Palliative care update

1. Palliative care update Mark J. Dearden, Do

2. objectives • How to recognize the time for palliative care • Good and bad to why palliative care is now in vogue

3. Hospice • We are very familiar with hospice • Terminal Illness with less than 6 months life expectancy • Common Diagnosis • Cancer • Dementia • Pulmonary • Cardiac • CVA

4. Hospice • Excluded Diagnosis • Failure to Thrive • debility

5. hospice • Hospice is now under significant Scrutiny • Denial of claims • Lack of supporting documentation • Within hospice and by the attending's

6. Hospice • AS attending's • List all Dx (try and focus on one or two specific Diagnosis’s) • Document decline • Wt. changes • Physical decline • Cognitive decline • Decrease in medication needs • Social hx changes • Home to assisted living to nursing home

7. Hospice • Still have to use the Medicare guidelines for admissions • They are only guidelines • We look at a primary diagnosis • However with good supporting documentation and significant secondary diagnosis’s a patient can qualify for benefit

8. Hospice • We are waiting to long to recommend hospice • It is easier to define 12 months or less of life but much Harder to define 6 months or less

9. Palliative care

10. challenge • Aging u.s. population • Chronic illness • 2030 • >=65 years (71 million) • 80% 1 chronic condition • 50% 2 or more

11. challenge

12. Stratification of Patients – Why It’s Essential 10% of the Population Accounts for 68% of All Health Care Costs Mean Annual Percent of Percent of Total Per Person Population Health Care Expenses Cost Advanced Illnesses Multiple Chronic Conditions $101,000 At Risk $ 15,000 $ 3,700 Stable $ 580 National Sample of 21 Million Americans Between 2003 and 2007 Source: Truven Health Analytics, Market Scan, 2012

13. U.S. Health System has Made Real Progress Death Rate (age-adjusted) is one-half what it was in 1940

14. Hospital Progress: Decline in Inpatient Deaths AHRQ: Deaths per 1,000 Hospital Admissions in U.S. 1994-2004 Improvements 2011-2012 Sources: Sg2. Edge Update. October 15, 2007; AHA, April 2013

15. Not Sustainable for those who pay for Care International Comparison of Spending on Health, 1980–2010 Average spending on healthper capita ($US PPP) Total health expenditures aspercent of GDP Notes: PPP = purchasing power parity; GDP = gross domestic product. Source: Commonwealth Fund, based on OECD Health Data 2012.

16. True success is achieving the admission rates of Bend, Oregon THAT’s what the market wants and economics demand Iowa Does Better, However…The Data Shows Big Opportunity to Improve Source: Dartmouth Atlas for Health Care, 2007 data available in 2012

17. True success is achieving the admission rates of Bend, Oregon THAT’s what the market wants and economics demand Iowa Does Better, However…The Data Shows Big Opportunity to Improve Source: Dartmouth Atlas for Health Care, 2007 data available in 2012

18. Hospital Prices Are NOT the Culprit

19. Not Sustainable for Physicians: Can’t Keep Doing More to Make Up for Declines in Rates CF indexed to Health Ins Premiums: Up 178% $102.25 Driven by Volume Not Price Per Unit CF Adjusted for Inflation: Up 33% $51.40 $34.04 CMS RVU CF: Down 7% Actual Rates Paid to Physicians Per Unit of Work Have DECLINED

20. When Providers “Do the Hard Work” of Decreasing Costs & as Margins are Compressed a “Value Gap” is created Savings Can Amount to Billions of Dollars– All of Which Accrues to Payers and Purchasers Unless We Are in Shared Savings or Other Risk Arrangement • Bending trend to meet CPI creates $1.3B to $2.1 B in annual value capture opportunity in future years. • Government, insurance companies, individuals, employers and integrated networks will compete to capture the value. • There is a significant first mover advantage. By contracting for risk, and driving down the cost of care below trend, MHN can capture disproportionate share in the shift to value. $ Time

21. Not Sustainable for Consumers: More Primary Care Providers Needed to Meet Future Needs Source: Thomson Reuters- “Vocabulary of Healthcare Reform” Jan, 2012 • Estimated shortfall of 130,000 doctors in the U.S. by 2025 • 16,000 additional primary care doctors needed today • Growth in need for primary care driven by: • Shift in emphasis to disease management and prevention • Baby boomers’ march into the ranks of the elderly, where needs increase • Aging physicians’ retirements

22. Health Reform on Two Pages • COVERAGE • Hope to cover 32 million more people, or 94%; 23 million will remain uninsured • Medicaid expansion • Subsidies for private insurance • Requirement to have insurance • INSURANCE REFORMS • Creates Health Insurance Exchanges to facilitate access and manage subsidies • Regulates insurance plan coverage, premiums & expenditures (85% medical loss ratio) • Eliminates pre-existing conditions exclusions, lifetime & annual limits for insurance plans • Requires coverage for preventive care without co-pays • DELIVERY SYSTEM REFORMS • Incentives for value: • Both carrots and sticks – to reduce utilization & improve quality • New payment programs: Shared Savings, bundled payments • Encourages integration • Innovation Center

23. Health Reform on Two Pages • OTHER • Wellness & Prevention • Quality & Safety • Workforce education, training • Increased regulatory oversight • Community Needs Assessment • SAVING MONEY • Increased Taxes • Fraud and Abuse / RAC recoveries • LARGE portion of savings through cuts to health care providers– at least $155 BILLION less paid to hospitals over 10 years • Incentives to reduce utilization of services • Reduce waste • EMPLOYERS • Coverage requirements • Subsidies to assist in covering employees • Communica-tion and Reporting Requirements • Cost-sharing limits • Penalties & taxes

24. Health Care Reform – Shifting Risk to Providers Our View of the Future Health Care Economic Model Episode-Based Treatment-Based Population-Based • Global Payments • Discreet Popula-tions • Disease based • Pay for Perform-ance • Cost • Quality • Access • Service • Bundled Payments • Individuals’ Care Across Settings Fee for Service • “Own” the Lives • Shared Savings • Capitation • Soon: Paid for Events • Assume Performance Risk • Integrated Healthcare Delivery • Today: Paid for Volume • Maximize Clinical Operations • Highly Effective Delivery System • Tomorrow: Paid for Lives • Manage Population Health • Insurance Risk Capable 24

25. The Compelling Opportunity:Truly Align Mission with Strategy • Accepting more risk for clinical care and costs – i.e. a pre-defined payment for the care of a population, or sharing in the savings generated by improved care processes – creates: • A real economic opportunity to align financial incentives with longstanding efforts to improve people’s health status and reduce the utilization of services • Incentives / resources to engage with patients in new ways • An opportunity to align Mission with strategy • We all have said for decades that our Mission is to improve care and enhance the health status of the communities we serve. For the first time, the economic incentives are changing to support our efforts to fulfill this Mission. 25

26. Challenge • End of life (EOL) care needs • Fragmentation • Unidentified/unaddressed • Hospice • Late Referrals • Length of stay • benefit

29. Palliative Care solutions • Inpatient consultation Model • Median time 2.5 days • Comprehensive assessment difficult • Lack of follow up mechanism

30. Palliative care solutions • Clinic based outpatient model • Limitations • Travel • Hours of operation • Referrals • reimbursement

31. Community – based CPC model

32. Benefits • People decline beyond point of attending outpatient clinics but do not need hospitalizations • Minimize disruptions • Increase quality of life

33. Cpc across transitions

34. Prognosis Independent • Needs • Symptom control • Quality of life • Care Giver needs • 6 months threshold crossed • Desire disease directed therapies when appropriate

35. Cpc model

36. Mission • Integration into care practices • Focus on quality care • Symptoms • Communication • Family satisfaction • Decrease hospital readmission • Assisting physicians with high risk patients

37. Goals • Pain and symptom management • Medical information • Goals of care discussion with patient • Spiritual and emotional support

38. Care model

39. readmissions • 1/5 Medicare patients readmitted within 30 days of hospitalization • ½ readmits occur before follow-up • Estimated cost $17.4 billion

40. Cleveland Clinic ED visits 0 ED visits 1-2 ED visits 3+ ED visits

41. Challenges to CPC • No standards • Lack of support staff • Use of technology • Limited team interactions • Chronic non-malignant pain

42. New Mantra “Bringing palliative care to where patients are mentally, physically, emotionally, spiritually, socially, sexually, and geographically.”

43. Conclusions • CPC begins with patient and community • Increase patient satisfaction • Decreases ED / hospital days • Decreases Medicare resources use • Need more programs across the nation

44. Take home • It is good that palliative care is expanding • It is good that end of life care is being discussed • It is interesting it took the accountable care act to expand end of life care • It is sad that the threat reality of reduced payment for 30 day readmissions to both the hospitals and physicians has made hospice and palliative care more in vogue