Transcript Palliative Care in the Nursing Home

Palliative Care 2012:
Matching Care to Our
Patient’s Needs
Diane E. Meier, MD
Director
Center to Advance Palliative Care
[email protected]
www.capc.org
www.getpalliativecare.org
Core Principle
1. “The secret of the care of the patient is
caring for the patient.” Francis Peabody, Harvard
University, 1921
The Ends of Medicine:
Our Professional Obligations
“I will follow that system of regimen which,
according to my ability and judgment, I
consider for the benefit of my patients”
-Oath of Hippocrates, 400 BC
“May I never see in the patient anything but
a fellow creature in pain.”
- Maimonides, 12th century AD
Objectives
1. What’s wrong with the U.S health
care system?
2. How can it be fixed?
3. How is palliative care important to
improving value (quality and cost) in
health care reform?
4. Changing the delivery system to
improve access to quality palliative
care in and beyond the hospital
Health care in the U.S.
• What are the ends of medicine?
– What are they in the U.S.?
• What should they be? “To cure
sometimes, relieve often, comfort always.”
• The problem: “The nature of our
healthcare system- specifically its reliance
on unregulated fee-for-service and
specialty care- …explains both increased
spending and deterioration in survival.”
Muenning PA, Glied SA. What changes in survival rates tell us about
U.S. health care. Health Affairs 2010;11:1-9.
How They Think About it in
Washington:
The Value Equation-1
Value of health care = Quality
Cost
Numerator problems
– 100,000 deaths/year from medical errors
– Millions more harmed by overuse, underuse, and
misuse
– Fragmentation
– Medical practice based on evidence <50% of the time
– 50 million Americans (1/8th) without access
– U.S. ranks 40th in quality worldwide
The Value Equation- 2
Value of health care = quality
cost
Denominator problems
• Insurance premiums increased by 181% in the
last 10 years.
• U.S. spending 17% GDP, >$8400 per capita/yr
• Nearing 30% of total State spending
• Despite high spending, 15% of our population
has no insurance, and half are underinsured in
any given year.
• Health care spending is the #1 threat to the
American economy and way of life.
EFFICIENCY
International Comparison of Spending on Health, 1980–2009
Average spending on health
per capita ($US PPP*)
Total expenditures on health
as percent of GDP
8,000
18
United States
Canada
Germany
France
Australia
United Kingdom
7,000
6,000
16
14
12
5,000
10
4,000
8
3,000
United States
France
Germany
Canada
United Kingdom
Australia
6
2,000
4
2
2008
2006
2004
2002
1998
1996
1994
1992
1990
1988
1986
1984
1982
0
1980
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
0
2000
1,000
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2011 (database), version 6/2011.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
88
Sun Sentinel (Broward County edition)
Tuesday, August 9, 2011
Health Care vs Determinants of Health
Growth in Massachusetts State Budget Spending FY2001 to FY2012
(Inflation adjusted)
Source: Massachusetts Budget & Policy Center Budget Browser
100%
80%
60%
%
40%
20%
0%
Health Care
-20%
-40%
-60%
PrimarySecondary
Education
Law and
Public Safety
Public Health
Environment
and
Recreation
Higher
Education
Local Aid
What is this money buying us?
Organization for Economic Development and Cooperation
Among OECD member nations, the United
States has the:
• Lowest life expectancy at birth.
• Highest mortality preventable by health
care.
Cost: Hospital Spending per Discharge, 2009
Adjusted for Cost of Living
Dollars
18,000
17,206
16,000
14,000
12,163
12,000
11,988
10,000
9,398
9,131
9,026
8,000
7,312
7,312
7,295
6,000
4,667
4,527
FR
GER
4,000
2,000
0
US*
CAN*
NETH
SWITZ
Source: OECD Health Data 2009 (June 2009).
NOR*
SWE
NZ
OECD
Median
AUS*
Wall
Street
Journal
page 1
Sept. 18, 2003
Medical Spending in the U.S.
$2.9 trillion in 2010
 The costliest 5% account for
50% of all healthcare spending
Medicare Payment Policy: Report to Congress. Medpac 2009 www.medpac.gov
Health Affairs 2005;24:903-14.
CBO May 2009 High Cost Medicare Beneficiaries www.cbo.gov
nchc.org/facts/cost.shtml
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Target Population for Palliative Care
Distribution of Total Medicare Beneficiaries and Spending,
2009
37%
90%
63%
Average per capita
Medicare spending
(FFS only): $7,554
Average per capita
Medicare spending
among top 10%
(FFS only): $48,220
10%
Total Number of FFS Beneficiaries:
37.5 million
Total Medicare Spending:
$417 billion
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service
beneficiaries, excluding Medicare managed care enrollees.
SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2009.
Palliative Care is Central to
Improving the Value Equation
• Because our patient population is driving
most of the spending
• >95% of all health care spending is for the
chronically ill
• 50% of all healthcare spending goes to the
sickest and most complex 5% of patientsthose in need of palliative care.
Why Palliative Care is Important to
Improving Value in Health Care
• Improves patient quality/length of life
– Reduces pain, depression and other symptoms;
in several studies prolongs life
• Improves family satisfaction and well-being
• Reduces resource utilization and costs
….and does so for the sickest 5%-10% of the
population driving over half of total healthcare
costs.
Conceptual Shift for Palliative Care
Palliative Care Language
Endorsed by the Public
Palliative care is specialized medical care for people with
serious illnesses. This type of care is focused on providing
patients with relief from the symptoms, pain, and stress of
a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient
and the family. Palliative care is provided by a team of
doctors, nurses, and other specialists who work with a
patient's other doctors to provide an extra layer of support.
Palliative care is appropriate at any age and at any stage in a
serious illness, and can be provided together with curative
treatment.
Exceptionally High Positives
Once informed, consumers are extremely positive
about palliative care and want access to this care if
they need it:
 95% of respondents agree that it is important that patients
with serious illness and their families be educated about
palliative care.
 92% of respondents say they would be likely to consider
palliative care for a loved one if they had a serious illness.
 92% of respondents say it is important that palliative care
services be made available at all hospitals for patients with
serious illness and their families.
Palliative Care Teams
Address 3 Domains
1. Physical, emotional, and spiritual distress
2. Patient-family-professional
communication about achievable goals for
care and the decision-making that follows
3. Coordinated, communicated, continuity of
care and support for practical needs of
both patients and families across settings
Palliative Care Improves Value
Quality improves
–
–
–
–
–
Symptoms
Quality of life
Length of life
Family satisfaction
Family bereavement
outcomes
– Care matched to
patient centered goals
Costs reduced
– Hospital costs
decrease
– Need for
hospitalization/ICU
decreases
Palliative Care Improves Quality in
Office Setting
Randomized trial simultaneous standard cancer care with
palliative care co-management from diagnosis versus
control group receiving standard cancer care only:
– Improved quality of life
– Reduced major depression
– Reduced ‘aggressiveness’ (less chemo <
14d before death, more likely to get hospice,
less likely to be hospitalized in last month)
– Improved survival (11.6 mos. vs 8.9
mos., p<0.02)
Temel et al. Early palliative care for patients with non-small-cell lung cancer
NEJM2010;363:733-42.
Palliative Care at Home for the Chronically Ill
Improves Quality, Markedly Reduces Cost
RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer
Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care,
1999–2000
KP Study Brumley, R.D. et al. JAGS 2007
Usual Medicare home care
Palliative care intervention
40
35.0
30
20
13.2
11.1
9.4
10
5.3
2.3
0.9
2.4
4.6
0.9
0
Home health
visits
Physician
office visits
ER visits
Hospital days
SNF days
RCT of Nurse-Led Telephonic
Palliative Care Intervention
• N= 322 advanced cancer patients in rural NH+VT
• Improved quality of life and less depression
(p=0.02)
• Trend towards reduced symptom intensity
(p=0.06)
• No difference in utilization, (but v. low in both
groups)
• Median survival: intervention group 14 months,
control group 8.5 months, p = 0.14
Bakitas M et al. JAMA 2009;302(7):741-9
Consequences of Late Referral to
Palliative Care
Serious Adverse Outcomes for Bereaved
Caregivers:
Compared to care at home with hospice,
• Care in ICU associated with 5X family risk
of Post Traumatic Stress Disorder; and
• Care in hospital associated with 8.8X
family risk of prolonged grief disorder
Wright A et al. Place of death: Correlation with quality of life of patients
with cancer and predictors of bereaved caregivers mental health.
JCO 2010; Sept 13 epub ahead of print
Effect of Palliative Care on Hospital
Costs
How Palliative Care Reduces Cost
•
•
•
Improved resource use
Reduced bottlenecks in high cost units
Improved throughput and consistency
The Conceptual Model:
Dedicated medical team =
Focus + Time =
Decision Making / Clarity / Follow
through
Palliative Care Growth
Source: Center to Advance Palliative Care, 2011 capc.org/reportcard
America’s Care for Serious Illness
A State-by-State Report Card on
Access to Palliative Care in Our Nation’s Hospitals
Source: Center to Advance Palliative Care, 2011 capc.org/reportcard
NYS Palliative Care Programs
by Hospital Type
New York (2008)
New York (2011)
United States
(2011)
% (#) ALL
56% (75/134)
hospitals w/PCPs
72% (106/147)
47% (1894/3989)
% (#) > 300 Bed
hospitals w/PCPs
77% (30/39)
89% (55/62)
85% (597/699)
Public hospitals
25% (2/8)
89% (17/19)
54% (192/356)
Sole Community
Provider
50% (7/14)
53% (8/15)
37% (151/406)
Dartmouth Atlas Data
and NY State Ranking, 2009
Medicare
reimbursement last 6
months of life
$9384
51st
ICU admission during
last hospitalization
19%
45th
Medicare deaths in
hospital
37%
51st
ICU days/decedent
last 6 m.
3.2
30th
Hospital admits/1000
decedents
1532
43rd
New York State Summary
• 147 Hospitals
• 72% (106/147) have a palliative care program.
• Grade of “B” on the CAPC State-by-State
Report Card up from “C” in 2008
• NY State costs are among the highest in the
nation. www.dartmouthatlas.org
• NY State palliative care programs see <1% of
admissions – huge opportunity for growth, since
goal is 4-6%
Hope for the Future: Younger physicians exposed
to palliative care more than their predecessors.
% “Great Deal” or “Some” Exposure to Palliative Care
by Physician Age
− 37 −
National Quality Forum: Palliative Care is
One of Six National Priorities for Action
http://www.nationalprioritiespartnership.org/Priorities
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National Recognition of
Importance of Palliative Care to
Healthcare Value
• MedPAC: Called a meeting of national
experts in palliative care in May 2011 to
understand what Medicare payment
policies might advance access and quality
• The Joint Commission: Announced
September 2011 release of a Palliative
Care Advanced Certification Program.
Palliative Care: “on the map” with IHI
http://www.ihi.org/I
HI/Programs/Impro
vementMap
41
Strategic Partnerships
New Delivery and Payment Models +
Palliative Care
Accountable Care Organizations?
Patient Centered Medical Homes?
Bundled payments?
Adding palliative care targeted to the highest cost
+ risk populations to the specifications for these
strategies is key to their success at improving
quality and reducing cost.
Major Health Systems Get It
Making multimillion dollar investments in
palliative care integration across settings:
• Partners Health System/ Harvard Medical
School
• U. of Pittsburgh Health System
• Duke U. Health System
• North Shore-LIJ Health System
Payers Get It
Examples of private sector
approaches to community-based
palliative care
RESOURCES
Matching (Payer) Resources to
Needs
Demand Management
DM/CM
NEEDS
CCM-palliative care
Payers Have Skin in this Game
Resources: Don’t Waste Time
Reinventing the Wheel
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www.capc.org
www.getpalliativecare.org
Registry https://registry.capc.org/
Audioconferences http://www.capc.org/support-from-capc/audio-conf/
E-learning via CAPCcampus on-line http://campus.capc.org/
CAPCconnect forum http://www.capc.org/forums/
Joint Commission technical assistance
http://www.capc.org/palliative-care-professional-development/Licensing/joint-commission
• Palliative Care Leadership Centers
http://www.capc.org/palliative-care-leadership-initiative/overview
Although the world is full of
suffering, it is full also of the
overcoming of it.
Helen Keller
Optimism 1903