By using telemedicine and relocating the center of care to where a person lives, we have an opportunity to address more unmet demand for palliative care, while giving more control to the seriously ill to meet their stated needs.
RECENTLY, MICHAEL WAS CALLED TO
the hospital for a transitional palliative care consult. He walked into the room to see a Native American man in bed, surrounded by 8 people and a laptop computer on a cart. This man had been a lawyer, activist, probation officer, and more—a defender of his people. At his side was Aggie Pilgrim, chairperson of the International Council of 13 Indigenous Grandmothers, now 92, but still traveling the world with other elder women of First Nation communities to disseminate and preserve their cultures and healing traditions. The others in the room were all ages: from a babe in arms to millennials to baby boomers.
At the end of the bed, the laptop screen showed 8 more family members gathered in support, from Maryland, Los Angeles, Sacramento, and elsewhere. Aggie said a beautiful prayer, pulled out a bundle of white sage, lit it, and passed it around—while, frankly, Michael worried it would set off the hospital’s smoke alarm.
Welcome to the future. This was a videoconference that we, at ResolutionCare,1 had no role in setting up. It was set up by empowered people who used ubiquitous, readily available technology to bridge geographic distance and provide family support. Clearly, there’s a disruption afoot.
The arc of remote consultation support through videoconferencing, or telemedicine, is an evolution from high-cost, technologically complex systems to readily available, low-cost technology that is easily used by both physicians and people receiving care.
Fifteen years ago, Telemedicine 1.0 was the first effort to connect subspecialists in tertiary referral centers to satellite clinics. It involvedthe use of fiber-optic cables, expensive carts at both ends, and dedicated telemedicine centers. Because it was so capital-intensive, it never really took off in northern California, our home base. Although it did provide a great service for many remote communities outside of major metropolitan areas, its high barrier to entry limited its use.
Telemedicine 2.0 has leveraged the rise of ubiquitous smartphones, always-on connectivity, and cloud-based processing to deliver a sizable impact on how physicians provide care. Organizations like Doctor on Demand, Teladoc, and American Well have activated networks of remote-working primary care physicians to provide low-cost, effective telemedicine encounters for episodic problems (such as a sniffy nose or sore throat). Both consumers and employers see huge value when someone can see a doctor while on a coffee break and go back to work. The low barrier to entry has been responsible for an explosion in service providers and locations—including kiosks in CVS and Walgreens. This is driving growth in teledermatology and behavioral health, among other fields.
What we’re doing, as palliative care specialists at ResolutionCare, is what we call Telemedicine 3.0. In some ways, version 3.0 represents the evolution of the technology so that it can disappear— and thus allow for the return of the deep relational work that’s always been at the heart of caring. We’re using these technologies to reach people with ease via technology they already have at their fingertips (or that we provide) to reach them in their homes, to unburden them from travel and transport, and to offer a patientand home-centered locus of care. We’re discovering substantial benefits for the patients, unanticipated efficiencies, and surprising nuances that are intrinsic to this new medium.
Telemedicine and the Seriously Ill
The evolution from the episodic care of Telemedicine 2.0 to the use of telemedicine for the longer-term, chronic issues faced by individuals who are seriously ill (Telemedicine 3.0) eases the burdens of both sick patients and their doctors, and lets us go back to the raison d’être of most physicians: caring for people. The Patient Experience Some cancer patients will make more than 150 trips in their last year of life for infusions, physician appointments, lab draws, imaging, and fractionated radiotherapy. Removing the need for yet another clinic visit can have an immeasurable impact on that patient’s quality of life (QOL). When people must drag their tired, broken bodies into clinics to satisfy every stakeholder but themselves, when they have to take time off work, deal with parking, and leave their own turf to sit in a doctor’s office and wait (and wait) to be seen—while surrounded by other really sick people— you can imagine the negative effect on their physical, mental, and spiritual states.
Home visits, by contrast, remove many of those burdens for sick people. For the physician, seeing individuals where they live, and gaining all the extra information gleaned just by walking into their homes, has many real benefits that can improve care. However, the doctor may be viewed as an invader—there’s a power dynamic, and simply by being a doctor and walking into a person’s home, you shift the control from them to you. When sick people know the doctor is coming, they work really hard to get the home all cleaned up, to appear a certain way, to take a shower and fluff themselves up. Even though a home visit frees them from certain burdens, they burden themselves in other ways because they have a sense of what’s acceptable for the doctor to see.
Now compare that to telemedicine and a videoconference using a cloud-based platform, where the person doesn’t need to travel or clean up, and simply needs a wall that looks presentable. The burden of preparation and getting everything ready has been removed. From the doctor’s perspective, you don’t have to allow for commute time and traffic—the “house call” can seamlessly fit into your day without disruption.
Surprisingly—at least for those who haven’t done it yet—the intimacy, the immediacy, the feeling of being right there in the room together, is palpable. One would think that the technology might get in the way somehow, but instead, it disappears. The call is an interaction between 2 people, face-to-face, sharing and talking intimately. Yet, that connection takes less time overall. Whereas an in-person home visit for a new-patient consult takes between 90 to 120 minutes, a telemedicine first consult takes 60 to 70 minutes.
Because we work as part of an integrated, multidisciplinary team, some of our telemedicine sessions include just the sick person and the physician, while other sessions might include other care providers, such as a nurse, social worker, chaplain, or family members. The needs of the person we’re caring for tell us what to do, whom to involve, and when. As we often say at ResolutionCare, “We do what makes sense.” This doesn’t, however, totally remove the need for in-person visits. The information gained in those visits is brought back to the interdisciplinary team and helps us understand the full context of this person’s living situation. We do a better job of shared decision making when we have that complete picture.
Locus of Control
Besides improving a person’s QOL and gaining efficiency for the physician, one of the most important benefits of telemedicine for palliative care is that it helps the sick person retain a feeling of control over his or her life. This is in sharp contrast to the market view that takes sick people and makes them “patients,” subject tothe rules of our medical world, where they often have procedures done to them rather than for them.
Sick people aren’t patients; they’re people. Over the past 50 years, we’ve medicalized illness and our natural progression toward death. We’ve constructed our technology-intensive, industrial model around “fix it, fix it, fix it”—and that model fails sick people miserably. By relocating the center of care to where a person lives, we release them from being patients and offer them guidance within the medical landscape that we’re familiar with and they’re not. How ironic that innovative technology is responsible for bringing us back to the human-centered, relational model of care that’s been subverted for the past 50 years. Our experience at ResolutionCare suggests that our use of telemedicine in palliation will increase—because of the efficiency of the approach, the opportunity to address more unmet demand, and the increased control afforded patients.
Value-Based Payment for Telemedicine
Much of the fix-it model, and the reason we do procedures to people rather than for them, has come about because of how payers traditionally reimbursed for services. The fee-for-service (FFS) model is a one-size-fits-all, check-the-box, and move-on-to-thenext- patient approach. Each person receiving palliative care has the same menu of possible services, and his or her individual situation or needs have no place in the formula. This assumed homogeneity does not match our experience in practice, as differences in socioeconomic class, disease type, and length of time on service can greatly impact the depth and scope of care required and the patient census each multidisciplinary team can accommodate.
But the landscape is changing. Payers, providers, and people receiving care are seeing the need and are demanding that palliative care be available as a covered benefit. In California, Senate Bill 1004 requires Medi-Cal managed care plans to offer access to palliative care programs—and 4 other states have similar laws either in place or on the horizon. This is occurring while the supply of specialty palliative care resources is overwhelmed by the number of sick people who are clinically appropriate for care.
In contrast to FFS, value-based payment allows for coverage of the entire multidisciplinary palliative care team, rather than just the physician and nurse practitioner. This, in turn, helps increase the capacity of subspecialty palliative care across all disciplines and is an investment strategy by insurance partners to entice more providers into the field. With value-based payment payers say, “We’ll pay you not on the basis of doing X, Y, and Z—but on how you address the life goals articulated by the patient and family.” You can then use an adaptable and nimble response to the individual circumstances of an individual person to try and reach those goals. It’s outcomes-based (see ).
Table. Difference in Focus: From Volume to Value-Based Payment
Physician-based care >80% of the time
Team-based care, with 20% use of physician and 80% use of mid- or low-level providers in a multidisciplinary team:
In-person visit (patient goes to provider, or provider to patient)
Combined in-person and telemedicine visits
Payment by visit
Payment for patient care by month (per patient per month) for team-based care
Quality care standard: length of life
Quality defined as patient satisfaction and/or quality outcomes, with payment for these outcomes
ResolutionCare’s value-based reimbursement is in the form of per-patient-per-month (PPPM) payment. Our current PPPM reimbursement model reflects the challenges associated with the rural population we serve and provides support for experimenting with the use of new delivery resource models, new approaches to care, and new community affiliations and partnerships. Some of our PPPM payments are unencumbered, meaning they are a flat fee with no strings attached. Other value-based reimbursement models provide a base rate, with bonuses associated with the achievement of select quality measures and the reduction in select utilization indicators.
When it comes to metrics, payers are looking at quality and satisfaction. But in the end, the most important metric to them is decreased cost. Adding kind, person-centered care always increases satisfaction; we are committed to the value of the person’s QOL. The costs of care go down when you provide an alternative to high-cost, low-value, and high-stress interventions.2 Palliative care increases the length of a person’s life and decreases payers’ net costs.3 Those people who move on to hospice after a palliative care intervention have longer lengths of stay in hospice.2
We anticipate that value-based reimbursement will both grow and change over time as we better understand population needs and differences, and have greater consensus in the field regarding the critical indicators of quality. Multiple forms of value-based payment are likely, with future reimbursement to include a base rate plus quality and shared cost savings components.
Where We Go From Here
Eighteen months ago, at the time of ResolutionCare’s last article for this journal,4 we talked about a looming seismic change that would make the healthcare system spawned by our current FFS model unrecognizable in 5 years. At ResolutionCare, where we have cared for more than 500 souls to date, the exploding demand for palliative care and the potency of value-based payments allows us to address medical symptoms, anticipatory planning, social determinants of health, and whatever yields value for each patient.
We began a successful pilot program with Partnership Health Plan in September 2015 that will go until California Senate Bill 1004 takes effect in April 2017. At that point, we expect to continue the value-based system of payment established by the pilot, with a capitation rate to be decided. Through our newly formed ResolutionCare Institute, a 501(c)3 organization, we will continue our affiliation with the University of New Mexico’s Project ECHO5 to provide palliative care education to primary care practices in our region and beyond. Working with Project ECHO and with academics for the development of a palliative care curriculum, we’re creating affiliations that will offer our environment as an educational experience for physicians and other professionals in training. It will also be a source for our publications and research activity, and allow us to participate in important research to advance our field.
Where we need to go, and still have work to do, is involvingcommunity partners in our work with seriously ill people. Healthcare has been very narrowly defined as hospital-based care and invasive procedures. With the communities we serve, we’re finding that the populations we care for need much more than procedures: the palliative care social workers at Resolution- Care could spend 50% of their time on housing issues alone.
As value-based payment becomes the norm, where we’re given a block amount of money to create value for our clients, we may sometimes find that the best use of that money is to buy them food, transport them to their appointments, find them transitional or permanent housing, or get them to the dentist for a painful tooth. These services may not be covered under anyone’s plan, but they’re central—and critical—to that person’s well-being and QOL.
In the end, telemedicine and value-based payment returns us to soulful, person-centered care that is based on how we can best serve each individual’s very specific needs. Payers are realizing that this approach leads to higher satisfaction, fewer unnecessary interventions, and lower cost. Michael D. Fratkin, MD, is founder and chief medical officer, ResolutionCare.
Stephen G. Franey, MBA, is chief financial officer and chief strategy officer, ResolutionCare.
ADDRESS FOR CORRESPONDENCE
Michael D. Fratkin, MD
Founder and CMO, ResolutionCare
2440 23rd Street, Suite B
Eureka, CA 95501