Transcript Slide 1

Palliative Care and Hospice in Health Care Reform:
More Essential than Ever Before
Allan Ramsay, MD
Green Mountain Care Board
[email protected]
www.gmcboard.vermont.gov
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Objectives
 Understand why improving primary care and
palliative/hospice care are integral to the success of health
care reform, here and everywhere
 Review communication skills necessary for discussing
prognosis in life limiting conditions- a “primary” palliative care
skill (CHF and ESRD)
 Identify issues that could lead to improved utilization of
palliative/hospice care in Vermont
Most importantly to encourage you- yours is the best possible
care!
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Why did I apply to be on the GMCB?
 There are limitations within the academic and tertiary care
model to do the right thing and drive social change
 I was disgusted with the cynical and outrageous rhetoric
about “death panels” that arose during the ACA debate
 I hoped I could nudge primary and palliative/hospice care
policy wherever possible
 This is the right place: Vermonters care about each other,
trust each other, and can adapt to change
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Myths surrounding palliative and hospice care
To the best of your knowledge, would you say the new law does or does not allow a
government panel to make decisions about end‐of‐life care for people on Medicare?
Don't know
17%
Yes, law
does this
36%
No, law does
not do this
48%
NOTE: Percentages do not sum to 100 percent due to rounding.
SOURCE: Kaiser Family Foundation Health Tracking Polls, July 2010.
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Why is palliative care important to health care reform?
 >95% of all health care spending is for the chronically
ill
 63% of all Medicare spending goes to the 10% of
beneficiaries with 5 or more chronic conditions
 Despite high spending, there is evidence of poor
quality of care and lack of integrated care
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Target Population for Palliative Care
Distribution of Total Medicare Beneficiaries and Spending, 2005
37%
Average per capita
Medicare spending
(FFS only): $7,064
90%
63%
Average per capita
Medicare spending
among top 10%
(FFS only): $44,220
10%
Total Number of FFS Beneficiaries:
37.5 million
Total Medicare Spending:
$265 billion
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare FFS
beneficiaries, excluding Medicare managed care enrollees.
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What is the best possible care of those with life
limiting conditions?
Primary Care
(always)
Specialty
Palliative Care
Care
Hospice
(often)
(most times)
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Implications for Health Care Reform from a Small Town
in Colorado
Provides high quality, low cost care despite a high-risk patient
population.
Seven critical success factors:
1. Primary care physicians are in control
2. Clinicians are paid for quality not quantity via risk sharing
3. All-payer rate standardization
4. Regionalization of costly services
5. Limits on supply/capacity for costly services
6. Primary physicians follow their patients in the hospital
7. There are well integrated palliative care and hospice
services
Bodenheimer T, West D. Low cost lessons from Grand Junction, Colorado
NEJM 2010; 363:1391-93.
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How do palliative care and hospice affect the cost drivers of medical
care?
 Both counter the financial disincentives that prevent
communication about achievable goals
 Both can remediate the lack of training most clinicians
have related to the true needs of the seriously ill, including
symptoms, communication, coordinated transitions
 Both compensate for lack of primary coordinated care for
the patient with advanced illness/multiple chronic
conditions
 Both address the perpetual lack of communication
 Palliative care and hospice can compensate for the fact
that, much of the time, no-one is in charge!
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Cost implications of hospital based palliative care
Estimated Benefits
Low
Medium
High
Patient cases (% of discharges)
2%
4%
6%
Patient cases (cases/year)
405
809
1214
Savings due to reductions in direct
costs/case
$1,196,216
$2,392,432
$3,588,648
Intervention cost/case
($550)
($356)
($356)
Costs of intervention net of revenues
($222,571)
($288,128)
($432,192)
Increase in net income
$973,645
$2,104,304
$3,156,457
300 Bed Hospital Example Using CAPC-PCLC Study Results. Higher estimates for
the low scenario represent less efficiency due to scale and also variations in revenue
Source: Siu et al. Health Affairs, 2009
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Workforce: the #1 major barrier to access (how do you
solve this-simple: financial incentives)
 Oncologists: 1 for every 145 patients with new
cancer diagnosis
 Cardiologists: 1 for every 71 heart attack victims
 Palliative Medicine: 1 for every 1,200 people with
serious advanced illness
 Vermont has fewer than 12 FTE certified palliative
care physicians for 650,000 residents (12 hospitals)
 Twenty states including Vermont have no access to
post graduate training in palliative medicine
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The message is the other barrier to more widespread
use of palliative care (Public Opinion Research, CAPC, 2011)
 Studies suggest the palliative care
message has not been clear and
this no doubt effects utilization.
 Patients do understand the value
of palliative care, physicians have
greater difficulty with the
concept that palliative care is not
just for the actively dying.
The message to colleagues, patients,
policy makers and the public:
Palliative care is about matching the
treatment plan to the patient
goals.
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MR is a 95 year old active woman with long standing HBP, CHF, and CRI (Creat2.5). She has discussed dialysis as a future event with her primary physician
and decided she would not want this intervention.
 MR has an NSTEMI, goes to the cath lab for a stent, and
returns home with pain relieved
 5 days later she is re-admitted with acute dyspnea, CHF, and
creatinine is 5.8. Cardiology/nephrology recommend dialysis
 First session leads to hypotension and acute ischemic pain in
the right leg
 10 days later she develops gangrene in the leg which leads to
amputation
 Family requests a palliative care consultation to assist with
pain control
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What do you think when you are considering end of life care for
CHF?
1.
Many of my specialist colleagues
believe palliative care means
stopping all cardiac meds so they
resist my involvement.

True or false
2.
Specialists seem overly optimistic
about the benefits of ‘bridge”
therapies for CHF because they
see them work in the hospital
setting (inotropic agents, diuretic
infusions, BiPap, CPR).

True or false
3. It is so difficult to determine
prognosis in patients with CHF
that a hospice referral is rarely
appropriate for end of life care.
True or false
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Prognostic Uncertainty in CHF
(Circulation 2009;120:2597-2606)
 Accurate prognostication is difficult in CHF
 This uncertainty can provide a basis for initiating end-of-life
discussions:
– Advance care planning
– Educating patients and families about the unpredictable,
but usually terminal nature of CHF (danger of sudden
death)
– Ascertaining specific goals of care
 People are almost never upset when they have planned ahead
and outlived our predictions!
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How do cardiologists do with prognosis?
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Jackson, Vicki. Medicine Grand Rounds 2010.
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Coping and Denial
 Denial can be adaptive or maladaptive
– Adaptive denial allows us to deal with acute psychological
stress until we can process and mobilize coping strategies
– Maladaptive denial: inhibits coping and decision making
 Middle knowledge of death- “partial awareness and partial
denial”
 People in this middle knowledge place are vulnerable to
different providers giving them get different viewpoints on
prognostic awareness and acceptance.
Block, Susan. Psychological issues in End-of-life Care. Journal of Palliative Medicine 2006.
Langner, Thomas. Choices for Living: Coping With Fear of Dying. 2002
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Do patients with CHF have pain?
(J Pain Symptom Manage 35;594)
(Eur J Cardiovas Nurs 2003;213)
 Multiple studies of symptom burden in patients with late
stage CHF have shown a pain prevalence of 33-67%
 Comparisons of pain reports between NSCLC and CHF patients
show a similar incidence
 Edema (anasarca), ascites, ischemic bowel, arthralgia,
arthritis, pleuritic pain from effusions.
 These misconceptions lead to undertreatment and significant
EOL suffering
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Inotropic Therapy for CHF
(J Card Failure 2010;16(6):475)
 Dobutamine (beta receptor agonist) is being used more
aggressively for relief of symptoms in late stage CHF
 Some home care infusion companies will provide dobutamine
without proof of benefit with invasive cardiac testing
 Mortality is high in patients on chronic inotropic therapy (>
50% at six months)
 Cost is high, even with reduction in hospital days
 Patients being considered for chronic inotropic therapy should
have a palliative care consult
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CPR and CHF
(NEJM 2009;361:22)
 CPR studied from 1992 to 2005 in a national Medicare data base
(433,985 pts)
– 18 % pts survived to d/c- no diff over time
– Fewer surviving pts were discharged home
– A gradual increase occurred in the # of pts who had CPR prior to
dying in the hosp
 Informed Assent (“It’s not really your choice”)
– All providers agree that CPR would not lead to restoration of
meaningful life- is not indicated
– Patient/family have the right to disagree
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A Palliative Care………………….Cardiology conversation


MR’s CHF has worsened even with
optimal disease directed therapy
Maybe we could balance her disease
directed therapy with more attention
to symptom directed therapy as well

I think we can control her pain and
nighttime dyspnea with better
medical management.

We can titrate hydromorphone to
control her pain, it has less risk in
ESRD. That is our purpose of
balancing disease directed and
symptom directed treatment near the
end of life.

I don’t think it is time for palliative
care yet, she is not ready to give up

What do you mean, stopping her
dialysis, she is not ready for that.

I don’t want her to get confused by
being on a lot or morphine. That will
also effect her blood pressure.

I guess that makes sense. I just
worry about how bringing up
palliative care or hospice will make
her feel hopeless.
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The patient perceived presence of an… End of life discussion?
 Multiple studies show there is no association with harm
 Studies also show a positive association with:
– Better QOL at the EOL
– Less use of aggressive therapies at EOL
– Better caregiver bereavement outcomes
 We clinicians think we have more “power” to take away hope
than we actually do, often because we have not learned the
right language of hope.
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Our non-integrated system has lead us to become dependent on
achieving only medical goals of care
 The next test, the next treatment, the single goal of life
prolongation at all costs
 Patients have a different set of goals
 It takes time and effort to understand the patient/family goals
 That is the essence of excellent palliative care
Patient-centered care demands that the patient is in charge
and we are the servants
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MR had been in the hospital for 5 weeks when the palliative care
consultation occurred
 Hydromorphone was given before and after dialysis treatment to relieve
ischemic pain. This had been withheld because there was concern for
“monitoring” mental status changes during dialysis.
 Palliative care conducted a family meeting to discuss goals. “Have you
considered things you would want or not want if things don’t go as
planned.”
 Decision was made to not allow CPR if cardiac arrest occurs during the
hospitalization.
 Patient and family will consider how long they would want post-operative
life supporting therapies if further surgical procedures are planned.
 Cardiology and nephrology were unable to attend the family meeting but
agreed with the changes in the plan of care.
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Palliative Care Service performance measures
(J Pall Med 2009;12:609)
 Timely completion of consultation
 Documentation of patient status (prognosis, functional status,
psychosocial issues, spiritual issues with a plan for addressing
these)
 Goals of care (planned family meeting if necessary)
 Overall level of physical comfort
 Facilitation of system to address goals
 Patient and family satisfaction
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New Delivery and Payment Models when true health care reform is
implemented….
 Delivery system re-design is targeted to the highest-risk
populations-- those with advanced disease and/or multiple
chronic conditions and functional impairment-- will be key to
success at improving quality and reducing cost.
 Who has the training and skills- I would argue that better
integration of primary, palliative, and specialty care is the first
step.
 Who has already demonstrated quality and cost impact for this
population? (palliative care)
(Policy) Goal: Add palliative care to the eligibility/specifications/metrics
for medical homes, accountable care organizations, and bundling
strategies.
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The Palliative Care “Delivery System”
 Primary palliative care (outpatient PCMH or inpatient)
– Giving bad news and discussing prognosis
– Advanced care planning
– COLST
 Tertiary Palliative Care (usually inpatient delivery)
– Complicated symptom management
– Multidisciplinary intervention during acute illness
– Goals of care discussions about burdensome life supporting therapies
We need to assure a smooth transition from palliative care to
end of life care (Hospice) to achieve the best outcomes
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What happens next for M.R.?
 MR is transferred to SAR
and readmitted 5d later for
low BP during dialysis
 MR tells her family she only
wants to go home and live
to see the birth of her next
great-granddaughter
 Palliative care recommends
referral to the local home
hospice program
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The Hospice message is clear– except does everyone understand
all it’s benefits?
 Hospice associated with highest family satisfaction among last
places of care: 71% rated excellent vs. 47% hospital, 42% NH,
47% home care
Teno JM et al. JAMA 2004;291:88-93.
 Hospice associated with longer survival (+ 81 days CHF; + 39
days lung cancer; + 21 days pancreatic cancer; no difference
colon, breast, prostate cancers)
Connor SR et al. JPSM 2007;33:238-46.
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The conceptual shift of palliative care to
hospice care
Life Prolonging Care
Life Prolonging
Care
Medicare
Hospice
Benefit
Hospice Care
Old
New
Palliative Care
Dx
Death
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60%
50%
0%
Arizona 1
Utah 2
Florida 3
Delaware 4
Iowa 5
Oregon 6
Colorado 7
Rhode Island 8
Michigan 9
Kansas 10
Ohio 11
Texas 12
Georgia 13
New Mexico 14
Nebraska 15
Nevada 16
Wisconsin 17
Idaho 18
Missouri 19
Minnesota 20
National
Washington 21
Pennslyvania 22
Illinois 23
South Carolina 24
New Jersey 25
New Hamshire 26
North Carolina 27
Maine 28
Louisiana 29
Alabama 30
Massachusetts 31
California 32
Connecticut 33
Indiana 34
Oklahoma 35
Tennessee 36
Maryland 37
Montana 38
Virginia 39
West Virginia 40
Arkansas 41
Kentucky 42
South Dakota 43
Mississippi 44
Hawaii 45
District of Columbia 46
North Dakota 47
Vermont 48
New York 49
Wyoming 50
Alaska 51
We need to improve our system of hospice referrals!
(Medicare Hospice Deaths / Total Medicare Deaths)
National:
39.6%
VT #48:
25.6%
40%
30%
20%
10%
(Hospice Analytics Market Report)
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Clinical Guidelines for starting/stopping dialysis
(National Renal Physicians Association)
 Physicians should conduct advance care planning prior to
starting dialysis
– Medicare pays for six “educational” sessions prior to starting dialysis
however there is no requirement for ACP
 Consider forgoing dialysis for:
– People over 75 with life limiting co-morbid conditions
– Significantly impaired functional status
– Severe chronic malnutrition
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The likely outcome of MR’s treatment plan compared to if she
had a cancer diagnosis (Arch Int Med 2012: April 23)
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M.R. speaks with……………....her family physician
 I want to go home on hospice and
not come back to the hospital, is
that ok?
 Can I continue dialysis until my
great granddaughter is born?
 When I stop dialysis how will
things go for me?
 Thank you for being here for me.
 I believe that is a very good plan,
you have been through a lot.
 We can admit you to hospice
however continuing dialysis will
become more of a burden.
Making plans with your family
about when to stop is important.
 At some point after your GGD
has taken her new breaths, we
will be sure your breaths are
gentle and lead you to lasting
peace.
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Guess what- Vermont may be the birthplace of
meaningful health care reform!
 Palliative care and hospice
should be at the heart of this
effort
 Palliative care- have a strong
message about the ability of
palliative care to improve
quality and reduce costs.
 Hospice- support a bill to
extend hospice to those with a
1 year median prognosis and
let’s resurrect open access.
 We can’t let our backbone be
just a wishbone….
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The first driver of policy change: Showing Up
 There must be effective lobbying by membership
organizations + their individual members
 Develop relationships with your key local legislators
 A unified voice is crucial– Submit public comments when asked
– Come to the Statehouse if a bill is being debated (only one in
the nation without a metal detector- I think)
– Use social media for engagement or to mobilize
 Remember- our issue is bipartisan
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Questions and Comments
In an attempt to display competency or undying love, we lose
sight of the double-edged nature of our cutting-edge wizardry.
We battle away until the last precious hours of life, believing
that cure is the only goal. We inflict misguided treatments on
not just others but ourselves. During these final, tortured
moments it is as if the promise of the nineteenth century has
become the curse of the twenty-first.
from:
Final Exam: A Surgeon’s Reflections on Morality
Pauline Chen, MD
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