Hospice and Palliative Care: Value-Based Care Near the End of Life Mary Dittrich, MD, FASN Senior Medical Director, Remedy Partners Joseph W. Shega, MD National Medical Director, VITAS Healthcare 2017 Remedy Partners, LLC. All Rights Reserved.
Presenters Mary Dittrich, MD, FASN Senior Medical Director, Remedy Partners Dr. Mary Dittrich is a nephrologist and partner at Boise Kidney & Hypertension Institute in Meridian, Idaho. Dr. Dittrich received her medical degree from the University of Colorado Health Sciences Center in Denver, Colorado. She subsequently served a residency in Internal Medicine followed by a Chief Residency in Internal Medicine at the University of Washington Hospital. She went on to complete fellowship training in Nephrology also at the University of Washington in Seattle, Washington. She previously served as the Chairman of the Medical Advisory Board for Liberty Dialysis and was the Chief Medical Officer for Liberty Health Partners before joining Remedy Partners as Senior Medical Director. Dr. Dittrich and her husband have three children. Joseph Shega, MD National Medical Director, VITAS Healthcare Dr. Joseph Shega is a geriatrician and hospice and palliative care physician who currently serves as the National Medical Director for VITAS Healthcare. He completed medical school at Northwestern University and an Internal Medicine Residency at the University of Pittsburgh followed by a geriatric fellowship at University of Chicago. He is an Associate Professor of Medicine at the University of Central Florida and a member of the National Academy of Sciences Rountable on Quality Care for Persons with Serious Illness. He has over 50 peer reviewed publications related to persons with serious illness and serves on the editorial board for the Journal of Pain and Symptom Management. Hospice and Palliative Care: Value-Based Care Near the End of Life 2
Webinar Objectives In this webinar, we will discuss: The role of palliative and hospice care in value-based care How to define and distinguish between palliative care and hospice care The services covered under Medicare s hospice and palliative care benefits Current research on patient outcomes under palliative and hospice care The role of palliative care and hospice in advance care planning How to identify patients who may benefit from palliative care and hospice Hospice and Palliative Care: Value-Based Care Near the End of Life 3
Palliative Care, Hospice and Value-Based Care A small proportion of chronically or acutely ill patients contribute disproportionately to health care spending and often receive fragmented or ineffective care. Palliative care and hospice aim to prevent or control discomfort or suffering and support the best possible quality of life for patients suffering serious illness and their families. Palliative care and hospice services improve patient-centered outcomes such as pain, depression, and other symptoms; patient and family satisfaction; and the receipt of care in the place that the patient chooses. Meier DE Increased access to palliative care and hospice services: opportunities to improve value in health care. Milbank Q. 2011 Sept ; 89(3): 343-80. Hospice and Palliative Care: Value-Based Care Near the End of Life 4
Palliative Care, Hospice and BPCI BPCI admission may occur at the time of initial diagnosis of an acute condition (e.g., pneumonia) or during an exacerbation of a chronic disease (e.g., COPD) or at the time of a planned or emergent surgical procedure. These situations provide an excellent opportunity to discuss goals of care, complete advanced directives and potentially introduce the concept of palliative or hospice care. The discussions around discharge are another excellent time to deliver information regarding expectations for recovery and planning regarding life sustaining treatment and potential for rehospitalization in the event of worsening health status. Hospice and Palliative Care: Value-Based Care Near the End of Life 5
Costs of Hospice Care for BPCI Patients In the BPCI program, the holistic and longitudinal care of the patient requires providers be familiar with and have access to hospice and palliative care services. BPCI patients that go on hospice during their episode continue to be included in the program, although costs specific to hospice services are excluded. Other costs still add up as usual. Hospice and Palliative Care: Value-Based Care Near the End of Life 6
What about PAC facilities? Almost a quarter of elderly patients die in skilled nursing facilities (SNFs) each year Admission to a nursing home is associated with cognitive dysfunction, poor functional status, advance age and frailty. These factors increase the need for advanced directives as well as the appropriateness of hospice or palliative care. These discussions take time and length of stay in post-acute facilities is generally longer than the anchor inpatient stay, thus providing a unique opportunity to address palliative care and hospice. Hospice and Palliative Care: Value-Based Care Near the End of Life 7
Paradox of Care What Americans Want What Americans Get 71% choose quality of life over interventions, receive the opposite (Wehri, 2011) 80 90% prefer to be at home at end of life Not to be a burden on their family 30% of documented care aligns with preferences (Wehri, 2011) Over-medicalized care in last year of life accounts for 25% of Medicare spending (Calfo, 2004) Only 1/3 of deaths occur at home (CDC, 2014) 30% are in the ICU the month preceding death (Teno, 2013) 33% experience 4+ burdensome transitions in last 6 months life 50% of older adults in emergency department in last month of life 25% seniors are bankrupted by medical expenses (Kelley, 2013) 46% of caregivers perform nursing tasks, such as wound care and tube feeding (Reinhard, 2012) In the last year of a patient s life, family care averages nearly 66 hours per week (Rhee, 2009) Hospice and Palliative Care: Value-Based Care Near the End of Life 8
Hospice and Palliative Care Interface Palliative Care Palliative Care Hospice Hospice Curative/disease-modifying therapy Palliative care Time course of illness Last months of life Family bereavement care Hospice and Palliative Care: Value-Based Care Near the End of Life 9
Palliative Care and Hospice Philosophy Symptom Management Goals of care Communication Patient and family centered Goals-of-care discussions result in timely hospice referrals End-of-life discussions Shared decision making Care transitions Prognosis Hospice and Palliative Care: Value-Based Care Near the End of Life 10
Eligibility Palliative Care No prognosis requirements Hospice 6 months or less on average should the terminal illness run its normal and expected course Physician estimate Clinical determination Nutrition Cognition Function Symptoms Healthcare Utilization Disease Specific Decline Hospice and Palliative Care: Value-Based Care Near the End of Life 11
Reimbursement Mechanism Palliative Care Medicare Part B Fee for service Grants Member-based per month (health plan contracted) Hospice Medicare Part A Medicaid Private insurance Charity care Hospice and Palliative Care: Value-Based Care Near the End of Life 12
Location of Care Palliative Care Fee for service Hospital Outpatient Skilled facilities Long term care Member per month Community-dwelling Hospice Patient home Community Assisted living Long term care Level of care Routine home care Continuous care Inpatient care Respite care Hospice and Palliative Care: Value-Based Care Near the End of Life 13
Professional Services Palliative Care Depends upon the goals and resources of the program No regulatory requirements Hospice Interdisciplinary team mandated Physician Nurse Social worker Pastoral counselor CNA Optional support OT/PT/speech Respiratory therapy Music, massage, pet Hospice and Palliative Care: Value-Based Care Near the End of Life 14
Other Support Palliative Care No required services Hospice Medications Equipment Bereavement care 24-hour availability Supplies Incontinent products Nutritional support Wound care products Hospice and Palliative Care: Value-Based Care Near the End of Life 15
Summary of Evidence Palliative Care Improved satisfaction with care Improved pain and symptom management Decreased healthcare costs (inpatient) Increased completion of advance care planning Improved adherence to healthcare wishes at the end of life End-of-life discussions Increased hospice utilization with longer length of stay Decreased mortality (outpatient palliative care in lung cancer) Muir C. Journal Pain and Symptom Management. 2009 http://www.jpsmjournal.com/article/s0885-3924(10)00316-7/fulltext Temel JS et al. NEJM 2012. http://www.nejm.org/doi/full/10.1056/nejmoa1000678#t=article Morrison, R. S. et al. Arch Intern Med 2008. http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414449 Gade G. et al. J Palliat Med. 2008. https://www.ncbi.nlm.nih.gov/pubmed/18333732 Ciemins et al. J Palliat Med 2007. https://www.ncbi.nlm.nih.gov/pubmed/18095814 Hospice and Palliative Care: Value-Based Care Near the End of Life 16
Early Outpatient Palliative Care in Advanced Lung Cancer Temel JS et al. NEJM 363(8):733-741, http://www.nejm.org/doi/pdf/10.1056/nejmoa1000678 Hospice and Palliative Care: Value-Based Care Near the End of Life 17
Hospice Length of Stay Days of Care 80 70 60 50 40 30 20 2014 Average Length of Stay 71.8 72.6 71.3 2012 2013 2014 18.7 18.5 17.4 30-89 days 18% Proportion of Patients by LOS 90-179 days 9% 180+ days 10% <7 days 35% 10 0 Average Length of Service Median Length of Service 15 to 29 days 13% 8-14 days 15% NHPCO 2014 Facts and Figures - Hospice Care in America. https://www.nhpco.org/sites/default/files/public/statistics_research/2014_facts_figures.pdf Hospice and Palliative Care: Value-Based Care Near the End of Life 18
Prognosis Considerations How does a clinician determine hospice appropriateness? A medical prognosis (of a) life expectancy of six months or less, as determined by two physicians, if the illness runs its normal course Benefits Improvement and Protection Act (BIPA) 2000 Certification of terminal illness of an individual who elects hospice shall be based on the physician s or medical director s clinical judgment regarding the normal course of the individual s illness. Many resources available to facilitate with prognosis estimation, including VITAS app Hospice and Palliative Care: Value-Based Care Near the End of Life 19
Hospitalization, ADL Change & Death Boyd, et al. Recovery in Activities of Daily Living Among Older Adults Following Hospitalization for Acute Medical Illness. J Am Geriatr Soc. 2008 Dec; 56(12): 2171 2179. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc2717728/ Hospice and Palliative Care: Value-Based Care Near the End of Life 20
Not All Hospices Offer Same Support Expanded Team Goals of care After-Hours Services High-Acuity Care Mandatory Elements Core Professionals Levels of Care 24/7 Availability Medical Equipment Intensity of Service Advanced Technologies Death Attendance Physician Support Hospice and Palliative Care: Value-Based Care Near the End of Life 21
Levels of Care Level of Care Description Reimbursement Proportion of Days 2014 Routine Home Care where the patient resides $186/$146 93.8% General Inpatient Inpatient facility for complex or acute symptoms $694 4.8% Continuous Respite Shifts of care provided where patient resides until crisis is resolved Short-term care in an approved facility to give caregiver a break $910 1.0% $161 0.4% Hospice and Palliative Care: Value-Based Care Near the End of Life 22
Summary of Evidence Hospice Care Improved satisfaction with care Improved pain and symptom management More likely to die in location of choice: at home Decreased hospital 30-day readmissions Decreased healthcare costs Prolongation of life Family support Bereavement services Teno et al. JAMA 2004 Kelley, Health Affairs 2013. https://www.ncbi.nlm.nih.gov/pubmed/14709580 Shega et al. Journal of Pain and Symptom Management 2008, http://www.jpsmjournal.com/article/s0885-3924(07)00749-x Conner et al Journal of Pain and Symptom Management 2007, https://www.nhpco.org/sites/default/files/public/jpsm/march-2007-article.pdf Hospice and Palliative Care: Value-Based Care Near the End of Life 23
Hospice Use Decreases Hospital Utilization Kelly, A. Hospice enrollment saves money and improves quality. Health Affairs 2013. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3655535/ Hospice and Palliative Care: Value-Based Care Near the End of Life 24
Healthcare Costs, Cancer, Last Year of Life Exposure (weeks) Non-Hospice Hospice Difference 1 $71,582 $66,779 $4,803 2 $70,987 $63,013 $7,848 3-4 $72,660 $59,595 $13,065 5-8 $74,890 $56,986 $17,903 9-26 $72,432 $60,326 $12,106 27-52 $66,035 $65,300 $735 >52 $48,918 $56,368 -$7.387 Total $71,517 $62,819 $8,697 Obermeyer, Z et. Al. Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients With Poor-Prognosis Cancer. JAMA 2014. https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4274169/ Hospice and Palliative Care: Value-Based Care Near the End of Life 25
Value of Advance Care Planning Basis for high-quality person-centered care Opportunity to discuss wishes/preferences and care choices 89% of people surveyed said healthcare providers should discuss such issues, but only 17% had the talk Serves as an open and continuous dialogue to continue to match preferences with care Code status/power of attorney for healthcare Role of hospice versus emergency room/hospital Hospice and Palliative Care: Value-Based Care Near the End of Life 26
ACP Codes Overview CPT codes 99497 and 99498 can be used on the same day with other E/M codes The time accountable for the ACP codes must be included separately from the other service Time for the ACP codes may not be used to meet the time requirement for other E/M service codes CPT Code 99497 99498 Description Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure). Hospice and Palliative Care: Value-Based Care Near the End of Life 27
Hospice appropriateness Helpful resources Streamline referrals Hospice and Palliative Care: Value-Based Care Near the End of Life 28
Send hospice overview to patient/family Hospice and Palliative Care: Value-Based Care Near the End of Life 29
Contact Us For More Information Mary Dittrich, MD, FASN Senior Medical Director Remedy Partners mdittrich@remedypartners.com Joseph W. Shega, MD National Medical Director VITAS Healthcare Joseph.Shega@vitas.com