Effective Palliative Care Programs Require Health System Change
Effective Palliative Care Programs Require Health System Change
Public and private health care systems have begun to integrate palliative care with conventional medical care as a way to improve quality of care and physician, patient, and family satisfaction, and reduce health care costs. Combining palliative care with capitated payment offers a promising strategy for reducing the high health care costs that are incurred in the dominant fee-for-service payment systems. To explore the development of successful palliative care programs in the current health care system, the Innovations Exchange Team interviewed two experts in palliative care and organizational change:
Diane Meier, MD, FACP
Director, Center to Advance Palliative Care
Professor, Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine
Joanne Lynn, MD, MA, MS
Director, Center for Elder Care and Advanced Illness, Altarum Institute
Please explain what palliative care is and who benefits from it.
Diane Meier: Palliative care is specialized medical care that focuses on supporting individuals with serious illnesses by relieving their symptoms, pain, and stress. The goal is to improve the quality of life for patients and their families. Palliative care is offered to people at any age and at any stage of illness. In the palliative care field, there are 3 types of patients: those with curable diseases, such as a 23-year-old with leukemia who receives a bone marrow transplant with a 70-percent success rate; those with serious illnesses such as emphysema or Alzheimer's disease that may last for decades; and those with progressive incurable diseases such as metastatic cancer. All three groups of patients can benefit from palliative care.
Joanne Lynn: Most people drift into disability for several years when they have serious chronic conditions, and eventually die from an infection, stroke, or other complication. When we sense that a patient is near the end of life, we offer hospice, which is a form of palliative care for patients who are clearly dying.
Meier: The term “end-of-life care” can be misleading, because only 23 percent of Americans die from terminal cancer, compared with 77 percent who die from serious chronic illnesses, according to the National Center for Health Statistics. Medical professionals can't predict until the last few weeks of someone's life how long a person will live. For example, a person who is diagnosed with advanced Alzheimer's disease, and has recurring pneumonia and difficulty swallowing, may live for several more years.
Can you describe what integrated palliative care means?
Meier: To integrate palliative care with medical care, the clinicians and specialists within a palliative care team work with the patient's regular physicians and other health care professionals. Integrated palliative care includes care coordination, self management, and treatment of distressing symptoms, along with efforts to improve a person's functional capacity and support the patient's family. Palliative care professionals work in hospitals, nursing homes, hospice centers, home settings, and doctors' offices.
Because there are not enough palliative care specialists available to meet the needs of all Americans with complex chronic and serious illnesses, every clinician providing care for seriously ill patients will have to become familiar with the core principles and practices of palliative care.
Lynn: The need for palliative care arose when people with serious and chronic conditions were living longer and needed an alternative to hospice care, which was designed for people with progressive illnesses and short prognoses. This led to efforts to integrate palliative care with geriatric medical care. The key is building a comprehensive plan that integrates palliative care with traditional diagnostic procedures and medical care, and that also provides symptom relief and emotional support.
Do palliative care professionals provide patient- and family-centered care?
Meier: The goal of palliative care is to improve the quality of life for patients and their families. Palliative care professionals help patients and their families determine the care they want and need, and then develop a coherent care plan that matches their wishes. The palliative care team spends a lot of time listening to patients and their loved ones, understanding their medical situation, and discussing what they can expect in the future. Palliative care programs recognize the important contribution that families make in caring for patients with serious illnesses. A recent American Association of Retired Persons (AARP) study showed that family caregivers, despite having little training, provide a variety of clinical services at a professional level.
What are examples of palliative care programs in integrated delivery systems?
Meier: The Department of Veterans Affairs (VA) offers home-based palliative care services to veterans as a covered benefit. As an agency with a global budget and a central planning authority, the VA was the first integrated delivery system to train geriatricians to provide care for the aging veteran population. Approximately 10 to 15 years later, the VA was the first health system to train interdisciplinary palliative care clinicians to care for veterans with chronic serious illnesses.
Kaiser Permanente, another single-payer and integrated delivery system, has offered its members home-based palliative care services for years. Private payers such as United Health Care, Aetna, and Blue Cross Blue Shield (BCBS) are testing capitated payment models for community and home-based palliative care programs. For example, BCBS partnered with Hospice of Michigan's @HOMe Support program, along with other health care systems in southern Michigan, to develop a home- and community-based integrated palliative care program. By offering integrated palliative care and increasing its use of capitated payment models in Michigan, BCBS is improving the quality of care for its sickest members, and, as a result of better care, helping people avoid the emergency department (ED) and the hospital, achieving significant cost savings.
Another excellent example of an integrated palliative care program is the Advanced Illness Management (AIM) program developed by Sutter Health in northern California. The program connects major health care settings, including hospitals, physician offices, and home-based services, to bridge the gap between acute care and end-of-life care for Medicare patients with late-stage chronic illnesses. The AIM program provides ongoing counseling to eligible patients and families to help them understand their options and clarify their care goals, and then designs care plans that will help them achieve those goals.
What is the business case for developing integrated palliative care programs?
Meier: Although Sutter Health still uses a fee-for-service model, the AIM program is a version of integrated palliative care that Kaiser, the VA, and other large health care systems are developing within a global capitated budget. Health care reform is shifting the focus away from volume of services under a fee-for-service system toward a greater emphasis on improving quality of care through incremental development of capitated models. Examples of various capitation models include bundled payments , patient-centered medical homes , and accountable care organizations. In all of these models, providers are given a fixed amount of money to spend on a patient or patient population. To stay within their budget, providers make choices about what to invest in. An important area is ensuring that patients receive the necessary care and support to stay in their homes to avoid visits to the ED and hospital.
Integrated health systems have financial incentives to invest in a continuum of high-quality palliative care in the community. Caring for high-risk patients in their homes and in community settings is usually much less expensive than caring for them in the ED and hospital. In addition, Medicare has started imposing financial penalties on hospitals that readmit patients within 30 days of discharge for the treatment of three conditions: heart failure, heart attack, and pneumonia.
Lynn: The original statute that established the Medicare program has been interpreted to exclude supportive care, because coverage was limited to interventions that improved health. However, the Center for Medicare & Medicaid Innovation, which was recently established by the Centers for Medicare & Medicaid Services, is funding cooperative agreements and challenge grants, which aim to demonstrate the integration of supportive care with traditional medical services.
Should increasing hospice use be a goal of the health care system?
Meier: To increase hospice use by those who need it and would benefit from it is an important goal. Once patients and families understand they can receive hospice in their home and are confident that providers will respond to their calls, they learn that hospice is designed to keep them well and out of the hospital. However, Medicare beneficiaries can access the hospice benefit only if they waive other routine Medicare benefits for their terminal illness that could prolong life. The line is often blurred between life-prolonging care and palliative care. If someone has emphysema and pneumonia, is treating the pneumonia palliative or life-prolonging? Of course, it is both. Unfortunately, the current Medicare statute presents a false dichotomy in which patients have to choose between hospice care and routine care for their terminal illness.
What factors contribute to the success of an integrated palliative care program?
Meier: Successful programs generally have the following characteristics:
- Positioning of the program as providing additional support to doctors. Unless doctors feel the program is designed to support the care of their patients and not interfere with it, it is doomed to fail.
- Strong leadership and vision. This is important for achieving the necessary cultural changes in the health care system.
- Sophisticated information technology systems. The use of electronic health records facilitates care coordination and communication. Anyone on a patient's care team should be able to use a computer to retrieve the patient's records.
- A capitated or value-based payment system. Such a system rewards providers who reduce inpatient care, unlike a fee-for-service system in which providers risk the loss of inpatient revenue.
- A patient- and family-centered approach to care. Recognizing that the unit of care is the patient and the patient's family, palliative care provides support and training for family members.
- Provision of training for frontline clinicians. Most practicing clinicians in the United States have had no training in the core principles and practices of a palliative care approach to serious illness. Health systems must provide and require access to such training if they want to really change outcomes for this patient population.
What is significant about the Sutter Health AIM program's ability to increase the use of hospice care; limit the need for inpatient and ambulatory care; reduce overall care costs; and achieve high levels of satisfaction among physicians, patients, and caregivers?
Meier: The results reinforce a growing body of evidence that delivering patient- and family-centered care to people with complex, serious, and chronic illnesses is better for everyone. Patients and families feel the quality of care is better, and physicians feel they provide better care for patients because the system supports the achievement of patient and family goals. Because patients are empowered to remain safely at home or in a community setting, this approach also costs less overall.
The AIM program assured timely and appropriate access to the Medicare hospice benefit for patients who will clearly die. Hospice provides intensive around-the-clock availability of palliative care expertise in whatever setting the patient calls home. Overall, more than 90 percent of hospice care is provided in people's homes rather than institutions, which is what patients want, and as a consequence, also saves the health care system money.
A 2007 study in the Journal of the American Geriatrics Society examined home-based palliative care at Kaiser Permanente and found similar results. Home-based palliative care increased patient satisfaction and led to a threefold increase in the number of home visits for patients with chronic obstructive pulmonary disease, heart failure, and cancer. The program also reduced the use of other medical services—including hospitalizations, ED visits, skilled nursing facility services, and doctor's office visits—by 50 to 75 percent.
Lynn: The question is whether Sutter can scale up the program so it becomes standard practice. The role of community-based management of local services is often overlooked. For example, local integrated networks in Canada bring together health care partners from hospitals, community care, community support services, community mental health and addiction services, community health centers, and long-term care facilities. These networks manage the budget and develop innovative, collaborative solutions that provide more timely access to high-quality services.
What organizational change is necessary to achieve this kind of program?
Meier: Visionary health system leadership is the single most important predictor of a program's successful integration with the health care system. To achieve fundamental cultural changes in health care delivery, the leader must have vision, commitment, and skill as a role model and communicator to an entire workforce.
Another factor is that younger physicians are more comfortable with palliative care than older physicians who were never exposed to it during their training. There are now at least 85 palliative care programs offering more than 234 fellowship positions. Physicians who learn about palliative care during their training are more likely to apply palliative care principles and practices in their future practice.
What are the barriers to achieving such complex and comprehensive organizational change?
Meier: Many health care professionals are still being paid by fee-for-service, which rewards service volume rather than quality of care. The sooner the public and private sectors can shift to payment bundling and capitated models, the faster the business case can be made for developing integrated palliative care programs. The reason for the slow speed of change is that health care makes up 15 to 20 percent of the U.S. economy, and the disruption would be substantial. Until the financial incentives shift away from volume and towards quality of care, it will continue to be difficult to change behavior.
The most immediate agents of change are private payers who are not subject to the same challenges as government-funded health care insurance (Medicare and Medicaid). Many are developing community-based integrated palliative care models because it so dramatically improves the quality of care for the sickest and most vulnerable, and as a consequence reduces hospitalization and improves bottom-line performance.
Another challenge is getting providers on board. Getting physicians to change their behavior is like turning the Titanic—it has to be done slowly and deliberately so physicians don't see global budgets or capitation models as rationing and payers telling them how to practice medicine. Sutter Health named their program Advanced Illness Management to avoid the suggestion that patients are at the end of life and that the program is focused on telling physicians how to practice medicine.
Lynn: Many integrated palliative care services are not reimbursed under the fee-for-service system. We need to either move people into delivery systems that use a managed care approach, or we need to find a different approach. We also need to start working much more closely with social services and supports in the community.
Disclosure Statement: Dr. Diane Meier and Dr. Joanne Lynn reported having no financial or business/professional affiliations that would be considered a conflict of interest with the work described in this perspective.
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