1. 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.

2. Discussion Points: Identifying the issues
Enhanced Personalized Health Care
Vision for hospice care
Reflections on barriers to advancing palliative care
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3. Identifying the Issue The US Population is getting older
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4. Identifying the Issue
The number of patients with multiple comorbidities is also increasing
'Multiple Chronic Conditions in the United States.' Credit: RAND Corp
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5. 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
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6. 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
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7. 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

8. 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
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9. 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.

10. 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”

11. Barriers to Optimization of Palliative Care
Landscape as seen by the provider
“My office is busy: I generally have 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.”

12. 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

13. 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
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14. 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

15. 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

16. 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.

17. Thank You!