
7 5% of all hospitalized patients
7.5%
-Direct cost savings = $6 b/yr
or $60 billion
billi over 10 yrs
Estimates conservative, based on 2007 levels of penetration; relatively
high % of live hospital discharges (savings much greater for hospital
deaths), payer mix 40% Medicare.
Going to Scale
1. Palliative care program infrastructure already in place in
>80% of large U.S. hospitals where most advanced illness
cared for
2. ABMS approved subspecialty (2007), ABIM board
certification exam (2008)
(2008), ACGME accreditation for
palliative medicine fellowships
3. Technical assistance and tools available and widely utilized
(www.capc.org)
4. Improve
p
workforce p
pipeline
p
through
g loan forgiveness,
g
, career
development awards, exemption to GME cap for palliative
care fellowships
5. NQF Quality Guidelines for Palliative Care in place;
upcoming NQF call for palliative care measures
6. Joint Commission Palliative Care Certificate Program
developed, not yet released
Increased Number of Programs
Hospital Palliative Care Programs in the United States, AHA survey data
1700
1500
1300
1100
900
700
500
2000 2001 2002 2003 2004 2005 2006 2007 2008
Caveats to Scaleability
• Variability in access to
palliative care
• Workforce pipeline
Where You Live Matters
Variable access to palliative care
• 33% of all hospitals
• 50% of hospitals
p
with > 50 beds
• 80% of hospitals > 250 beds
– (+)predictors: >50 beds, teaching, cancer program,
higher educational level in the community
– (-)predictors:
( ) di t
<50
50 b
beds,
d south,
th public
bli or sole
l
community provider, for profit hospitals
Goldsmith B et al. J Palliat Med 2008
Workforce is the Primary
y Barrier to
Access
• Oncologists: 1 for every 145 patients
with new cancer diagnosis
• Cardiologists: 1 for every 71 heart
attack
tt k victims
i ti
• Palliative Medicine: 1 for every
y 31,000
,
people with serious advanced illness
• In 23 states + DC no access to post
graduate training in palliative medicine
Achievable Results: Near Term
1. Increase % of U.S. hospitals reporting a
palliative care program from 50% to 75%
2. Improve program penetration from 1% of
g to 2-3% of discharges
g
discharges
3. Engage private sector philanthropy to
invest in workforce pipeline + new
program launch
4 Promote standardization + adherence to
4.
quality guidelines
Achievable Results: Long Term
1. Regulatory requirement: A palliative care program
meeting
i quality
li standards
d d iis a condition
di i off
accreditation.
2 Evidence
2.
E idence base
base: AHRQ and NIH allocate 2% of
funding to research on symptom relief, communication,
and CER on care delivery in last 3 years of life
life.
3. Education: Palliative medicine is a required core
competency
p
y for medicine and nursing;
g; schools and
residencies are tracked and ranked on performance.
4. Health professions career choices are linked to
society’s needs: Medicare support of GME and loan
forgiveness biased towards primary care, geriatrics
and
d palliative
lli ti medicine
di i (M
(MedPac
dP JJune 2010 report).
t)
Policies to Improve Access
1. Financial incentives to doctors +
nurses to
t train
t i in
i and
d provide
id palliative
lli ti
care
2. Financial incentives to hospitals/NHs
that provide palliative care (and penalties
for those that don’t)
3. Hospital/NH accreditation requirements
Policies to Improve Quality
1. Standardization, metrics: Palliative
care p
programs
g
meeting
gq
quality
y standards
are a condition of accreditation.
2 Workforce is trained: Faculty to teach
2.
workforce exist; exemption to GME cap
f
funds
palliative medicine fellowships.
f
3. Evidence exists: NIH, AHRQ + VA fund
research in palliative medicine.
Life is pleasant. Death is
peaceful It's the transition
peaceful.
that'ss troublesome.
that
troublesome
– Isaac Asimov
US science fiction novelist & scholar (1920 - 1992)
Art Buchwald, Whose Humor Poked
the Powerful, Dies at 81
RICHARD SEVERO
P blished January
Published:
Jan ar 19,
19 2007,
2007 New
Ne York Times
As he continued to write his column, he found
material in his own survival. “So far things are
going
g
g my
y way,”
y, he wrote in March. “I am known
in the hospice as The Man Who Wouldn’t Die.
How long they allow me to stay here is another
problem. I don’t know where I’d go now, or if
people would still want to see me if I weren’t in
a hospice. But in case you’re wondering, I’m
having a swell time — the best time of my life.”