Adult Palliative Care in a Value Based Payment Model

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Presentation transcript:

Adult Palliative Care in a Value Based Payment Model Dana Lustbader MD, FAAHPM ProHEALTH Care, New York

Frank Frank is an 87 year old man with dementia, heart failure and kidney disease Uses a walker to get around Frequent ER visits for weakness Avoidable hospitalizations His 86 year old wife and adult son are overwhelmed Prognosis is uncertain Not eligible for hospice

Frank lives with his 86 year old wife in a two story walk up and is a retired teacher. Usual Care Home-based Palliative Care Doctor’s voicemail says “if this is any emergency, go to the nearest ER” Calls to 911 Hospitalizations Family distress Progressive functional decline, confusion with each admission 24/7 phone coverage, team based care, home visits Telemedicine visits with son Caregiver support Dinner - Meals on Wheels Friendly visitor program No ER visits, hospital admissions in 9 months

Health Care Gap for Adults with Advanced Illness Stage 1 Stage 2 Stage 3 Care Gap Terminal Mourning Chronic Disease 2  20 Years Palliative Care 0-24 months Hospice End of Life Grief Support 5 % Population 50 % Cost

Ensure Palliative Care Needs Met: Data Driven Referrals Risk in waiting for physician referrals – too late Hot Spotter List - High spend and high need Can use health plan, CMS, ACO claims data Utilization (e.g. ER, hospital admissions, SNF) Frailty, functional impairment, disease burden Risk scores, Charlson Comorbidity Index, LACE > 11

Palliative Care Triggers 5+ chronic conditions Advanced illness (e.g. Cancer, HF, COPD) Progressive disease CKD with debility Frailty or functional decline 2+ hospital admissions; ER visits

Staffing and Services Palliative Care Team Pod = 0.5 MD; 3 RNs; 0.5 SW for 250 patients Cadence of encounters based on patient and family needs. Minimum of one house call per month. Services House Calls Video Calls – “telepalliative care” 24/7 support Volunteer Department

“Telepalliative Care” – Use Cases Acute Issue – patient has new distressing symptom, cough, infection, wound Advance Care Planning – can include other doctors, family members from around the world Scheduled F/U Visit – increased care access for remote and rural patients Caregiver Support – provide positive feedback and emotional support to stressed and undervalued family caregivers

What is Palliative Care? Telepalliative Care What is Palliative Care? Team Meeting Urgent Issue Routine Visit

651 decedents; 82 enrolled in a palliative care compared to 569 with usual care who died 2014-2016. Cost per patient during the final three months of life was $12,000 lower with palliative care than with usual care ($20,420 vs $32,420; p = 0.0002). Palliative care reduced hospital admits 34%. Cost savings about $2,100 PMPM for non decedents.

Palliative Care Associated with $12,000 Cost Savings Avg Part A, B, D Spend by Month Prior to Death Control Group (N=569) Palliative Care (N=82) P-value Month of death (Month #0) $15,391 $8,432 0.0002 Month #1 $10,712 $6,423 0.0154 Month #2 $6,317 $5,564 0.8025 Last 3 months $32,420 $20,420 Month #3 $4,539 $3,807 Month #4 $3,799 $4,589 0.0271 Month #5 $3,533 $4,053 0.0525 Last 6 months $44,291 $32,869 0.0207

Avg Palliative Care LOS: 109 days   Control 12 Month Spend: $60,709 HBPC 12 Month Spend: $50,274  

Palliative Care Patients Who Died More Likely to be at Home with Longer Hospice LOS 34 15% 7 85% (n=167/197)

How to help seriously ill people and their loved ones get palliative care? Fee for service is the enemy of high quality palliative care. It incentives high care intensity; often discordant with patient and family preferences. Speed up and reward full accountability for high quality palliative care through alternative payment models (APM) and measurement (patient and family experience).