Keck Center: National Academies of Sciences, Engineering, and Medicine Financing and Payment Strategies to Support High-Quality Care for People with Serious Illness Keck Center: National Academies of Sciences, Engineering, and Medicine November 29, 2017 David Debono, M.D. National Medical Director for Oncology Anthem Inc.

Discussion Points: Identifying the issues Enhanced Personalized Health Care Vision for hospice care Reflections on barriers to advancing palliative care Company Confidential

Identifying the Issue The US Population is getting older Company Confidential

Identifying the Issue The number of patients with multiple comorbidities is also increasing 'Multiple Chronic Conditions in the United States.' Credit: RAND Corp Company Confidential

Identifying the Issue Fragmented care between primary care providers and specialists Limited Advance Care Planning Inadequate Symptom Control Aggressive care near the end of life including ER visits, ICU stays, inpatient hospitalizations and chemotherapy Limited Hospice utilization Company Confidential

Enhanced Personal Health Care A Value-Based Payment program 54,000 providers serving 4.5 million members (2015) Clinical Goal is improvement in patient-centered care Palliative Care Goals Identify high-risk members with daily hot-spotter reports so that resources can be shifted to serve these members Monthly data feeds revealing care gaps and risk stratification Company Confidential

Enhanced Personal Health Care Provider requirements Members have 24/7 access to providers through extended hours and after hours call coverage Have a dedicated position that supports participation in EPHC Regularly participate in collaborative learning sessions Use a disease registry to manage patients with chronic conditions Engage in care planning for high-risk populations Engage in quality and performance measurement

Enhanced Personal Health Care Significant human resources investment Transformation Teams Clinical Liaisons Information Technology Build Allow for two-way data sharing between practices and Anthem Value-based Payment Model Resources to providers to develop necessary infrastructure Shared Savings requires both the achievement of quality metrics and meeting savings targets Company Confidential

A Different Vision for Hospice Care Expanded hospice access: An ongoing initiative in its formative stages and not executed at this time: Change prognosis requirement to 12 months Allow for disease-modifying therapy to continue during hospice care It is anticipated that there will be quality improvements in parameters such as advance care planning, aggressive care near the end of life, less ER and inpatient utilization1 1. Wade M. http://www.ehcca.com/presentations/palliativesummit1/wade_ms3.pdf

Barriers to Optimization of Palliative Care The Landscape as seen by the patient “No one has talked to me about palliative care” “There are no palliative care clinics in my hometown” “My doctor sends me to the emergency room when I get sick and I usually wait forever” “I am afraid of the costs of treatments, but I don’t want my doctor to know this: maybe he won’t give me the best treatment.” “I am scared: things seem to be getting worse: I worry about things all the time”

Barriers to Optimization of Palliative Care Landscape as seen by the provider “My office is busy: I generally have 10-15 minutes with a patient and then have to do documentation. Spending extended periods of time with every patient that needs it is not feasible.” “The guidelines say that patients with advanced cancer should be referred to a palliative care team early in their course. But there are no outpatient palliative care teams in my community.” “I am concerned about referring a patient too early to palliative care. They might lose hope. I know my patients and I know when they are ready for things like hospice.”

Barriers to Optimization of Palliative Care The Landscape as seen by the Payer “Advance Directives have been completed by just 26% of American Adults1 Our members are getting aggressive care they didn’t want.” “Despite hospice being an established part of the medical ecosystem, the median LOS has not changed and 42% of members use hospice for 14 days or less2. Our members are not getting the full benefit from hospice.” “The issues that our members are dealing with are profound. Medical bills, anticipatory grief, pain and other symptoms, caregiving… Unfortunately, with all these things going on at once, there often is not a central team in place to help members navigate these choppy waters.” Rao JK, et al. Am J Prev Med 2014;46(1): 65-70 NHPCO.org

Potential Outpatient Palliative Care Models Primary Palliative care Requires extensive training of practitioners Time intensive work, not conducive to busy outpatient practices Resource intensive to develop a multidisciplinary team Consideration for alternative payment models for care coordination if quality metrics achieved Company Confidential

Potential Outpatient Palliative Care Models Community-based specialty palliative care Scarcity of practitioners Most practitioners are dedicated to inpatient work or hospice work Fully funding a comprehensive palliative care team is difficult for hospices and hospitals. Accountable care organizations/value-based payment models not easily generalized to all practice types

Potential Outpatient Palliative Care Models Third Party Organizations Specialty trained professionals Leverage Board-certified Palliative Medicine physicians Telehealth options, home-based options and clinic-based options 24/7 access to a palliative care team Willingness to participate in value-based payment models Have demonstrated ability to scale palliative care Enhanced quality and cost of care

The Future Hybrid Approach is Likely Large health systems/academic centers may be more interested in entering value-based payment models where they are responsible for quality (and ultimately cost) and utilize their own practitioners. Sizable independent practices may want to develop their own primary palliative care approach and cultivate novel value-based payment models – initially based on achieving quality metrics. Third party organizations may provide a scalable outpatient solution across markets, across geographic regions, and across different-sized medical practices with reimbursement tied to value based payment models.

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