Looking into the Future of Serious Illness...

8/9/2018

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Looking into the Future of Serious Illness Care

Janet Bull, MD, MBA

CMO, CIO Four Seasons

Innovation and Excellence in Advanced Illness at End of Life 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, NC

Disclosures

• Research Funding

• AstraZeneca

• Tabula Rosa

• Four Seasons Consulting Group – Principal

• Chief Innovation Officer – Teleios Collaborative Network

Innovation and Excellence in Advanced Illness at End of Life The Carolinas Center’s 42nd Annual Hospice & Palliative Care Conference – September 2018 – Charlotte, ,NC

Objectives

• Explore the evolving healthcare landscape

• Discuss value based payment reform

• Describe Four Seasons CMS Healthcare Innovations Project and the impact of community-based palliative care

• Understand Alternative Payment Model impact on hospice and palliative care agencies

• Discover innovative solutions to deliver more efficient/effective care

Innovation and Excellence in Advanced Illness at End of Life

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Evolving Healthcare Landscape


Why Healthcare Reform?

Unsustainable Costs

Poor Quality

Disparities with high number of uninsured (26 million)

Focus on treatment, not prevention

Inefficient delivery system

Fragmented care – focus is on acute crisis


Spending Unsustainable


OECD Kaiser Foundation 3/2017

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US – High End of Life Costs

Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009.

Quality Indicators


Social Determinants

OCED Countries

• $1.70 social per healthcare $

US • $.56 social per healthcare $


OCED – Organization for Economic Co-operation and Development (36 counties)

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Social Determinants

40% of all medical spending is precipitated by unmet social needs

• health literacy

• transportation needs

• lack of family and caregiver support

• food insecurity

• unsafe housing

• financial


Moving to Value Based Care


Creation of CMMI Center

• Created through Affordable Care Act

• Designing, testing, and implementing new payment models

• Launched over 40 new payment models

• Goal – improve quality, lower costs, increase experience of care

• Funded 10 billion thru 2019, then 10 billion each decade


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CMS Innovations Center


Results


It’s working!

The Future of Healthcare

Conway, P CMS Health Care Delivery and System Reform, 3/24/15

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A Shifting Paradigm

Traditional Care Transformational Care

Physician led Team led

Acute clinical needs Goal directed care

Silo care – specialistsAcute care

Coordinated health teamsPost acute care

Fee for service Value based purchasingBundled payments

The Solution - Payment Reform

Fee for Service

Pay for Performance

Risk-sharing/

ACOs

Quality

Demonstration

Cost/quality-directed decision makingGroup Accountability

*Outcomes-directed decision making

*Physician Accountability

*Physician choice

*Physician Accountability

MACRA Legislation

Repeals Sustainable Growth Formula

• Freezes Part B payments 2020-5

Fee for Service

• MIPS

Alternative Payment Model

• ACOs

• Bundled payments

• Episodic care

• CMMI models


Medicare Access & Children’s Health Insurance (CHIP) Reauthorization Act of 2015

In 2017, pure FFS accounted for only 37% of the market

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Four Seasons’ CMS Innovation Project


CMMI Grant 9/2014-17

Scale model into 14 counties, delivered longitudinal across all care settings

• Improve healthcare outcomes

• Improve patient and family experience of care

• Reduce total cost of care

• Increase access to high quality care

• Developing/Testing a New Payment System


Expanding Palliative Care Across

Western NC and Upstate SC

Upstate

South

Carolina

Western

North

Carolina

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Lessons Learned

• Define Eligibility

• Develop good processes/referrals

• Risk stratification for visits

• Standardize care

• Define metrics to track


Defining Eligibility A Monumental Task

Mary’s Story

Palliative Care Intervention

o Symptom management - Nausea, vomiting, fatigue

o Family distress – 2 children in middle school/financial hardship

o Social worker – counseling, assist with Medicaid application

o Chaplain – spiritual support

Stage III breast cancer72% 5 year survival rate

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Tom’s Story


o Goal: stay out of the hospital, die at home

o Symptom management of dyspnea

o Lives in rural area in WNC; little access to primary care

End stage COPDPrognosis 2-3 years

Recurrent ER visits/2

Doris’s Story


o Advance care planning (full code)/education of disease process

o Medication review with discontinuation of 5 meds

o Social worker and spiritual support

o Hospice referral after 2 months when patient clearly declining

Advanced dementiaPrognosis 8-10 months

Behavioral issues, polypharmacy2 hospitalizations/12 months Daughter exhausted, stressed

CMMI Eligibility Criteria

Patients with life limiting illness in last 3 years of life presented often with:

• Serious Illness Diagnosis

• Functional Status Impairment

• High healthcare utilization

• Nutritional, cognitive, functional decline

• High symptom burden

• High caregiver burden

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Typical PC Model


Value Map Referral Process


Risk Assessment


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Standardizing the Visit


Quality Data Assessment Tool


Symptom Assessment


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Advance Care Planning


Tracking of Palliative Care


Hospice Transitions 2190 (45%)

Palliative Care Deaths 794 (16%)

Palliative Care Discharges 2063 (42%)

Bull et al. Tracking Patients in Community Based Palliative Care through the Centers for Medicare and Medicaid Services Healthcare Innovation Project. J Palliat Med. 2017; 20(11):1231-1236

Poor Functional Status of CMMI Patients


PPS Score Total

0-60% 86%

70% 8%

80-100% 6%

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Challenges Inform Innovation

• Rural Service Area

• Workforce shortage

• Knowledge basis

• Financial

• Infrastructure Issues

• Electronic health records

• MIPS reporting


Telehealth - TapCloud


Telehealth Intervention


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Customized Engagement


Clinical Dashboard


Interface with Clinicians


Remote Patient Monitoring

2953 check ins

Clinical Dashboard 2082 responses (1374

texts from patients with 1342 responses)

13,382 Pushed Messages

Scheduling, medication reminders

Bonsignore, L, Bull, J, Evaluating the Feasibility and Acceptability of a Telehealth Program in a Rural Palliative Care Population: TapCloud for Palliative Care. JPSM, 7/2018 56;7-14

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Qualitative Analysis


Bonsignore, L, Bull, J, Evaluating the Feasibility and Acceptability of a Telehealth Program in a Rural Palliative Care Population: TapCloud for Palliative Care. JPSM, 7/2018 56;7-14

Understand Impact of Alternative Payment Model for Palliative Care


Alternative Payment Model

• Unsustainable financial model under current fee for service reimbursement structure

• New E/M codes are helping but still fall short

Advance care planning

Non Face 2 Face prolonged service codes

Complex chronic care management codes

Transitional care management codes

• With new codes lose ~$160 month


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AAHPM’s APMPatient and Caregiver Support for Serious Illness


Quality Measures

• Comprehensive

assessment performed

• Screening for pain,

dyspnea, nausea,

constipation

• Discussion regarding

emotional needs

• Discussion of spiritual

concerns

• Documentation of

advance directives

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Capitated Model AAHPM

• Tier 1 - $400/month

• Tier 2 - $650/month

• Risk adjustment for quality and Total cost of care


PTAC - APM

PTAC

• Voted to approve for limited scale testing

CTAC’s Advanced Care Model

AAHPM PACSSI Model

• In letter to the Secretary on 5/7/2018

“PTAC recommends that the developers of both models work collaboratively with CMS”

“ the need for palliative care services for Medicare beneficiaries is urgent and that such care can only be provided by changes to the Medicare payment policy”


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Secretary Azar’s Response

“I am particularly interested in the two serious illness models submitted by the Coalition to Transform Advanced Care (C-TAC) and the American Academy of Hospice and Palliative Medicine (AAHPM),” wrote Azar. "We agree with PTAC that a payment model that establishes incentives to provide optimal care for seriously ill beneficiaries should be tested by CMS, and Innovation Center staff have met with submitters and other stakeholders about both proposed models. While it is unlikely that all of the features of any proposed model would be tested as proposed, HHS is clearly benefitting from PTAC's comments and recommendations as we explore designing a future payment model for seriously ill beneficiaries.”

June 21, 2018


What About Other Payors?Medicare AdvantageManaged Medicaid

Commercial Plan


Medicare Advantage

• Continues to grow

• In NC 2013-2017 has grown by 11%; now 32% of all Medicare patients

• Multiple providers

• Increased contracting


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Rise of Medicare Advantage

Metrics for MA Plans

• Hierarchal Condition Categories (HCC) system –determines the risk and reimbursement

• Healthcare Effectiveness Data and Information Set (HEDIS) – performance measures –get bonus from CMS

• Cost – driven by hospitalization

• Satisfaction scores


Other Plans

• Commercial plans leading in value based care with high number of demonstration pilots

• Multiple managed Medicaid plans now offering capitated payment for palliative care


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Developing Innovative SolutionsOutpatient Palliative Care

TelehealthProject ECHO


Continuum of Care


SiloedHigh regulations

Innovation Occurring

What will the future bring?

Move to brink of death care…….• Lower LOS; lower census• Less NH patients• Less dementia/debility type patients• Less reimbursement• Less # organizations• Increased focus on fraud and abuse• Higher % For Profit• Competitive models with little incentive to

move patients to hospice care

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Opportunities


Shifting Epicenter to Home


Fun

ctio

n

Death

Low

Multiple hospitalizations Death usually follows

disease exacerbation

High

Hospital

RehabHome

Health

Home

Health

Hospice Care

Office Visits

PC

Home

In Reality…

Where is the best access point?

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What’s in the Syringe?

• Understanding values and goals of care of patients

• Open, honest conversations about prognosis and risks/benefits of treatment options

• Education on disease process and what the future holds

• Expertise in managing pain and symptoms

• Support in dealing with the stress of serious illness

• Psychosocial support

• Spiritual support

• Navigation and coordination

Impact of EOL Conversations


N = 322 Had conversationDid not have conversation

ICU Admission 4.1% 12.4%

Ventilator 1.6% 11.0%

Resuscitation 0.8% 6.7%

Chemotherapy 4.1% 6.7%

Outpatient hospice 76.2% 57.4%Wright, A. A. et al. JAMA 2008;300:1665-167

The Carolinas Center

Palliative Care BootcampApril 18-19, 2019

Asheville, NC

• Agenda Different models of care

Collaboration with payors

Strategic planning

Staff productivity

Financial models


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Changing Landscape


3rd party with Payors

•Aspire

•Landmark

•Turnkey

Non Profit Collaboratives

•Ohio Hospice

•Teleios (TCN)

APMs

• Independence at Home

•ACOs

HealthcareSystems

•Northwell Health

•Ascension

•Providence

•Bon Secours

Payors

•Cambia

•Optum

•BCBS

•United

Future Challenges

• Medicare Carve out is eliminated

• New vendors entering the space between chronic illness – hospice

• Hybrid blends that are not under hospice regulatory restrictions


Surviving May Depend on…..

• Quality

• Efficient and effective

• Different models of care

• Innovation

• Partnerships

• Post Acute Continuum

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Collaboration Brings…..

• Leverage infrastructure needs

• Payor contracting and negotiation

• Streamline operations to achieve economies of scale

• Benchmark data

• Sharing of best practices

• Expertise by increasing resource access


Quadruple Aim

Patient Experience

of Care

Better Outcomes

Lower Costs

Care for the Clinical

Team


Workforce Shortage


Kamal, Bull, Myers. Future of the Palliative Care Workforce: Preview to an Impending Crisis. The American Journal of Medicine 2017 130, 113-114

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62%Burnout Rate – Hospice and Palliative Care Providers


Kamal et al. Prevalence and Predictors of Burnout Among Hospice and Palliative Care Clinicians in the US. JPSM. 2016; 51(4):690-6.

Project ECHO (Extension of Community Healthcare Outcomes )

• Medical education – trains clinicians in rural/underserved areas to provide specialist-level services

• Specialists at a “hub” mentor and train clinicians in local communities “spokes” to manage a condition that was previously outside their area of expertise

• teleECHO sessions include case presentations/didactics, and promotes mentoring/knowledge sharing


Project ECHO


Expand Provider Network

Primary Care

NPs/PAs PC

Improve Skillset

Case base learning

Didactics

Enhance Outcomes

Symptom scores

Hospice transitions

Provider satisfaction and self efficacy

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In Conclusion

• Healthcare reform is here to stay

• Reform will be driven by Alternative Payment Models where risk is incorporated

• Medicare Advantage is projected to increase it’s growth

• Hospice, while siloed in the healthcare system has a unique opportunity to move upstream and develop community based palliative care programs


In Conclusion

• Patterning with others to leverage opportunities for payor contracts and demonstrate ROI will become more important

• Telehealth will offer solutions to increase access, improve care delivery, and assist with the workforce shortage issues


Thank [email protected]


Looking into the Future of Serious Illness...

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