1. Palliative Care Opportunities and Ethical Dilemmas Created by the Affordable Care Act Jan Slater JD, MBA

2. The Current Healthcare Delivery System
Healthcare consuming 18% of the US GDP is unsustainable The US spends 34% more per capita on healthcare than Denmark, the next highest country Health indicators place the USA 38th healthiest country Volume driven reimbursement is unsustainable

3. People do not change until the pain of staying the same…
… exceeds the pain of changing.
Anonymous

4. So What’s New in Health Care Reform?

5. Affordable Care Act; One Year Later
Partisan lines are drawn.
Should we repeal or leave it alone?
A middle position; keep the good things and re-engineer the components that fail.

6. Goals of Healthcare Reform
Improve quality of healthcare
Reduce Costs, and
Improve population health
Palliative care naturally advances all three goals

7. The Role of Transparency
Transparency; An Innovation encouraged by the ACA and demanded by Consumers
The Role of Transparency
Price Transparency
Quality
Transparency

8. The “Viral” Influence of Transparency:
In the future the consumer will make health care decisions on the basis of VALUE
VALUE = Outcomes + Satisfaction
Cost
The CONSUMER ultimately determines which of these elements constitute VALUE

9. Read all about it !!
April 2005

10. The Role of Transparency
Quality Transparency
The Role of Transparency
Quality
Transparency
Price Transparency

11. 2011-2013 Core Measures: Heart Failure Pneumonia
Heart Attack
Heart Failure
Pneumonia
Surgical Care Improvement
HCAHPS

12. 2014 Clinical Quality Measures:
Emergency Department Throughput
Stroke
VTE
AMI
CAP
Surgical Outcomes
New Born Care
More HCAHPS

13. Transparency of Cost and Quality
Transparency is the best thing that’s happened to cost and quality since antibiotics...by decreasing variance and improving results
Dr. Steven Berlowitz

14. That which is measured, tends to improve
That which is measured, tends to improve. That which is measured publicly, tends to improve faster.

15. “What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public made a big difference in motivating them to improve”.
Dr. Steven Berkowitz
Change

16. What is “Quality” to the Healthcare Consumer?
More responsive and patient centered healthcare
Treatments at home and in out-patient settings:
Enabled by technology and home health care
Fewer inconveniences and cost related to illness
Less disability, pain and discomfort due to interventions
Palliative care is already focused on these attributes

17. The Role oPriceansparency
Price Transparency
The Role oPriceansparency
Price
Transparency
Quality
Transparency

18. Opportunities for Palliative Care
Price Transparency
Healthcare providers will compete by offering value
Cost conscious healthcare providers
P4P will become the rule
Cost saving measures that improve patient satisfaction will be in demand
Opportunities for Palliative Care
will be significant

19. If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better…
…Or you’re getting worse.
Tom Peters
Change

20. The Increasing Trend of Higher Deductibles
From 1999 to 2013, average annual employer and worker contribution for health insurance increased 300%
Out-of pocket cost for healthcare increased from $500 in 2006 to $1100 in 2013
Greater costs will be pushed to consumers who will become more:
health literate
responsible purchasers of healthcare

21. Influence of Cost on the Purchase of Healthcare
Tom has the flu and feels bad! Tom has great insurance but a $3,000 deductible
What does he do?
Treatment Options: Approximate*
Out of Pocket Wait
Emergency Department $ hrs
Urgent Care hr
PCP visit hr (if available)
Local Pharmacy min
Self Treat.. rest, OTC meds ? None
* The actual cost may not be known until the evaluation is completed.

22. Price Transparency; Opportunity for Palliative Care
Currently:
Physician discomfort speaking about costs
No access to cost information to make informed decisions
Future:
Cost information will be available
Discussion of cost will be part of every informed consent discussion.
Cost information will facilitate more honest discussions when consumers demands futile care
More rational decisions will be made by all

23. Current System vs New Models
Currently patients with chronic conditions:
See several physicians
No coordination of care
Leads to repeated hospital admissions

24. One Successful Model: Patient Centered Medical Home (PCMH)
PCMH: short waits, responsive primary care, team based care, high tech solutions
Team make up: PAs, RNs, pharmacists, dietitians, mental health professionals and case managers
Emphasis on care coordination and preventive medicine
Use of data bases of medical information to screen for diseases and flag needed preventive measures
Great improvements in patients’ and healthcare professionals’ satisfaction

25. Examples of Quality Improvement
Healthcare providers take on the problem of patient non-compliance
Reduce readmissions of CHF patients with at-home technology
Reduce diabetic amputations with frequent visits to wound clinics
Specialty teams to care for high risk, high cost patients

26. Examples of Quality Improvement continued
Chronic disease specific clinics
Alignment of rural and urban hospitals for care coordination
“Choosing Wisely” initiative to legitimized our ability to cut back on what's unnecessary.
Information technology
EMR
Health Information exchanges
Evidence based protocols
Genomics will permit development of personalized medicine

27. Won’t All This Run Up Costs?
Skeptics doubt it is possible to improve quality and reduce costs  
Without financial reform the pressure of P4P requires keeping a foot in both the volume boat and the value boat which are traveling in opposite directions
How to retool the organization to jump entirely into the value boat but keep it steadfast on the volume course?  

28. The American Healthcare System is Repair-Centric and NOT Prevention-Centric.
We wait for train wrecks and then clean them up.
What if we prevented the train wreck in the first place??
“You can fix a problem at step 1 for $1 or fix it at step 10 for $30.”  
W. Edward Deming

29. How to Cut Costs Focus on what costs the most:
Hospitalizations,
ED visits,
care for the frail, high-risk elderly and patients with multiple high-risk chronic conditions.  
Use "upstream" interventions, to save on "down-stream" costs.  
Invest in future wellness to prevent train wrecks.

30. You can always count on Americans to do the right thing…
…after they’ve exhausted all the other possibilities !!”
Winston Churchill

31. Implications of Innovation for Palliative Care
There was a time when death was a part of every day life
Today we are strangers to death
What has changed from days past?
1. The power of advanced technology
2. Most injuries and infectious diseases are curable
3. Less emotional closure and peace with the death of a loved one
4. We don't know what to expect when someone is dying
Monica Williams-Murphy M.D. and Kristian Murphy It’s OK to Die

32. Should we use technology because we have it?
Carotid endarterectomy in a bed bound 91-year-old?
Ventilator for a patient speechless for 10 years with a peg tube?
CPR on 75-year-old with end-stage diabetes in cardiac arrest?
Emergency evacuation of brain hemorrhage for patient with advance dementia?

33. Lessons for doctors:
When physicians feel compelled to cure illness and families press for “everything to be done” for a dying patient:
Comfort care should replace cure focused medicine.
Death is not "failure ". We all die.
“Artificial life-support "may be "artificial death extension.”
Monica Williams-Murphy M.D. and Kristian Murphy It’s OK to Die

34. What is a “Good Death "?
Attributes of a "good death“ as identified by healthcare professionals:
A sense of control and honoring wishes of one who is dying
Assuring comfort and dignity
A sense of closure
Affirming unique personal qualities of the dying
Trust in the healthcare providers
Acceptance of impending death
Honoring the dying persons beliefs and values
Monica Williams-Murphy M.D. and Kristian Murphy It’s OK to Die

35. Advance Care Planning
An ongoing process of planning for future medical care
Identify who to speak on your behalf
Describe decisions you want them to make
Ensure wishes, values and goals are honored
Two documents that assist Advance Care Planning:
Advance Directive,
OkPOLST document.

36. Advanced Directive (“AD”) Act, 63 OS §3101
Provides a statutory form to document medical care the “declarant”wishes to receive when incompetent.
Declarant may request or refuse life-support under four conditions:
terminally ill,
persistently unconscious,
has an end-stage condition,
or “other” as described by declarant.
Declarant may appoint a primary and a secondary proxy
Declarant can choose to be an organ/ tissue donor

37. Advanced Directive (“AD”) Act, 63 OS §3101
The AD must be signed by the adult declarant when competent
witnessed by two witnesses who are not legatees, devisee's or heirs of the declarant.
Requirement for physicians to comply with AD or arrange care by another physician or healthcare provider willing to comply with the AD.

38. 63 OS §3101: Useful Tips for Advising Patients regarding ADs
Appointment of co-proxies complicates medical decision making
A Proxy’s duty to make decisions based on known wishes of the declarant is often misunderstood
If declarant desires a trusted Proxy to make all medical decisions , advise the declarant to:
leave section 1. Living Will blank and complete remainder of AD;
make clear in Living Well subsection (4), that declarant wishes the proxy to make decisions that are in the best interest of the family, however, the declarant would not want his/her life artificially prolonged and consents to withdrawal of life-sustaining treatment and AAHN
Families need permission to permit a loved one to die naturally

39. 63 OS §3101: Useful Tips for Advising Patients about ADs continued…
At least one proxy should be younger than the declarant
Copies of executed ADs should be given to the proxies, key family members, the attending physician and hospital
Failure to have an advance directive can cause family strife
Oklahoma law only permits a healthcare proxy, an attorney-in-fact, or a guardian (“Legal Representative”) to make decisions to withdraw or withhold life-sustaining treatment on behalf an incapacitated person

40. Physicians Order for Life-Sustaining-Treatment (POLST)
Physician’s order form that outlines wishes for medical treatment and goals of care for patients with life limiting and irreversible conditions;
Translates and advance directive or durable healthcare power of attorney into a physician’s order
Can stand alone without an advance directive
Lists choices of medical treatments.
Can be completed by Legal Representative if patient is no longer able to communicate

41. POLST Document continued..
Becomes valid, when discussed with a patient and/or Legal Representative and appropriately completed. It must be signed by a physician.
Combining the OkPOLST with an AD is more likely to ensure patients’ wishes are honored at end-of-life
it is a physician’s order and
travels with the patient across health care settings
OkPOLST form becomes effective at the time the order is signed
Use of OkPOLST is always voluntary
More information at

42. OkPOLST Form