1. Palliative Care 2012: Matching Care to Our Patient’s Needs Diane E. Meier, MD Director Center to Advance Palliative Care diane.meier@mssm.edu www.capc.org www.getpalliativecare.org

2. Core Principle 1.“The secret of the care of the patient is caring for the patient.” Francis Peabody, Harvard University, 1921

3. The Ends of Medicine: Our Professional Obligations “I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients” -Oath of Hippocrates, 400 BC “May I never see in the patient anything but a fellow creature in pain.” - Maimonides, 12 th century AD

4. Objectives 1.What’s wrong with the U.S health care system? 2.How can it be fixed? 3.How is palliative care important to improving value (quality and cost) in health care reform? 4.Changing the delivery system to improve access to quality palliative care in and beyond the hospital

5. Health care in the U.S. What are the ends of medicine? –What are they in the U.S.? What should they be? “To cure sometimes, relieve often, comfort always.” The problem: “The nature of our healthcare system- specifically its reliance on unregulated fee-for-service and specialty care- …explains both increased spending and deterioration in survival.” Muenning PA, Glied SA. What changes in survival rates tell us about U.S. health care. Health Affairs 2010;11:1-9.

6. How They Think About it in Washington: The Value Equation-1 Value of health care = Quality Cost Numerator problems –100,000 deaths/year from medical errors –Millions more harmed by overuse, underuse, and misuse –Fragmentation –Medical practice based on evidence <50% of the time –50 million Americans (1/8 th ) without access –U.S. ranks 40 th in quality worldwide

7. The Value Equation- 2 Value of health care = quality cost Denominator problems Insurance premiums increased by 181% in the last 10 years. U.S. spending 17% GDP, >$8400 per capita/yr Nearing 30% of total State spending Despite high spending, 15% of our population has no insurance, and half are underinsured in any given year. Health care spending is the #1 threat to the American economy and way of life.

8. International Comparison of Spending on Health, 1980–2009 * PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/2011. Average spending on health per capita ($US PPP*) Total expenditures on health as percent of GDP 8 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011. EFFICIENCY 8

9. Sun Sentinel (Broward County edition) Tuesday, August 9, 2011

11. What is this money buying us? Organization for Economic Development and Cooperation Among OECD member nations, the United States has the: Lowest life expectancy at birth. Highest mortality preventable by health care.

12. Cost: Hospital Spending per Discharge, 2009 Adjusted for Cost of Living Source: OECD Health Data 2009 (June 2009). Dollars

13. Wall Street Journal page 1 Sept. 18, 2003

14. Medical Spending in the U.S. $2.9 trillion in 2010  The costliest 5% account for 50% of all healthcare spending Medicare Payment Policy: Report to Congress. Medpac 2009 www.medpac.govwww.medpac.gov Health Affairs 2005;24:903-14. CBO May 2009 High Cost Medicare Beneficiaries www.cbo.govwww.cbo.gov nchc.org/facts/cost.shtml Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.

15. Target Population for Palliative Care Distribution of Total Medicare Beneficiaries and Spending, 2009 Total Number of FFS Beneficiaries: 37.5 million Total Medicare Spending: $417 billion Average per capita Medicare spending (FFS only): $7,554 Average per capita Medicare spending among top 10% (FFS only): $48,220 NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2009.

17. Palliative Care is Central to Improving the Value Equation Because our patient population is driving most of the spending >95% of all health care spending is for the chronically ill 50% of all healthcare spending goes to the sickest and most complex 5% of patients- those in need of palliative care.

18. Why Palliative Care is Important to Improving Value in Health Care Improves patient quality/length of life –Reduces pain, depression and other symptoms; in several studies prolongs life Improves family satisfaction and well-being Reduces resource utilization and costs ….and does so for the sickest 5%-10% of the population driving over half of total healthcare costs.

19. Conceptual Shift for Palliative Care

20. Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment. Palliative Care Language Endorsed by the Public

21. 95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care. 92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness. 92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families. Once informed, consumers are extremely positive about palliative care and want access to this care if they need it: Exceptionally High Positives

22. Palliative Care Teams Address 3 Domains 1.Physical, emotional, and spiritual distress 2.Patient-family-professional communication about achievable goals for care and the decision-making that follows 3.Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings

23. Palliative Care Improves Value Quality improves –Symptoms –Quality of life –Length of life –Family satisfaction –Family bereavement outcomes –Care matched to patient centered goals Costs reduced –Hospital costs decrease –Need for hospitalization/ICU decreases

24. Palliative Care Improves Quality in Office Setting Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only: –Improved quality of life –Reduced major depression –Reduced ‘aggressiveness’ (less chemo < 14d before death, more likely to get hospice, less likely to be hospitalized in last month) –Improved survival (11.6 mos. vs 8.9 mos., p<0.02) Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.

25. Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care, 1999 – 2000 KP Study Brumley, R.D. et al. JAGS 2007

26. RCT of Nurse-Led Telephonic Palliative Care Intervention N= 322 advanced cancer patients in rural NH+VT Improved quality of life and less depression (p=0.02) Trend towards reduced symptom intensity (p=0.06) No difference in utilization, (but v. low in both groups) Median survival: intervention group 14 months, control group 8.5 months, p = 0.14 Bakitas M et al. JAMA 2009;302(7):741-9

27. Consequences of Late Referral to Palliative Care Serious Adverse Outcomes for Bereaved Caregivers: Compared to care at home with hospice, Care in ICU associated with 5X family risk of Post Traumatic Stress Disorder; and Care in hospital associated with 8.8X family risk of prolonged grief disorder Wright A et al. Place of death: Correlation with quality of life of patients with cancer and predictors of bereaved caregivers mental health. JCO 2010; Sept 13 epub ahead of print

29. Effect of Palliative Care on Hospital Costs

31. How Palliative Care Reduces Cost Improved resource use Reduced bottlenecks in high cost units Improved throughput and consistency The Conceptual Model: Dedicated medical team = Focus + Time = Decision Making / Clarity / Follow through

32. Source: Center to Advance Palliative Care, 2011 capc.org/reportcard Palliative Care Growth

33. America’s Care for Serious Illness A State-by-State Report Card on Access to Palliative Care in Our Nation’s Hospitals Source: Center to Advance Palliative Care, 2011 capc.org/reportcard

34. NYS Palliative Care Programs by Hospital Type New York (2008)New York (2011)United States (2011) % (#) ALL hospitals w/PCPs  56% (75/134)72% (106/147)47% (1894/3989) % (#) > 300 Bed hospitals w/PCPs 77% (30/39)89% (55/62)85% (597/699) Public hospitals25% (2/8)89% (17/19)54% (192/356) Sole Community Provider 50% (7/14)53% (8/15)37% (151/406)

35. Dartmouth Atlas Data and NY State Ranking, 2009 Medicare reimbursement last 6 months of life $938451st ICU admission during last hospitalization 19%45th Medicare deaths in hospital 37%51st ICU days/decedent last 6 m. 3.230th Hospital admits/1000 decedents 153243rd

36. New York State Summary 147 Hospitals 72% (106/147) have a palliative care program. Grade of “B” on the CAPC State-by-State Report Card up from “C” in 2008 NY State costs are among the highest in the nation. www.dartmouthatlas.org NY State palliative care programs see <1% of admissions – huge opportunity for growth, since goal is 4-6%

37. Hope for the Future: Younger physicians exposed to palliative care more than their predecessors. − 37 − % “Great Deal” or “Some” Exposure to Palliative Care by Physician Age

38. National Quality Forum: Palliative Care is One of Six National Priorities for Action http://www.nationalprioritiespartnership.org/Priorities 38

39. National Recognition of Importance of Palliative Care to Healthcare Value MedPAC: Called a meeting of national experts in palliative care in May 2011 to understand what Medicare payment policies might advance access and quality The Joint Commission: Announced September 2011 release of a Palliative Care Advanced Certification Program.

41. 41 Palliative Care: “on the map” with IHI http://www.ihi.org/I HI/Programs/Impro vementMap

42. Strategic Partnerships

43. New Delivery and Payment Models + Palliative Care Accountable Care Organizations? Patient Centered Medical Homes? Bundled payments? Adding palliative care targeted to the highest cost + risk populations to the specifications for these strategies is key to their success at improving quality and reducing cost.

44. Major Health Systems Get It Making multimillion dollar investments in palliative care integration across settings: Partners Health System/ Harvard Medical School U. of Pittsburgh Health System Duke U. Health System North Shore-LIJ Health System

45. Payers Get It Examples of private sector approaches to community-based palliative care

46. Matching (Payer) Resources to Needs Demand Management DM/CM CCM-palliative care RESOURCES NEEDS

47. Payers Have Skin in this Game

48. Resources: Don’t Waste Time Reinventing the Wheel www.capc.org www.getpalliativecare.org Registry https://registry.capc.org/ Audioconferences http://www.capc.org/support-from-capc/audio-conf/ E-learning via CAPCcampus on-line http://campus.capc.org/ CAPCconnect forum http://www.capc.org/forums/ http://www.capc.org/forums/ Joint Commission technical assistance http://www.capc.org/palliative-care-professional-development/Licensing/joint-commission http://www.capc.org/palliative-care-professional-development/Licensing/joint-commission Palliative Care Leadership Centers http://www.capc.org/palliative-care-leadership-initiative/overview

49. Although the world is full of suffering, it is full also of the overcoming of it. Helen Keller Optimism 1903