Health care provider organizations, payers, and the health policy community increasingly recognize the deficiencies in care for people with serious illness and for those approaching the end of life. While medical advances have provided great benefit to some, many people with serious illness still often experience physical and emotional distress, as well as lack of alignment between their personal values and goals and the medical care they receive.
Multiple studies have shown that specialized palliative care services address these needs in a way that usual care does not. With a focus on defining and adhering to patients’ goals of care, managing pain and symptoms, addressing psychosocial and spiritual issues, and coordinating care among multiple providers and settings, palliative care improves the quality of life and experience of care for people with advanced illness, while lowering costs by helping patients stay in the care setting of their choice (typically their home).
Despite robust evidence of the benefits of palliative care, growth of these services has been stunted by the lack of sufficient, defined funding streams. Only some members (typically physicians or advance practice nurses) of interdisciplinary palliative care teams can bill for their services; one study found that billing covers less than half of outpatient palliative care service costs.
While some health care organizations are moving toward accountable care models with global payment, where the cost of palliative care services can be offset by the avoidance of unwanted care, this movement has not kept up with the need for more palliative care services. Without a sustainable payment model, the potential of palliative care to address essential care needs cannot be realized. And without palliative care, the complex challenges faced by people with serious illness will not be adequately addressed.
To address these challenges, the California Health Care Foundation (CHCF) has supported a planning process for 10 teams of payer and provider organizations committed to strengthening and spreading palliative care services in California through innovative partnerships. These payer/provider teams represent the diverse entities invested in providing palliative care: the providers include large academic medical centers, regional hospitals (including a children’s hospital), hospices, and medical groups, while the payers include national insurers, regional insurers, a Medicaid managed care plan, and a medical group that is “at-risk” financially for a portion of its population.
These teams, each funded by a planning grant from CHCF, have engaged in a six-month planning process from October 2014 through March 2015. During this period, partners in each team met regularly to understand their respective priorities and to develop a plan for providing services. All teams shared ideas and challenges with other grantee teams in two in-person meetings and also received support through webinars led by innovators in payer/provider partnerships and through one-on-one technical assistance from initiative faculty. While final proposals have not yet been completed, teams have shared with the group of grantees their preliminary thinking on the following topics:
Population: identifying which patients would receive the services
Model of care: defining what the services would consist of, who would deliver the care, where the care would be delivered, and how often it would be delivered
Funding: clarifying a payment model for these services
Metrics: defining how the partners would assess the impact of the services
Not surprisingly, given the diversity of the partner organizations, planned approaches to each of these areas vary significantly, but some trends and themes have emerged:
Population: Teams plan to target services to patients based on a combination of variables such as life expectancy (some less than 12 months, some 12 to 24 months), diagnoses, utilization patterns, and functional status. Teams will use claims data, as well as assessments done by providers, to determine which services are most appropriate.
Model of Care: All partnerships plan to deliver palliative care services through an interdisciplinary team. Most of the programs will be home-based; however, a few teams plan to develop clinics. Several partners anticipate providing tiered services (with varying intensity, duration, and staffing) based on patient needs and acuity of illness. About half of the partners have cited plans to provide phone support to patients around the clock. Teams are planning a variety of approaches for outreach to referring providers and to patients.
Funding Approach: Funding models vary across the partnerships. Since these partnerships are new, many teams plan to evaluate and potentially adjust their funding model after an initial pilot phase during which they will learn more about costs and use of services. Proposed approaches include per-member per-month payment, shared savings strategies, monthly bundled services rate, and pay-for-performance and other reimbursement incentives.
Metrics / Monitoring Impact: Across partnerships, common planned metrics include process measures (such as completion of advance care plans or Physician Orders for Life-Sustaining Treatment, or POLST, documents), utilization outcome measures (related to use of hospital, emergency department, intensive care unit, hospice, and the palliative care service), and outcome measures on patients’ experience (such as patient/family satisfaction, pain and symptoms, site of death, and provider satisfaction).
Partnership teams are excited by the potential of working together to ensure their patients have access to these essential services. The provider organizations already have community-based palliative care services in place, but they have been limited in their ability to reach more patients because of funding constraints. The payer organizations recognize that this is a clear opportunity to improve care quality and experience for their patients and to differentiate themselves from other payers.
After partners submit their implementation plans, CHCF will assess how it can support the partners in implementing and evaluating their palliative care services, such as providing technical assistance related to metrics or data analysis. CHCF would consider additional grants for implementation when the planning grants are completed. CHCF is also committed to sharing the lessons learned as these partnerships continue to develop in order to help facilitate the spread of innovative payer/provider partnerships in palliative care.
Kate O’Malley was a senior program officer with CHCF’s High-Value Care team. In this position, she managed projects focused on improving care and lowering system costs for high-cost populations, especially toward the end of life. Prior to joining CHCF, she served as a senior project manager for nursing home quality improvement and as collaborative director for educational development with Lumetra in San Francisco. Earlier experience includes 20 years with On Lok Senior Health Services in San Francisco, in clinical and management roles, including the national replication of the On Lok model. As a geriatric nurse practitioner, O’Malley provided care to frail elders in community settings and also served as a Peace Corps volunteer in Kenya.
O’Malley received a degree in nursing from the University of Rhode Island, a master’s degree in health education from San Francisco State University, and certification as a geriatric nurse practitioner from the University of California, San Francisco. She is also a Certified Hospice and Palliative Nurse.