Health Management

BEST PRACTICES FOR OPTIMAL OUTCOMES

who couldn’t benefit because

Imitation-worthy the program is a covered
benefit without a copayment,”
says Greg Gadbois, MD,
medical director of Priority.

palliative care programs Priority established Tan-

dem365, a consortium of long-term
care facilities working together to
offer home-based care. The model
Five successful initiatives by MARI EDLIN combines medi-cal, behavioral and
social health-care and addresses
the needs of patients who are
critically ill and
The initiative is testing unable to access traditional out-
ing more and more like
P alli ative care is look- hospicecare,moving programsfromthesite

whether allowing concurrent care patient care due to psychosocial

of treatment—a hospital, in hospice leads to additional and financial burdens. It relies
nursing home or extended care coordination, better quality on a multidisciplinary team to
of life, fewer hospitalizations and create a life plan for patients.
care facility—to the home. While
both services provide com-
avoidance of preventable health
passionate care, what often sepa-
expenditures.
rates them is the curative services Medicare is not the only Palliative care is not
offered in palliative programs. insurer rethinking its approach to
Palliative care is not necessar-ily pal-liative care. Many MCOs are necessarily only for
only for end-of-life situations but also pursuing new initiatives. The
for patients at any point after hope is that these programs will end-of-life situations
diagnosis of a severe illness, says reduce costs and improve quality.
For example, cost savings might but for patients at
Lee Goldberg, project director,
be generated by ensuring patients
Improving End-of-Life Care, The any point after
Pew Charitable Trusts. are better informed about care
options, which can lead patients diagnosis of a
Medicare Care to opt against traditional
Choices Model hospitaliza-tion and prevent severe illness.
admissions and readmissions.
Under Medicare, patients with six
-LEE GOLDBERG, THE PEW
months or fewer to live who are in
Priority Health
hospice cannot receive concurrent CHARITABLE TRUSTS

care, a combination of treatment and About five years ago, Priority

compassionate service; how-ever, Health, a Michigan-based non-profit
seniors in private plans are not bound health plan, put palliative care on the
by the ruling. front burner with a comprehensive
initiative to make the public aware
The Medicare Care Choices
of the availability of services and
Model, which began in January 2016,
ensure physicians could deliver
is a demonstration initiative under the
them.
Centers for Medicare and Medicaid
Innovation for patients with advanced Using advanced analytics and
cancer, congestive heart failure, and clinical data, Priority identified
chronic obstruc-tive pulmonary which patients would benefit from
disease who are eli-gible for palliative care services, including
Medicare hospice benefits. nonmedical services such as
transportation. “We did not want to
offer it to members
The initiative has resulted in a
38% decrease in inpatient stays,
52% decrease in ED visits, 35%
decrease in total cost of care, 46%
fewer specialty care visits, and an
ROI as much as 4:1, depend-ing on
the patient and timing of
intervention, Gadbois says.
Priority partners with Aspire
Health, which provides patient
Continued on page 10

8 MANAGED HEALTHCARE EXECUTIVE ❚ JUNE 2017 Managed Healthcare Executive.com

 Health Management

from palliative care to hospice

at the right time, says Smith.
WHAT IS PALLIATIVE CARE? Blue Shield of California
Palliative care is specialized medical care for people with serious illness. The goal is to
improve quality of life for the patient, family and/or caregiver. Palliative care is provided Blue Shield of California, Hills Phy-
by a team of doctors, nurses, and other specialists to provide an extra layer of support. sicians Medical Group (the largest
independent physician association in
Northern California), and Snow-line
Hospice (a community-based
nonprofit hospice and palliative care
Specialized case management Physical health provider), are collaborating to
provide a home-based, palliative care
program.
The program includes an
inter-disciplinary team—a
PATIENT & physician, nurse, social worker,
LOVED ONES home health aide and chaplain—
Collaborative healthcare Community support that delivers comprehensive care
and support to seriously ill
patients and their families.
Torrie Fields, senior program
manager for palliative care, says
Pain & symptom Psychosocial support that although Blue Shield of
management California doesn’t deliver care as
an integrated healthcare system
Spiritual health would, it can still make a
contribu-tion by:
Source: Cambia Health Solutions, Regence BlueCross BlueShield of Oregon

❚ Supporting provider networks;

❚ Ensuring community members
Continued from page 8 program. Services include: receive services throughout the

support services, including state;

strategies to relieve symptoms
and pain, assistance in deci-sion
making, and emotional and
spiritual support for patients
and caregivers.
Regence
Regence, which offers plans in
Idaho, Washington, Oregon, and
❚ Nurse care management;
❚ Increased staffing and training
with a focus on perinatal and
pediatric patients;
❚ Emphasis on patient values,
needs and desires;
❚ Caregiver and
psychosocial support;
and
❚ Directly engaging members and
partnering with employers about
advance care planning and health-
care directives for employees;
❚ Educating PCPs; and
❚ Supporting state and federal
policy initiatives as an advocate
for access improvement.

Utah, rolled out a palliative care
program in 2015, including ad-
vance care planning, care coordi-
nation, team conferences among
palliative care providers, in-home
counseling, provider training to
engage patients and families in end-
of-life care planning, and increased
access to services.
The program tries to be inclu-
sive, opening the door to anyone
with a serious or complex illness
without any designated time until
end of life, says Bruce Smith, MD,
executive medical director of the
❚ Provision of nonmedical
needs, such as
transportation and food.
Physicians, specialists, ad-
vanced practitioners, nurses,
social workers, behavior health
providers and clergy can submit
claims for advance care planning.
Members pay a standard copay
for office visits without additional
fees for home care.
As a result of the program, 67%
of palliative care patients are in
hospice when they die, indicating it
successfully transitions patients
Like Priority, Blue Shield pro-
vides its palliative care program to
members as a standard benefit
without a cost share.
The payer works closely with
providers to identify which patients
should have access to palliative care.
“We want to ensure that our
members receive services where and
when they need them,” says Fields.
“We don’t want younger people with
illness to feel isolated. Palliative care
is not just for older adults; anything
can hap-pen at any stage of life.”

10 MANAGED HEALTHCARE EXECUTIVE ❚ JUNE 2017 Managed Healthcare Executive.com


“We wanted to move
up the conversation
and not wait until
members became
sicker and conditions
exacerbated—make
it a normal part of
health maintenance.”
SUSAN WANG, MD, SOUTHERN
CALIFORNIA PERMANENTE
MEDICAL GROUP
Kaiser Permanente
Southern California Permanente
Medical Group, part of Kaiser
Permanente, recognized a need
to engage its members in
advance care planning.
“We wanted to move up the
conversation and not wait until
members became sicker and
conditions exacerbated—make it a
normal part of health mainte-nance,”
says Susan Wang, MD, vice
president of the medical group and
lead for life care planning. “A
palliative care program falls right in
step with Kaiser Permanente’s
population health approach.”
Kaiser looked to the national
Respecting Choices model, an
advance care planning model that
embraces person-centered care, for
inspiration. Kaiser initially targeted
members at high risk but more
recently has developed multimodal
techniques for identi-fying members
who would benefit from advance
care planning. For example, when a
woman has just had a baby that
might be the right time to discuss
family planning and leverage
support.
Wang says Kaiser identifies
patients based on mortality risk—
from members without a health-care
directive to those with chronic illness
to those with advanced
Health Management
illnesses who are at risk of
dying. It targets each member
with an appropriate, sometimes
scripted, conversation; and
plans to train trainers to conduct
and improve discussions.
Although Kaiser Permanente’s
palliative care program doesn’t differ
too much from other insur-ers, it
embeds supportive services within
standard care. Member copays cover
home-based care. “Home-based care
is the new fron-tier,” Wang says.
Sharp HealthCare
Sharp HealthCare, is an integrated
regional healthcare delivery system in
San Diego. A primary objective of its
palliative care program is to prevent
members from using the hospital as a
tool for decompensa-tion
management of chronic ill-ness, such
as dementia, says Daniel Hoefer, MD,
chief medical officer of Transitions,
Sharp HealthCare’s outpatient
palliative care program. “When these
patients are recog-nized early, they
won’t need those services,” he says.
Sharp created a program to
teach providers how to identify
these patients. “We also teach
evidence-based prognostication
and use it to justify keeping/put-
ting people on the program.”
Program goals include reducing
ED visits, completing advance care
planning, and referring members to
hospice on a timely basis.
Like Kaiser Permanente, Sharp
puts a lot of stock in advance care
planning, which Hoefer says
improves quality of care, decreases
hospital deaths, increases hospice
use, and reduces ICU and ED visits
and hospital lengths of stay.
Transitions also provides in-home
patient and caregiver educa-tion
about disease processes and medical,
medication, and lifestyle change
management.
“The program helps patients and
their families understand what to
expect—not if something is going to
happen but when and
how to prepare,” says Suzi Johnson,
vice president, Sharp HospiceCare.
Reimbursement issues
Goldberg says it is difficult to get
reimbursed in a fee-for-service
system, requiring physicians to
patch together different CPT codes.
“Palliative care requires time-
intensive services and needs highly
specialized physicians to be with
patients, making it hard to figure out
how to cover costs,” he says.
Fields recommends a per-mem-
ber per-month bundled payment
“We also teach evidence-
based prognostication
and use it to justify
keeping/putting
people on the
program.”
DANIEL HOEFER, MD, SHARP HEALTHCARE
for services, enabling providers
to be more flexible in providing
what patients need.
Wang suggests that provid-ers
could bill by time because of
palliative care’s emphasis on
labor rather than on service
utilization. “We need meaningful
metrics, such as how many days
of the last six months were spent
at home, admissions and
readmissions, lengths of stay,
and ICU use,” she says.
CMS adopted a ruling in October
2015—it began January 1, 2016—
enabling providers to bill Medicare
Part B for documented care goal
conversations, discus-sions about
advance care plan-ning, and help
with understanding advance
directives.
Mari Edlin, a frequent contributor to Managed Healthcare
Executive, is based in Sonoma, California.
Managed Healthcare Executive.com
MANAGED
HEALTHCARE EXECUTIVE ❚ JUNE 2017 11
Copyright of Managed Healthcare Executive is the property of Advanstar Communications
Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's express written permission. However, users may print,
download, or email articles for individual use.