Transcript What Is Palliative Care? - Community Hematology Oncology

Highmark Update
A Bloschichak MD, MBA
Sr Medical Director, Provider Strategy
Highmark’s
Pay-4-Value
Programs
Highmark’s P-4-V Strategy
Highmark Goal: Move 75% of Highmark membership to “pay for value” programs
over the next 3 to 5 years
4
Hospital QualityBlue
Highmark’s PCMH/ACA Programs
More than 69% of members in
Western Pennsylvania now
receive care within a Pay-forValue program
More than 60% of members in
Central Pennsylvania now receive
care within a Pay-for-Value
program
Central Pennsylvania
Quality Blue PCMH
Western Pennsylvania
Quality Blue ACA/PCMH
• 287 practices representing
43 PCMH entities
• 1,738 practitioners
• 288,869 attributed members
• 432 practices representing
62 PCMH and 77 ACA entities
• 1,536 practitioners
• 545,434 attributed members
Delaware PCMH Pilot
West Virginia
Quality Blue PCMH
• 92 practices representing
30 PCMH entities
• 383 practitioners
• 34,437 attributed members
• 38 practices
• 113 practitioners
• 35,320 attributed members
More than 840 practices
More than 3,700 practitioners
More than 906,000 members
PERFORMANCE MEASUREMENT OVERVIEW
Quality = 50%
28 metrics plus 1
informational
Cost/Utilization = 50%
Total PMPM trend metric
DATA OVERVIEW:
• Quality Measures
• Care Management / Population Management
• Cost / Utilization
7
PMPM Assessment
Exceeding
Trend
Current Experience
7/1/2012 - 6/30/2013
Average
Category
Members
Children
6,890
Adults
14,170
Medicare Advantage
1,039
Composite
22,098
Actual
Experience
$220.59
$521.35
$1,072.77
$453.51
Projected Base Period
1/1/2013 - 12/31/2013
Base Period
PMPM
$225.85
$532.92
$1,097.90
$463.74
Projected Benchmark Period
1/1/2014 - 12/31/2014
Threshold
Market PMPM
Full Savings PMPM
PMPM
$236.72
$234.55
$228.03
$556.78
$552.02
$537.71
$1,149.59
$1,139.26
$1,108.25
$484.86
$480.65
$467.98
8
COST & UTILIZATION
Commercial Adult
Avg Attrib Members
Avg Member Risk
Curr
•Collapsed categories
within Inpatient and
Outpatient, and top 10
specialties within
Professional
•Broken into Commercial
Adult, Commercial
Pediatric, Medicare
Advantage
•Including Utilization/1000,
months, year over year
trend, and benchmarks
Top 10 Billing Specialties and
Primary Care
Summarized Milliman
Categories
membership
•Showing current 12
Member Months
Mkt Member Risk
Utilization / 1000
•Based on attributed
PMPM
13,744
2.31
Totals
represent
all spend
Trend
Mkt
164,923
2.63
PMPM
Trend
Curr
Trend
Mkt
Trend
Facility Inpatient
Medical
Surgical
Maternity
Psych / Substance Abuse
SNF / Rehab
Subtotal
19.5
23.1
13.3
5.8
1.3
63.0
(10.0%)
(5.1%)
(4.6%)
26.6%
(36.2%)
(5.4%)
25.4
25.5
13.4
4.6
2.7
71.6
10.3%
(1.5%)
4.1%
9.2%
19.8%
4.9%
$26.81
60.65
5.84
4.13
1.65
$99.07
(10.3%)
(1.0%)
3.4%
118.2%
(44.2%)
(2.5%)
$25.54
58.43
7.10
2.82
2.72
$96.61
14.2%
7.2%
13.3%
9.0%
9.9%
9.6%
Facility Outpatient
Emergency Room
Surgery - Hosp Outpatient
Surgery - ASC
Psych / Substance Abuse
Radiology
Pathology / Diagnostics
Pharmacy
Other
Subtotal
144.6
67.4
111.3
111.6
430.4
1,073.7
88.6
1,810.2
3,837.7
(2.0%)
6.6%
(1.5%)
(13.9%)
1.5%
5.3%
(27.0%)
10.5%
4.9%
183.3
92.3
109.0
78.8
492.5
1,004.8
161.5
2,121.0
4,243.2
7.8%
4.6%
4.6%
(3.2%)
9.9%
5.4%
10.2%
25.1%
15.1%
$19.89
40.32
22.68
1.18
25.37
12.25
4.37
33.87
$159.92
6.5%
11.8%
6.9%
0.7%
7.3%
4.1%
(60.8%)
3.9%
2.3%
$25.57
42.09
14.04
1.11
34.68
15.62
14.18
33.82
$181.11
13.5%
12.8%
8.3%
9.0%
14.9%
(6.5%)
12.9%
20.3%
12.2%
Professional - Show top 10 categories
Primary Care
Radiologist
Ancillary
Primary Care - Ped
Anesthesiologist
Orthopedics
Physical Therapy
Hospital
Psychologist
OBGYN
Other
Subtotal
4,355.8
1,348.8
874.5
65.8
331.9
550.0
2,159.7
613.0
458.3
630.1
6,043.0
17,430.8
9.8%
2.1%
1.8%
(14.3%)
(24.3%)
2.7%
5.2%
67777.3%
3.6%
(2.8%)
3.0%
7.6%
4,895.6
1,522.6
2,564.5
109.8
350.3
671.5
2,055.5
195.0
403.5
638.1
6,981.1
20,387.5
6.8%
3.5%
10.2%
(20.5%)
(2.0%)
9.2%
7.8%
459.0%
(10.7%)
(0.0%)
5.3%
6.4%
$24.21
9.94
7.71
0.39
7.51
6.61
6.61
6.20
3.96
6.62
46.48
$126.24
8.8%
(4.5%)
8.7%
(11.2%)
(1.1%)
3.8%
15.0%
107436.3%
3.7%
(2.1%)
(0.3%)
7.8%
$25.60
9.53
11.11
0.68
8.61
8.02
6.53
2.18
3.47
7.62
58.77
$142.11
8.2%
(2.8%)
10.3%
(13.4%)
8.8%
10.0%
10.3%
1066.8%
(11.7%)
(0.9%)
8.1%
8.0%
Other
Prescription Drugs
Other
Subtotal
16,568.9
884.4
17,453.4
(7.6%)
0.9%
(7.2%)
16,346.2
1,000.1
17,346.3
(4.2%)
0.8%
(3.9%)
$88.63
11.29
$99.92
1.7%
5.7%
2.1%
$95.54
11.69
$107.23
6.6%
(1.7%)
5.6%
Total Medical
Total Product
21,331.6
38,784.9
7.0%
0.1%
24,702.3
42,048.7
7.8%
2.7%
$385.23
$485.15
2.7%
2.6%
$419.84
$527.08
10.1%
9.2%
9
Specialist Pay-4-Value
Developed and implemented Specialist P-4-V programs in:
•
Oncology
 Oncology chemotherapy drug pathways
 OncMan oncology patient management P-4-V program. Focus is on
preventing hospitalizations and ER visits for dehydration and pain in
oncology patients actively receiving chemotherapy
•
Dialysis / ESRD
 In conjunction with DaVita
•
Orthopedics
 Orthopedics bundled payments utilizing “Potentially Avoidable
Complications and Costs” (PACs)
•
Cardiology
 Quality and efficiency feedback utilizing episodes of care
10
ACO / Shared Savings
Strategy is to build ACO / Shared Savings / Risk-Sharing partnerships
with provider groups and systems that illustrate maturity in:
• PCMH as foundation
• Quality
• Population Health – Culture and Tools
• IT – EHR, Patient portal, use of registries
• Care Management
• Care cost and utilization reports and trends
Currently have 6 ACO agreements in various stages of development in
our markets
11
“The Future Ain’t What It Used
To Be”
Yogi
12
Highmark’s Advance Care
Planning/End-of-Life (ACP/EOL)
Initiatives
The Palliative Care Dilemma - Nature of the Problem
Historic Highmark programs have not been able to change the trajectory of care
• Evident by a median hospice length of stay (LOS) of 14 days for Medicare Advantage
Life Prolonging Therapy
Hospice Benefit
Death
Life Prolonging Therapy
Diagnosis of
Serious Illness
Palliative/Complex Care
Coordination
Bereavement
14
Highmark’s Advance Care Planning/End-of-Life
(ACP/EOL) Initiatives
Mission:
Assist members to live better with serious, life limiting chronic illness by raising awareness of
advance care planning and end-of-life issues.
Primary Objective:
Educate members and their families on informed decision making. This can be accomplished
by guiding them through the process of clarifying and documenting their values, beliefs and
goals for the care they wish to receive, or not receive, when faced with a life limiting illness.
Secondary Objective:
Encourage providers to initiate advance care planning discussions with their patients and to
consider the value of palliative care both for patients receiving curative treatment and those
who can no longer benefit from it.
15
Highmark’s Advance Care Planning/End-of-Life
(ACP/EOL) Initiatives
How is this accomplished?
• Community outreach and collaboration to implement the use of POLST (Physician
Order for Life-Sustaining Treatment)
• Employee and Member Awareness Programs
• Quality Blue Hospital Pay for Value Programs
• Educational Tools for Providers
• Advanced Illness Services Program
16
What Is Palliative Care?
• The goal of palliative care is to
relieve suffering and provide the
best possible quality of life for
people facing the pain,
symptoms and stresses of
serious illness
• It is appropriate at any age and
at any stage of an illness, and it
can be provided along with
treatments that are meant to
cure
17
Palliative Care ≠ Hospice
• Palliative care is not restricted to end-of-life care and is appropriate for any patient with a
serious chronic illness, regardless of prognosis
• Hospice is a form of palliative care specifically targeted to the dying, those with a prognosis
of six months or less if the disease pursues its normal course
18
Palliative Care in Practice
• Controls pain and symptoms
• Uses the crisis of the hospitalization to facilitate communication and decisions
about goals of care with patient and family:
– Interdisciplinary approach
– Needs-based service - any diagnosis, any prognosis, any stage, any setting
– Provides practical support for family caregivers and helps patient remain safely
at home
• Coordinates care and transitions across a fragmented medical system
19
Chemotherapy + Early Palliative Care = A New
Equation
• Study in a Cancer Clinic of 151 patients with newly diagnosed metastatic non-small cell
lung cancer
• All patients received standard oncology care
• Half of patients randomized to simultaneous outpatient palliative care by board certified MD
and Advanced Practice Nurse following guidelines
• Outcomes for patients receiving palliative care:
- Better quality of life
-
Improved symptoms
-
Less depression
-
Less likely to receive aggressive end-of-life care
-
Extended life (11.6 vs 8.9 months)
N ENGL J MED 2010 363:733-42
20
The Palliative Care Dilemma: Proposed Solution
Integrate palliative care into curative care practices earlier in the disease trajectory
• Access to consultation with palliative care team following diagnosis of life-limiting illness
• Shifts care to home, providing the support to patients and families for whom the
physician would “. . . not be surprised if they died within the next year” for Medicare
Advantage members (identified with secondary CPT II codes: 1150F and 1152F)
Build and support the needs of a Palliative Care Network
• Include hospital-based palliative care programs, palliative care/hospice providers with a
home health license
Develop a coordinated process between Palliative Care Network and Highmark’s
Health Management Services
• Dedicated clinical team to manage members
21
Advanced Illness Services Program Implementation
• AIS is a specialized program to support members in dealing with a life-limiting illness
• Implemented in January 2011
• Uniquely qualified professionals provide emotional support, facilitate communication and
complex decision-making related to goals of care, arrange referrals to community
resources, coordinate care across care settings, and assist with control of pain and other
symptoms
• Program provides 100% coverage (no cost to the members) for a lifetime limit of 10
visits: palliative care physician consultation, CRNP, medical team conference, care plan
oversight, registered nurse, or social worker
22
Advanced Illness Services Program
A dedicated clinical team within Highmark:
• Registered nurses and licensed social workers
• Supports one-to-one relationships with members, families and providers
• Ensures authorization for AIS services based on physician attestation (auto authorization
©
process through NaviNet )
• Leverages access to available benefits and programs
• Remains a dedicated telephonic contact throughout the AIS program and potential
hospice election period
23
Who Is Appropriate For A Referral?
Ask yourself:
• Does this patient have an advanced long term condition or a new diagnosis of a serious
illness or both?
• Would you be surprised if this patient died in the next 12 months?
• Does this patient have decreased function, progressive weight loss, > 2 unplanned
admissions in last 12 months, live in a Nursing Home or Assisted Living, or need more
personal care at home?
• Does this patient have advanced cancer or heart, lung, kidney, liver, or cognitive
failure?
Diane E. Meier, MD, Department of Geriatrics and Palliative Medicine, Icahn School of
Medicine at Mount Sinai, Director, Center to Advance Palliative Care
24
Clinical Palliative Care Triggers
General Triggers:
• “Would you be surprised if this patient died in one year?”
• 2 or more admissions to hospital in 6 months with functional decline
• Psychosocial distress in a patient with a life-threatening illness
• Uncontrolled symptoms in a patient with a life-threatening illness
• Guideline met for hospice eligibility, but “not ready”
Disease Specific Triggers:
• Cancer: Stage III or Stage IV cancer
• CHF: NYHC Stage III or Stage IV heart failure and signs of fluid overload
• COPD: Oxygen dependent, low body mass/weight loss, poor functional status
• Stroke: Unable to take oral nutrition, change in mental status, aspiration
• Renal failure: Signs of uremia (itching, confusion), edema, in a patient not on dialysis
• Liver Failure: Encephalopathy refractory to medications, coagulopathy, renal
dysfunction
25
Members in the AIS Program
• May receive home health care in
addition to Advanced Illness
Services
• May reside in a long term care
facility such as a Personal Care
Home, Assisted Living, or Skilled
Nursing Facility
• May elect to enroll in hospice as
hospice enrollment is voluntary
26
Highmark Advanced Illness Services
Quick Reference Guide for Physician Practices
How do I refer my Highmark Medicare Advantage Members?
1. Directly through NaviNet: see box below
2. Directly to an AIS contracted agency: www.highmarkbcbs.com > Find a Doctor, Hospital or Other
Medical Provider > Search for Medical Supplies or Services > Enter a Plan, Enter an address or zip
code>Select a Service Type = Advanced Illness Services
3. Directly to a Highmark Health Coach: 1-888-258-3428, Monday through Friday, 8:30 am – 4:30 pm
NaviNet AIS Authorization Request Process
1. Select a Referred from Service Provider and enter the Proposed Date of Service
2. Enter Member ID with Date of Birth and/or Member First Name
3. Select Category: Advanced Illness Services
4. Select Service: Request
5. Enter a Referred to Facility: Enter ID or select one from the Search Option
6. Diagnosis Code V66.7 – Encounter for Palliative Care will automatically populate (no further
diagnoses are required – however, you may enter up to three)
7. Additional Information – Click this box to indicate the member meets eligibility (medical necessity) for
the AIS Program – a physician/non-physician practitioner with solid understanding of the patient’s
current patterns of care (i.e. any physician/non-physician practitioner who knows the patient’s
situation)
8. Complete the Referred From Provider Information
9. Provide any additional Comments, where applicable
10. Submit
27
AIS Headlines
• Exceeded enrollment targets each year from 2011-2013
• 2013 patient satisfaction survey indicates 88.2% of participants would refer friends or
family
• Developed and refined the predictive model utilized to determine the probability of death
within a year
• Increased the number of contracted hospice providers 35% in 2013 (81 total vs. 60) in
western and central PA, West Virginia, and NEPA
• 2013 utilization analysis compared AIS enrolled members who died with non-enrolled
members who died:
- AIS members had hospice median length of stay (LOS) of 35 days compared to nonAIS members with 13 day LOS with greater use of hospice at time of death, 71%
versus 52%
- Reduced ER visits/chemotherapy in last 30/14 days of life respectively
- Reduced hospital admissions in last 30, 90 and 180 days of life
- Lower Hospital Allowed Charges
28
Program Successes
•
Members and families embraced the program – many positive testimonials
•
Well received by provider community
•
Favorable utilization trends
•
Dedicated clinical staff committed to high quality end-of-life care
•
Predictive Model Tool identified members with chronic/terminal conditions
•
Enhanced functionality for hospice providers to complete authorizations
•
Development of a comprehensive web-site for providers with information on the program
•
Gold Award winner of the 2013 Fine Award for Team Work Excellence in Health Care http://www.prhi.org/plugins/content/ezjwplayer/ezjwplayer/player.php?data=JmZpbGU9SGl
naG1hcmtfdjUubXA0JndpZHRoPTk2MCZoZWlnaHQ9NTQwJnRodW1iPWZpbmVhd2FyZ
HMuanBnJiZiYXNlPWh0dHA6Ly93d3cucHJoaS5vcmcv
•
Recognized nationally by CAPC and C-TAC
29
The Role of the PCP and Clinical Staff in Getting the
Message Out
• Meet with practice physicians, office manager and staff to educate on palliative
care/end-of-life
• Encourage the clinical staff to: "Have the conversation" by asking the surprise
question:
"Would you be surprised if this patient died in the next year?"
If the answer is “No”, consider referral to the AIS Program
• Identify and utilize the resources available to help your patients and families deal with
chronic life limiting illness:
- Palliative care consult/palliative care services
- Advanced Illness Services
- Hospice services – members enrolling directly into hospice do not require the
services available through the AIS program
- POLST/POST/MOLST
30
Advanced Illness Services Resources Index
https://prc.highmark.com/rscprc/hbs/pub?document=/documents/ais-resources.html
31
Website Resources
www.polst.org
Center for Ethics in Health Care Oregon
Health & Science University
www.capc.org
Center to Advance Palliative Care
www.nhpco.org
www.hardchoices.com
www.eperc.mcw.edu
National Hospice and Palliative Care
Organization
“Hard Choices for Loving People”:
A resource for professionals, patients and
their families regarding end-of-life decisions
End-of-life and Palliative Care Education
Resource Center
32
Advance Care Planning Website Resources
www.prepareforyourcare.com
www.acba.org
www.wvendoflife.org/Resources--Links/Forms
www.highmarkblueshield.com
www.caringinfo.org
www.agingwithdignity.org
Prepare for Your Care website
Allegheny County Bar Association/Allegheny
County Medical Society Health Care Power
of Attorney and Living Will Forms
West Virginia Center for End-of-Life Care
Highmark Provider Resource Center
Download state specific Advance Directives
Five Wishes
www.eperc.mcw.edu
End-of-Life and Palliative Care Education
Resource Center
www.coalitionccc.org
Finding Your Way – Medical Decisions When
They Count Most
33
References:
Gawande , Atul, Letting Go,Hospice Medical Care for the Dying Patients: The New Yorker,
Annals of Internal Medicine, August 2,2010.
Hickman E. Susan PhD et al. The Consistency Between Treatment Provided to Nursing
Facility Residents and Orders on the Physician Orders for Life-Sustaining Treatment. JAGS
2011.
Temel,Jennifer MD et al. Early Palliative Care for Patients with Metastatic Non-Small –Cell
Lung Cancer, New England Journal of Medicine 2010;363:733-42.
Weissman, David E. MD and Meier ,Diane E. MD, Identifying Patients in Need of a Palliative
Care Assessment in the Hospital Setting, A Consensus Report from the Center to Advance
Palliative Care, Journal of Palliative Medicine, Volume 14,Number 1, 2011.
American Society of Clinical Oncology 2011, www.asco.org/pco/palliativecare
Campbell ML, Weissman DE, Nelson JE, Fast Facts and Concepts #253 May 2012,
http://eperc.mcw.edu/fastfact/ff_253.htm
34
“It Gets Late early Here”
Yogi
35