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Achieving Value Through Palliative Care
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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.
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
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