Hospice and Palliative Care 2019 and Beyond!

1. Hospice and Palliative Care 2019 and Beyond! Janet Bull, MD, MBA CMO Four Seasons Principal, Four Seasons Consulting Group

2. Objectives • Explore the evolving healthcare landscape • Discuss value based payment reform in palliative care • Understand Primary Care First Alternative Payment Model and the impact on hospice and palliative care agencies • Discover innovative telehealth solutions to deliver more efficient/effective care

3. Evolving Healthcare Landscape

4. Why Healthcare Reform?

5. US – High End of Life Costs Source: Fischbeck, Paul. “US-Europe Comparisons of Health Risk for Specific Gender-Age Groups.” Carnegie Mellon University; September, 2009.

6. Population Health Outcomes

7. Social Determinants OCED – Organization for Economic Co-operation and Development (36 counties)

8. Social Determinants 40% of all medical spending is precipitated by unmet social needs • health literacy • transportation needs • lack of family and caregiver support • food insecurity • unsafe housing • financial

9. Moving to Value Based Care • Cost/quality-directed decision making • Group Accountability *Outcomes-directed decision making *Physician Accountability *Physician choice *Physician Accountability Fee for Service Pay for Performance Risk-sharing/ ACOs Quality Demonstration

10. Hospice is an Example Value Based Care

11. Hospice Reimbursement Changes

12. Proposal to Change Election Statement • Include comprehensive nature of hospice care • A statement that while it’s rare some meds/services will not be covered (unrelated to terminal illness) • An addendum if requested is available to explain which drugs/diagnosis/services are not unrelated and why

13. Value Based Insurance Design (VBID) • Eliminate Medicare “carve – out” • Argument for – reduces fragmentation and allows for greater accountability of care • Concern – limit hospice providers, reduce payments • 5 year demonstration project – begin 2021

14. Hospice Growth Continues…. • 11,000 people turn 65 each day! • One of the most valuable programs in Medicare • However…… • Office Inspector General (OIG) increased scrutiny • Part D duplicate medications payment concern • New competitors outside of hospice industry

15. Continuum of Care Innovation Occurring Highest Value to Payors Siloed High regulations Carve in Competition Serious illness Care

16. Community Based Palliative Care Bridge across care settings Acute Crisis Inpatient Outpatient Home, Facilities If we don’t do this, others will!!!

17. Palliative Care Services • Symptom management • Prognostication • Advance care planning • Establish goals of care • Educate patients on their disease process • Spiritual and psychosocial support • Assist with community resources • Coordination of Care • Help patients navigate the healthcare system

18. Why We Need an Alternative Payment Structure • Unsustainable financial model under current fee for service reimbursement structure • New Fee for Service codes are helping • Advance care planning • Non-Face 2 Face prolonged service codes • Complex chronic care management codes

19. Why CMS Needs a New Payment Structure • Sickest patients are the most costly • Fragmented care • Duplicate care • Poor quality • Low satisfaction with care • No plan of care or care management Incentivize value (cost/quality) vs volume

20. Capitated Payment • Monthly Per Member Per Month (PMPM) • Eligibility Criteria • Team based care • Coordination/collaboration

21. Capitated Payment Covers Unreimbursed Services

22. Other Possibilities to Impact Care… • Transportation • Medication assistance • Electricity/Housing • Nursing Aides • Safety Issues • Caregiver issues

23. Primary Care First Model Blue States in Model – starting 1/2020 CAPC Blog

24. Goals of Serious Illness Population (SIP) • Provide high touch intensive intervention to help stabilize and transition to primary care home • Provide symptom management and Advance care planning • Coordination of care

25. Requirements for SIP • IDG (physician/NP + RN + SW) • 24/7 care • Ability to address social needs and social determinants • Wellness and healthcare planning (ACP) • Patient/family engagement This is a natural evolution for the hospice industry

26. SIP Payments ~ $350/month

28. Can you Break Even? • Construct model with higher RN/SW ratio to MD/NP/PA • Use telephone/telehealth app for video conferencing and remote patient monitoring • Use risk stratification and manage high risk patients well • Have good mix of patient population (20/60/20 – high to low risk) • Focus on meeting quality indicators

29. Work with Other PayersMedicare AdvantageManaged MedicaidCommercial PlanACO’s

30. Medicare Advantage • Continues to grow nationally • In 2018, in Washington State, 32% of all Medicare patients • Multiple providers • Increased contracting

32. Washington – Med Advantage 32%

33. Other Payers

34. As We Look Toward the Future…. • Expand upstream • Contract/collaborate with other payors • Realize evolving competitive landscape • Enhance technology approaches

35. Changing Landscape The competitor of yesterday may look very different from the competitor of tomorrow

36. How Do We Maintain… • High Quality • Efficient and effective care • Innovation • Integrate within Post Acute Continuum

37. Partnership Brings….. • Infrastructure needs • Payor contracting and negotiation • Streamline operations to achieve economies of scale • Benchmark data • Sharing of best practices • Expertise by increasing resource access

38. Challenges Inform Innovation • Rural Service Area • Workforce shortage • Knowledge basis • Infrastructure Issues • Electronic health records

39. Imagine A World…. • People had real time access to clinicians • Virtual visits possible for all disciplines • Remote patient monitoring - symptoms • Pharmacists part of the healthcare team • Focus included behavioral and psychosocial determinants • Personalized healthcare data was available and transferrable

40. Healthcare Transformation • All smart phones in 2020 mobile health apps • 37% health plans offer telehealth solution • Monitor EKG, blood sugars, chem profiles • IBM, Apple, Goggle • Walmart, Amazon Artificial Intelligence and Natural Machine Learning

41. 2 Telehealth Innovations for Palliative Care

42. Tapcloud: Integrated Solution Overview

43. TapCloud • Predictive Symptoms • Customized with machine learning (dx, meds) • Device agnostic • Syncs with biometric devices • Populates to a dashboard

44. Telehealth Intervention

45. Population Dashboard

46. Symptom Outcome Data • The Population • 101 Patients with serious illness were tracked for a full year • 100% Rural Population • 34% of patients ≥ than 80 yo • 11% of patients ≥ age of 90 yo • CHF, COPD & Oncology Bonsignore, L, Bull, J, Evaluating the Feasibility and Acceptability of a Telehealth Program in a Rural Palliative Care Population: TapCloud for Palliative Care. JPSM, 7/2018 56;7-14

47. Qualitative Analysis Bonsignore, L, Bull, J, Evaluating the Feasibility and Acceptability of a Telehealth Program in a Rural Palliative Care Population: TapCloud for Palliative Care. JPSM, 7/2018 56;7-14

48. Workforce Shortage Kamal, Bull, Myers. Future of the Palliative Care Workforce: Preview to an Impending Crisis. The American Journal of Medicine 2017 130, 113-114

49. Quadruple Aim

50. Project ECHO (Extension of Community Healthcare Outcomes ) • Medical education – trains clinicians in rural/underserved areas to provide specialist-level services • Specialists at a “hub” mentor and train clinicians in local communities “spokes” to manage a condition that was previously outside their area of expertise • TeleECHO sessions include case presentations/didactics, and promotes mentoring/knowledge sharing