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Achieving Value Through Palliative Care

Allison Silvers, MBA; Stacie Sinclair, MPP; and Diane E. Meier, MD, FACP
Palliative care is an underutilized and powerful resource in the drive towards value. In the current article, we review published evidence and highlight how Medicare Advantage plans, accountable care organizations, and oncology practices can benefit from concurrent palliative care under value-based payments.
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 patients4,10 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

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