Death and dying are inevitabilities of cardiac transplant. Either your patient will die without the transplant or someone else has to die first to save your patient. That relationship between the donor and patient is ever present, and even in the 1980s when intensive care units were ramping up and the mantra was: “do everything always”, I was having frequent conversations with patients about end-of-life issues.
I knew then that this infant field of palliative care was imperative to modern medical practice and was a much-needed specialty.
Today, I am happy to see that palliative care is one of the fastest growing specialties in American medicine. Just last week the Institute of Medicine (IOM) released their report “Dying in America.” This behemoth anthem will assist administrators, policy makers, and medical educators in developing the resources that are desperately needed in this field and changing the way we fund these services.
One of the most important factors about this growth industry is that it is truly driven by need. Our aging population combined with the financial shift in medicine from fee-for-service to value-based care has opened the door for new models that can adequately care for the chronically ill in a cost-effective yet high quality way.
To outline the problem, just a quick review of the numbers we are becoming all too familiar with.
Five percent of the U.S. population spends 50 percent of the healthcare dollars. The people making up this five percent are of two varieties. First are those with acute illness requiring long hospitalizations and recovery, who are otherwise healthy and will return to a normal life when they recover. Their care is very expensive, but maybe only for a year or two. The second cohort comprises the chronically ill and actively dying.
As we know, dying patients are expensive. Five percent of Medicare beneficiaries die each year and their end-of-life care accounts for about 30 percent of total Medicare spending with as much as 1/3 spent in the last month of life. (Christopher Hogan, et al. Medicare Beneficiaries’ Costs Of Care In The Last Year Of Life. Health Affairs, 20, no.4 (2001):188-195). The cost of death is astronomical because in the last 30 years, end-of-life care in this country has been a highway to the intensive care unit and death in the hospital. In fact, 70 percent Americans will die in the hospital, a long-term care facility, or nursing home, but the same percentage says they would prefer to die at home.
The chronically ill are also expensive. For example, let me introduce you to Matilda. She is an 80-year-old woman, a smoker with advanced chronic obstructive lung disease (COPD) on home oxygen, Type II diabetes, heart failure from coronary artery disease and an irregular heart rhythm called atrial fibrillation. She is on 12 medications and, in addition to her primary care doctor, sees three other specialists. Her primary caregiver is her 74-year-old husband, who is developing dementia and has health problems of his own. Their children call often but live out of state.
Unfortunately, Matilda has started that terminal re-admission cycle we see so often and has been in the hospital two times in the last three months for shortness of breath. Once was a COPD exacerbation and the other two were for volume overload from heart failure. She required nursing home care for 2 weeks after the last admission.
Each of these events costs tens of thousands of dollars—over and over and over again.
How could we help? Enter the palliative care model. Palliative care as a philosophy seeks to optimize quality of life and relieve suffering by focusing on maximizing symptom management to relieve pain and increase comfort. In reality this theory is applicable to so much more than the last few months of life. This philosophy can be applied to any chronically ill patient who is experiencing a cycle of hospital admissions and suffering from a lack of resources.
Instead of Matilda being the victim of her relapsing illness that always progresses to the point of hospitalization, imagine the model when we put Matilda in the center and bring the resources to her. Things like 24/7 telephone support can prevent a trip the emergency room in an ambulance. Home visits by providers to administer even intravenous medications can avoid hospitalizations.
We know this is cheaper and gets better outcomes. There are two seminal papers in the field: one from the New England Journal of Medicine in 2010 and one from the American Journal of Managed Care in 2007. The 2010 paper showed that a palliative care model versus a regular care model in cancer patients increased quality of life scores. Patients showed 58 percent less depression and 39 percent less aggressive end-of-life care, and longer median survival times by several months. (Temel et al. NEJM, August 2010, pp. 733-742).
The 2007 paper was a randomized controlled study of the palliative the care model as applied to a patient cohort that largely carried an oncologic diagnosis. The group randomized to palliative care had 30 percent fewer emergency department visits, 28 percent fewer hospital admissions and two years’ more life expectancy. This happened at an $18,000 per patient/per month lower price tag. (L. Sweeney, A. Halpert, J Waranoff. American Journal of Managed Care, February 2007, pp. 94-92.)
The secret to these cost savings and improved outcomes is that palliative care moves the locus of care to the home. Palliative care is patient-centered and delivers care where the patient is most comfortable resulting in better outcomes while at the same time being more cost effective.
There are three major palliative models out there now. Aetna Compassionate Care uses a telephonic case management program focused on patients facing a terminal illness to improve outcomes and decrease hospital admissions. Kaiser Permanente offers home-, hospital-, and clinic-based palliative care to customers at a capitated price. Finally, companies like Sutter Health Advanced Illness Management connect 24 hospitals and 5,000 physicians in Northern California to bridge the gap between acute care and end-of-life care for Medicare patients using a fee-for-service model. Blue Cross Blue Shield of Illinois is also doing something similar and has had great outcomes.
All three of these are successful, and an examination of their models reveal several commonalities, but the most important similarities are that they use a medical “team” model that provides more than just healthcare; they use a capitated or value-based payment system to reward providers who reduce inpatient care; and each uses a patient- and family-centered approach.
All this leads to the obvious question: if value-based care in the palliative setting means coordinated care, and the outcomes achieved can be cost saving, why isn’t everyone moving to this model? The reason is always the same: money.
Current reimbursement structures do not support palliative care models. We bill for procedures, not outcomes, and even the shift to paying for outcomes is physician-centered. Chaplains and social workers are imperative, but they do not generate revenue under the current model.
The problem is both the nature of fee-for-service medicine, but also the very way we define a billable service. The Social Security Act, which defines Medicare, has been interpreted to exclude supportive care, like that provided by most members of a palliative care team because coverage is limited to interventions that improved health only: “[care is covered unless] not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” SSA §1862(a)(1)(A); 42 U.S.C. 1395y(a)(1)(A)
And as we know, the Medicare model heavily influences most private insurers.
However I see this as an opportunity. We want the outcomes palliative care can offer. We want the cost-savings palliative care can generate.
The payment model simply has to change, and private payers are uniquely positioned to make these changes. In doing so, private payers can have a tremendous impact on the way we pay for healthcare in this country and also on their own bottom line.
The IOM report calls for this type of change, specifically addressing federal reimbursement. Some insurance companies are already reimbursing for end-of-life discussions.
But this is just a drop in the bucket. What palliative care is really about is the coordination of care for the chronically ill including adequate follow-up and non-traditional resources. We get there through market innovation and implementation of value-based models and a move away from fee-for-service.
This is a business opportunity as much as it is about changing the way we manage chronic illness to improve patient outcomes and quality of life. We need market innovators and risk takers, not necessarily legislators, to help get us there.