Achieving Value Through Palliative Care

MOVING TO VALUE IN HEALTHCARE MEANS

improving the quality of care delivered and the outcomes achieved while reducing unnecessary spending. Most healthcare organizations are pursuing value and the benefits that accrue under value-based payment, but too few are turning to palliative care to help achieve these goals.

Palliative care—which focuses on relieving the pain, symptoms, and stresses of a serious illness—changes healthcare delivery for both patients and their caregivers. Multiple studies and meta-analyses have shown that not only does palliative care improve patient experience and satisfaction,^1-3 but that it also reduces emergency department (ED) visits, hospitalizations, and days spent in intensive care,^4,5 thus reducing total spending.^6,7 It does this through:

• Safe and effective techniques for managing pain, shortness of breath, and other symptoms which would otherwise lead to ED and inpatient hospital use
• Communication expertise needed for long, often difficult discussions with patients and families about prognosis, goals of care, and the patient’s wishes and values.

These skills and expertise benefit both the patients and the healthcare system. Standardized access to palliative care for hospitalized patients with advanced cancer has been shown to significantly reduce receipt of chemotherapy after discharge, as well as oncology service mortality and 30-day readmission rates.⁸ However, the most effective results are produced when palliative care is introduced early in the disease trajectory and is provided concurrent with treatment. For example, randomized controlled trials involving patients with cancer found that early and concurrent palliative care: • Results in a dramatic reduction in major depression (16% vs 38%)⁹

• Increases survival by an average of nearly 3 months⁹
• Results in fewer hospital admissions (33% vs 66%), fewer ED visits (34% vs 54%), reduced intensive care unit (ICU) use (5% vs 20%), and lower direct costs of inpatient care in the last 6 months of life ($19,067 vs $25,754).¹⁰

A recent analysis by DataGen found that oncology episodes for cancer of the esophagus, liver, pancreas, lung, testes, and brain have the greatest likelihood of hospital admission and ED visits.¹¹ Not surprisingly, this list correlates with cancer types that report the greatest prevalence of pain¹²— patients and families turn to emergency services when symptoms are poorly managed. Yet expert palliative care mitigates the need for crisis intervention, thus simultaneously improving patient quality of life and cost-effectiveness.

In recognition of these results, the American Society of Clinical Oncology (ASCO) issued a provisional clinical opinion in 2012, stating that “combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”¹³ Despite the weight of the evidence and the ASCO opinion, barriers continue to exist to expanding the integration of palliative care into cancer care. These include:

• The persistent confusion between palliative care and hospice (particularly on the part of physicians)
• Insufficient clinician training in skilled communication and expert symptom management
• A limited understanding of how palliative care can contribute to the value equation

In response, the Center to Advance Palliative Care (CAPC) is working to highlight the merits of concurrent palliative care under value-based payments (VBPs), and to educate payers and providerson needed processes and skills. Specific areas of focus include the Medicare Merit-based Incentive Payment System (MIPS), Medicare Advantage (MA) plans, Medicare Accountable Care Organizations (ACOs), and the new Medicare Oncology Care Model (OCM).

Palliative Care and MACRA’s Merit-Based Incentive Payment System

The Medicare Access and CHIP Reauthorization Act (MACRA) expedites Medicare’s transition to VBP by subjecting eligible clinicians to bonuses and penalties based on their quality performance relative to their peers. MACRA creates 2 payment tracks, and the vast majority of clinicians will participate in the MIPS in the first year. Under MIPS, CMS will calculate payment adjustments based on performance in 4 categories:

1. Quality
2. Cost
3. Advancing care information
4. Improvement activities

The eventual weighting of the Quality and Cost categories in the composite score used to adjust provider reimbursement creates a compelling rationale to involve palliative care specialists in the care of seriously ill patients:

• Quality

Palliative care specialists manage symptoms and stress while patients undergo complex treatments, and they also support informed decisions as chronic illnesses progress. This improves the patients’ experience of care as demonstrated in studies showing significant improvement in satisfaction scores.¹⁴ Therefore, the inclusion of palliative care should improve results on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS surveys, which is expected to be one of the more popular “cross-cutting measures” under the quality category. Additionally, the provision of palliative care should help improve performance on a number of other proposed MIPS measures including advance care planning, pain assessment and follow-up, and medication reconciliation.

• Cost

The significant impact of palliative care in reducing ED, hospital, and ICU utilization in seriously ill patients^4,10 will benefit treating clinicians in their resource use calculations. Efficient resource use is also a key factor determining provider payments in all of the advanced alternate payment models.

Palliative Care and Medicare Advantage

Palliative care can support MA plans in decreasing cost and increasing revenue. On the cost side, as noted, palliative care reduces utilization among the high-need, high-cost members of a population. Several leading MA plans have expanded access to palliative care for their seriously ill beneficiaries, generating significant savings. For example, Aetna’s Compassionate Care Program, provided to the sickest 1% of the plan’s MA members, achieved the following¹⁵:

• Reduced ICU days by 86%
• Decreased total acute care days by 82%
• Reduced ED use by 78%
• Maintained member satisfaction above 90%
• Savings of roughly $12,000 per participating member.

On the revenue side, palliative care positively impacts the measures on which MA plans are evaluated, appearing as public ly reported data and overall Star Ratings. These Star Ratings are calculated by using data from 3 sources:

1. A subset of the Healthcare Effectiveness Data and Information Set measures (HEDIS measures)
2. Results of the CAHPS surveys
3. Results of Health Outcomes surveys

Measures that are likely to be improved by palliative care include:

• All-cause readmissions
• ED utilization
• Hospitalization for potentially preventable complications
• Medication reconciliation post discharge
• Utilization of the Patient Health Questionnaire-9 to monitor depression symptoms
• Relative resource use (specific diagnoses)
• The level of pain that interferes with activity rating by members
• Member rating on how well doctor communicates¹

Plans that perform better on their measures receive more stars, leading to higher premium payments and a greater ability to attract and retain members. Consumers consider the Medicare Star Ratings during the open enrollment period for MA¹⁶ and 5-Star plans have the advantage of being able to enroll members switching from other MA plans at any time during the year.¹⁷

Palliative Care and Medicare Shared Savings Programs (MSSP)

Similar to MA plans, Medicare ACOs are evaluated on their performance on a set of quality measures and have financial incentives to manage resource utilization. The MSSP is the most common type of ACO and, here, too, palliative care can impact a number of quality measures, including:

• All-cause unplanned admissions (for specific diagnoses)
• Ambulatory-sensitive admissions (for specific diagnoses)
• Skilled nursing facility 30-day all-cause readmissions
• Depression remission at 12 months
• Provider communications rating by patients
• Shared decision making rating by patients

Palliative care can be particularly valuable in reducing readmissions. National data from CMS on hospital readmissions shows that since 2010, 43 states have reduced readmissions by more than 5%, and, in 2015, the national readmission rate fell below 18%.¹⁸ However, 2015 data from the National Palliative Care Registry show that the average readmission rate for patients discharged alive from participating palliative care consultation services was only 13.8%.¹⁹ Perhaps more important than performance on specific quality measures is the role that palliative care can play in delivery redesign. Early analysis from a CAPC survey of MSSPs offering palliative care yielded 2 strategies that could have improved ACO results:

Home-Based Palliative Care for Highest-Risk Patients. Some of the more successful MSSPs stratify their population and connect the highest-risk patients with home-based palliative care services. These services involve an interdisciplinary team providing continuous comprehensive assessment, pain and symptom management, and expert conversations in the patients’ homes, adjunctive to the care delivered by their treating providers. Published findings from home-based programs within ACOs show between 34% and 56% reduction in hospital utilization, resulting in average savings of $12,000 per case.^20,21

Integration of Palliative Care Into Oncology Care. Several MSSPs have taken steps to integrate palliative care into oncology practices. At least 2 have conducted extensive training on advance care planning to ensure that patients’ wishes are articulated and documented, and then ensure that those documents are easily accessible in the electronic health record. Other ACOs have embedded palliative care specialists into their practices to help meet the needs of the most complex patients. An ACO contract with Moffitt Cancer Center requires the participating oncology practices to screen all patients for palliative care needs and include a palliative care specialist in the management of patients with documented need.

Implications for Palliative Care and the Oncology Care Model (OCM)

Similar to the models and programs described above, the integration of palliative care can improve performance for practices participating in the OCM, as CMS will be evaluating them on the following:

• Pain assessment and management
• Patient experience of care
• ED visits and hospital admissions
• Proportion of Medicare beneficiaries receiving chemotherapy in the last 14 days of life
• Percentage of patients admitted to hospice for less than 3 days in the last 30 days of life.

Beyond quality measures, OCM practices should extract lessons learned on palliative care integration from those successfully participating in MSSP and other ACO contracts. These include training oncologists and other clinicians in core palliative care skills, or co-locating palliative care experts in the oncology practices. The latter, in particular, can facilitate collaboration, allowing the oncology team to treat the disease while the palliative care team provides an added layer of support during and after the episode. OCM practices can pay for these services by allocating a portion of the monthly enhanced oncology services payment and performance-based payment, thus ensuring that palliative care services are available to all patients according to their level of need.

Palliative Care and Value-Based Payment: Moving Forward

When done properly, VBP can improve quality of care for patients by creating greater flexibility in service delivery while holding clinicians accountable for resource utilization. This commentary provides examples from 4 significant value-based programs demonstrating how palliative care can simultaneously improve performance on quality measures while reducing costs. These examples suggest that oncologists can benefit under VBP by integrating core principles of palliative care into their standard practice and/or establishing formal relationships with palliative care specialists.Allison Silvers, MBA, is vice president, Payment and Policy, Center to Advance Palliative Care.Stacie Sinclair, MPP, is policy manager, Center to Advance Palliative Care.Diane E. Meier, MD, FACP, is director, Center to Advance Palliative Care.

ADDRESS FOR CORRESPONDENCE

Allison Silvers, MBA

Vice President

Payment and Policy

Center to Advance Palliative Care

55 West 125th Street, Suite 1302

New York, NY 10027

E-mail: Allison.Silvers@mssm.edu

FUNDING INFORMATION

Funding for the Center to Advance Palliative Care’s payment analyses is supported in part by the following:

The Gordon and Betty Moore Foundation

The Allen H. and Selma W. Berkman Charitable Trust REFERENCES

1. Smith G, Bernacki R, Block SD. The role of palliative care in population management and accountable care organizations. J Palliat Med. 2015;18(6):486-494. doi: 10.1089/jpm.2014.0231.

2. Cheville AL, Alberts SR, Rummans TA, et al. Improving adherence to cancer treatment by addressing quality of life in patients with advanced gastrointestinal cancers. J Pain Symptom Manage. 2015;50(3):321-327. doi: 10.1016/j.jpainsymman.2015.03.005.

3. Casarett D, Pickard A, Bailey FA, et al. Do palliative consultations improve patient outcomes? J Am Geriatr Soc. 2008;56(4):593-599. doi: 10.1111/j.1532-5415.2007.01610.x.

4. O’Connor NR, Moyer ME, Behta M, Casarett DJ. The impact of inpatient palliative care consultations on 30-day hospital readmissions. J Palliat Med. 2015;18(11):956-961. doi: 10.1089/jpm.2015.0138. 5. Scibetta C, Kerr K, Mcguire J, Rabow MW. The costs of waiting: implications of the timing of palliative care consultation among a cohort of decedents at a comprehensive cancer center. J Palliat Med. 2015;19(1):69-75. doi: 10.1089/jpm.2015.0119.

6. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17(9):1054-1063. doi: 10.1089/jpm.2013.0594.

7. Whitford K, Shah ND, Moriarty J, Branda M, Thorsteinsdottir B. Impact of a palliative care consult service. Am J Hosp Palliat Care. 2014;31(2):175-182. doi: 10.1177/1049909113482746.

8. Adelson KB, Paris J, Smith CB, Horton J, Morrison RS. Standardized criteria for required palliative care consultation on the solid tumor oncology service [ASCO abstract 6623]. J Clin Oncol. 2014;32:5s (suppl).

9. Temel JD, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non— small-cell lung cancer. N Engl J Med. 2010;363(8):733-742. doi: 10.1056/NEJMoa1000678.

10. Scibetta C, Kerr K, Mcguire J, Rabow MW. The costs of waiting: implications of the timing of palliative care consultation among a cohort of decedents at a comprehensive cancer center. J Palliat Med. 2016;19(1):69-75. doi: 10.1089/jpm.2015.0119.

11. Price K, Dahl A. Achieving data driven success under the Oncology Care Model. The American Journal of Managed Care^® website. http://www.ajmc.com/contributor/kelly-price/2016/06/achieving-data-driven-success-under-the-oncology-care-model. Published June 30, 2016. Accessed October 19, 2016.

12. Breivik H, Cherny N, Collett B, et al. Cancer-related pain: a pan-European survey of prevalence, treatment and patient attitudes. Ann Oncol. 2009;20(8):1420-1433. doi: 10.1093/annonc/mdp001.

13. Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30(8):880887. doi: 10.1200/JCO.2011.38.5161.

14. Rabow M, Kvale E, Barbour L, et al. Moving upstream: a review of the evidence of the impact of outpatient palliative care. J Palliat Med. 2013;16(12):1540-1549. doi:10.1089/jpm.2013.0153.

15. Krakauer B, Agostini J, Krakauer R. Aetna’s Compassionate Care Program and end-of-life decisions. J Clinical Ethics. 2014;25(2):131-134.

16. Pearson CF. Sixty percent of Medicare Advantage enrollees now in plans with four or more stars. Avalere Health website. http://avalere.com/expertise/managed-care/insights/sixty-percent-of-medicare-advantage-enrollees-now-in-plans-with-four-or-mor. Published March 18, 2015. Accessed October 19, 2016.

17. CMS. 5-star special enrollment period. Medicare.gov website. https://www.medicare.gov/ sign-up-change-plans/when-can-i-join-a-health-or-drug-plan/five-star-enrollment/5-star-enrollment-period.html. Accessed October 19, 2016.

18. Conway P and Gronniger T. New data: 49 states plus DC reduce avoidable hospital readmissions. The CMS Blog website. https://blog.cms.gov/2016/09/13/new-data-49-states-plus-dcreduce-avoidable-hospital-readmissions/. Published September 13, 2016. Accessed October 5, 2016.

19. National Palliative Care Registry. 2015 National Palliative Care Registry summary data table. National Palliative Care Registry website. https://registry.capc.org/metrics-resources/summary-data/. Published 2016. Accessed October 19, 2016.

20. Lustbader D, Mudra M, Romano C, et al. The impact of a home-based palliative care program in an Accountable Care Organization [published online August 30, 2016]. J Palliat Med. doi:10.1089/jpm.2016.0265.

21. Cassel JB, Kerr KM, McClish DK, et al. Effect of a home-based palliative care program on healthcare utilization and cost [published online September 2, 2016]. J Am Geriatr Soc. doi: 10.1111/jgs.14354.

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