Achieving Value Through Palliative Care
Giving effective palliative care not only improves patient experiences and reduces the strain on the emergency department, but it can also benefit the healthcare system. By aiming to provide effective methods for managing pain, breathlessness and other symptoms that lead to ED visits, as well as providing useful, tailored communication to patients and their relatives, the health care system can achieve value through palliative care. Palliative care increases the length of survival by almost three months; cuts the number of hospital admissions in half; and lowers the costs of inpatient care for the last six months of life by around $6,000 when used in oncology cases. Barriers to achieving value through palliative care include the conflation of palliative care and hospice care, the lack of sufficient clinical training for communication and symptom management, and an inadequate understanding of how palliative care can provide value. The Medicare Access and CHIP Reauthorization Act (MACRA) aims to create a two-track merit-based incentive payment system, which will encourage medical staff to provide palliative care specialists to manage patient symptoms and stress.

MOVING TO VALUE IN HEALTHCARE MEANS

improving the quality of care delivered and the outcomes achieved while reducing unnecessary spending. Most healthcare organizations are pursuing value and the benefits that accrue under value-based payment, but too few are turning to palliative care to help achieve these goals.

Palliative care—which focuses on relieving the pain, symptoms, and stresses of a serious illness—changes healthcare delivery for both patients and their caregivers. Multiple studies and meta-analyses have shown that not only does palliative care improve patient experience and satisfaction,1-3 but that it also reduces emergency department (ED) visits, hospitalizations, and days spent in intensive care,4,5 thus reducing total spending.6,7 It does this through:

Safe and effective techniques for managing pain, shortness of breath, and other symptoms which would otherwise lead to ED and inpatient hospital use

Communication expertise needed for long, often difficult discussions with patients and families about prognosis, goals of care, and the patient’s wishes and values.

These skills and expertise benefit both the patients and the healthcare system. Standardized access to palliative care for hospitalized patients with advanced cancer has been shown to significantly reduce receipt of chemotherapy after discharge, as well as oncology service mortality and 30-day readmission rates.8 However, the most effective results are produced when palliative care is introduced early in the disease trajectory and is provided concurrent with treatment. For example, randomized controlled trials involving patients with cancer found that early and concurrent palliative care: • Results in a dramatic reduction in major depression (16% vs 38%)9

Increases survival by an average of nearly 3 months 9

Results in fewer hospital admissions (33% vs 66%), fewer ED visits (34% vs 54%), reduced intensive care unit (ICU) use (5% vs 20%), and lower direct costs of inpatient care in the last 6 months of life ($19,067 vs $25,754).10

A recent analysis by DataGen found that oncology episodes for cancer of the esophagus, liver, pancreas, lung, testes, and brain have the greatest likelihood of hospital admission and ED visits.11 Not surprisingly, this list correlates with cancer types that report the greatest prevalence of pain12— patients and families turn to emergency services when symptoms are poorly managed. Yet expert palliative care mitigates the need for crisis intervention, thus simultaneously improving patient quality of life and cost-effectiveness.

In recognition of these results, the American Society of Clinical Oncology (ASCO) issued a provisional clinical opinion in 2012, stating that “combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”13 Despite the weight of the evidence and the ASCO opinion, barriers continue to exist to expanding the integration of palliative care into cancer care. These include:

The persistent confusion between palliative care and hospice (particularly on the part of physicians)

Insufficient clinician training in skilled communication and expert symptom management

A limited understanding of how palliative care can contribute to the value equation

In response, the Center to Advance Palliative Care (CAPC) is working to highlight the merits of concurrent palliative care under value-based payments (VBPs), and to educate payers and providerson needed processes and skills. Specific areas of focus include the Medicare Merit-based Incentive Payment System (MIPS), Medicare Advantage (MA) plans, Medicare Accountable Care Organizations (ACOs), and the new Medicare Oncology Care Model (OCM).

Palliative Care and MACRA’s Merit-Based Incentive Payment System

The Medicare Access and CHIP Reauthorization Act (MACRA) expedites Medicare’s transition to VBP by subjecting eligible clinicians to bonuses and penalties based on their quality performance relative to their peers. MACRA creates 2 payment tracks, and the vast majority of clinicians will participate in the MIPS in the first year. Under MIPS, CMS will calculate payment adjustments based on performance in 4 categories:

Quality Cost Advancing care information Improvement activities

The eventual weighting of the Quality and Cost categories in the composite score used to adjust provider reimbursement creates a compelling rationale to involve palliative care specialists in the care of seriously ill patients:

Quality

Palliative care specialists manage symptoms and stress while patients undergo complex treatments, and they also support informed decisions as chronic illnesses progress. This improves the patients’ experience of care as demonstrated in studies showing significant improvement in satisfaction scores.14 Therefore, the inclusion of palliative care should improve results on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS surveys, which is expected to be one of the more popular “cross-cutting measures” under the quality category. Additionally, the provision of palliative care should help improve performance on a number of other proposed MIPS measures including advance care planning, pain assessment and follow-up, and medication reconciliation.

Cost

The significant impact of palliative care in reducing ED, hospital, and ICU utilization in seriously ill patients4,10 will benefit treating clinicians in their resource use calculations. Efficient resource use is also a key factor determining provider payments in all of the advanced alternate payment models.

Palliative Care and Medicare Advantage

Palliative care can support MA plans in decreasing cost and increasing revenue. On the cost side, as noted, palliative care reduces utilization among the high-need, high-cost members of a population. Several leading MA plans have expanded access to palliative care for their seriously ill beneficiaries, generating significant savings. For example, Aetna’s Compassionate Care Program, provided to the sickest 1% of the plan’s MA members, achieved the following15:

Reduced ICU days by 86%

Decreased total acute care days by 82%

Reduced ED use by 78%

Maintained member satisfaction above 90%

Savings of roughly $12,000 per participating member.

On the revenue side, palliative care positively impacts the measures on which MA plans are evaluated, appearing as public ly reported data and overall Star Ratings. These Star Ratings are calculated by using data from 3 sources:

A subset of the Healthcare Effectiveness Data and Information Set measures (HEDIS measures) Results of the CAHPS surveys Results of Health Outcomes surveys

Measures that are likely to be improved by palliative care include:

All-cause readmissions

ED utilization

Hospitalization for potentially preventable complications

Medication reconciliation post discharge

Utilization of the Patient Health Questionnaire-9 to monitor depression symptoms

Relative resource use (specific diagnoses)

The level of pain that interferes with activity rating by members

Member rating on how well doctor communicates1

Plans that perform better on their measures receive more stars, leading to higher premium payments and a greater ability to attract and retain members. Consumers consider the Medicare Star Ratings during the open enrollment period for MA16 and 5-Star plans have the advantage of being able to enroll members switching from other MA plans at any time during the year.17

Palliative Care and Medicare Shared Savings Programs (MSSP)

Similar to MA plans, Medicare ACOs are evaluated on their performance on a set of quality measures and have financial incentives to manage resource utilization. The MSSP is the most common type of ACO and, here, too, palliative care can impact a number of quality measures, including:

All-cause unplanned admissions (for specific diagnoses)

Ambulatory-sensitive admissions (for specific diagnoses)

Skilled nursing facility 30-day all-cause readmissions

Depression remission at 12 months

Provider communications rating by patients

Shared decision making rating by patients

Palliative care can be particularly valuable in reducing readmissions. National data from CMS on hospital readmissions shows that since 2010, 43 states have reduced readmissions by more than 5%, and, in 2015, the national readmission rate fell below 18%.18 However, 2015 data from the National Palliative Care Registry show that the average readmission rate for patients discharged alive from participating palliative care consultation services was only 13.8%.19 Perhaps more important than performance on specific quality measures is the role that palliative care can play in delivery redesign. Early analysis from a CAPC survey of MSSPs offering palliative care yielded 2 strategies that could have improved ACO results:

Home-Based Palliative Care for Highest-Risk Patients. Some of the more successful MSSPs stratify their population and connect the highest-risk patients with home-based palliative care services. These services involve an interdisciplinary team providing continuous comprehensive assessment, pain and symptom management, and expert conversations in the patients’ homes, adjunctive to the care delivered by their treating providers. Published findings from home-based programs within ACOs show between 34% and 56% reduction in hospital utilization, resulting in average savings of $12,000 per case.20,21

Integration of Palliative Care Into Oncology Care. Several MSSPs have taken steps to integrate palliative care into oncology practices. At least 2 have conducted extensive training on advance care planning to ensure that patients’ wishes are articulated and documented, and then ensure that those documents are easily accessible in the electronic health record. Other ACOs have embedded palliative care specialists into their practices to help meet the needs of the most complex patients. An ACO contract with Moffitt Cancer Center requires the participating oncology practices to screen all patients for palliative care needs and include a palliative care specialist in the management of patients with documented need.

Implications for Palliative Care and the Oncology Care Model (OCM)

Similar to the models and programs described above, the integration of palliative care can improve performance for practices participating in the OCM, as CMS will be evaluating them on the following:

Pain assessment and management

Patient experience of care

ED visits and hospital admissions

Proportion of Medicare beneficiaries receiving chemotherapy in the last 14 days of life

Percentage of patients admitted to hospice for less than 3 days in the last 30 days of life.

Beyond quality measures, OCM practices should extract lessons learned on palliative care integration from those successfully participating in MSSP and other ACO contracts. These include training oncologists and other clinicians in core palliative care skills, or co-locating palliative care experts in the oncology practices. The latter, in particular, can facilitate collaboration, allowing the oncology team to treat the disease while the palliative care team provides an added layer of support during and after the episode. OCM practices can pay for these services by allocating a portion of the monthly enhanced oncology services payment and performance-based payment, thus ensuring that palliative care services are available to all patients according to their level of need.

Palliative Care and Value-Based Payment: Moving Forward

When done properly, VBP can improve quality of care for patients by creating greater flexibility in service delivery while holding clinicians accountable for resource utilization. This commentary provides examples from 4 significant value-based programs demonstrating how palliative care can simultaneously improve performance on quality measures while reducing costs. These examples suggest that oncologists can benefit under VBP by integrating core principles of palliative care into their standard practice and/or establishing formal relationships with palliative care specialists.Allison Silvers, MBA, is vice president, Payment and Policy, Center to Advance Palliative Care. Stacie Sinclair, MPP, is policy manager, Center to Advance Palliative Care. Diane E. Meier, MD, FACP, is director, Center to Advance Palliative Care.

ADDRESS FOR CORRESPONDENCE

Allison Silvers, MBA

Vice President

Payment and Policy

Center to Advance Palliative Care

55 West 125th Street, Suite 1302

New York, NY 10027

E-mail: Allison.Silvers@mssm.edu

FUNDING INFORMATION

Funding for the Center to Advance Palliative Care’s payment analyses is supported in part by the following:

The Gordon and Betty Moore Foundation

The Allen H. and Selma W. Berkman Charitable Trust REFERENCES

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