November 29, 2012

1. End-of-life Planning: The Opposite of Death PanelsPreventing Unwanted, Indifferent and Unnecessary Care November 29, 2012

2. Spending Across Age Cohorts in the U.S.

3. Large Health Care Expenditures Occur Near End-of-Life (EOL) • 30% of Medicare expenditures are attributable to the 5% of beneficiaries who die each year • Health costs for patients in their final months of life account for 25% of Medicare's total spending. • Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45(2):565-576. • Barnato Amber E, McClellan Mark B, Kagay Christopher R, Garber Alan M. Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Services research. 2004 April;39(2)

4. Is It Possible that… As we approach end-of-life (EOL) • Waste exists: Unnecessary care • The waste is unwanted as defined by the patient • The savings achieved by eliminating the unwanted care is nontrivial

5. The Care People Want at EOL Patients’ priorities for quality care during advanced illness and at the end of life include • consistent and reliable medical information • expert pain and symptom management • avoiding inappropriate prolongation of the dying process • relieving burdens on loved ones • being prepared for death Frield M, Cassel C. Institute of Medicine (IOM Report). Approaching Death: Improving Care at the End of Life. Washington, DC: National Academy Press; 1997. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284:2476–82

6. The Gap Between Desired Care and Care Received at EOL is Large Most patients with serious illness said they would prefer to die at home • most patients (55%) died in the hospitals • care was rarely aligned with their reported preferences “The evidence therefore suggests that patients often prefer a more conservative pattern of end-of-life care than they actually receive -- and that a patient’s wishes can be less influential than the practice patterns at the hospital where care is delivered.” – The Dartmouth Atlas

7. A Gap Between Desired Care and Care Received at EOL is Substantial • Seventy percent of Californians say they would prefer to die at home. However, of deaths in California in 2009, 32% occurred at home, 42% in a hospital, and 18% in a nursing home. • Californians say the most important factors at the end of their life are making sure their family is not burdened financially by the costs of care (67% say this is extremely important) and being comfortable and without pain (66%). • Sixty percent say that making sure their family is not burdened by tough decisions about their care is "extremely important." However, 56% of Californians have not communicated their end-of-life wishes to the loved one they would want making decisions on their behalf. http://www.chcf.org/publications/2012/02/final-chapter-death-dying#ixzz2DUfPhnZ7

8. Employers are Impacted by EOL Care • Directly • Retiree populations • End-of-life management in the employed population • Indirectly • Cost shifting • End-of-life and elder care by the employed population

9. Direct and Indirect Sponsor Costs Near EOL • The cost of cancer treatment is typically among the top three most costly conditions representing, on average, 12% of total medical expenses. • Cancer is one of the leading causes of both short- and long-term disability. • More than 25% of employees are acting as caregivers to family members who are experiencing an illness, including cancer. National Business Group on Health and National Comprehensive Cancer Network, 2011

10. Indirect Sponsor Costs from EOL Management • The estimated average additional health cost to employers is 8% more for those with eldercare responsibilities. Excess medical costs reached almost 11% for blue-collar caregivers and over 18% for male caregivers. • The 8% differential in health care for caregiving employees is estimated conservatively as costing U.S. employers $13.4 billion per year. Working Care Givers and Employer Health Care Costs. New Insights and Innovations for Reducing Health Care Costs for Employers. University of Pittsburgh Institute on Aging. Feb 2010.

11. Knowing When to Stop “Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop.” – AtulGawande, Letting Go

12. Advance Care Planning Sits at the Center of the Triple Aim for EOL Advance care planning is a process by which people • think about their values regarding future healthcare choices • communicate wishes and values to their loved ones, their representatives and their healthcare team • record their choices for healthcare as guidance in the event that they can no longer speak for themselves. A health care (advance) directive is a legal document that allows you to set out written wishes for your medical care, name a person to make sure those wishes are carried out, or both. Patient Experience Population Health Advanced Care Planning Healthcare Expenditure

13. Advance Care Planning Can Work • Patients and with health care directives (and their families) have greater satisfaction with their care. • Feeling greater control • Reduced fear and stigma • Less family strife • Lower costs • Legal and certification (e.g., JCAHO) Requirements • Inform. Inform patient of right to have an ACD • Inquire. Inquire periodically whether patient has an ACD • Document. Document whether patient has an ACD • Assist. Upon request, refer patient to resources to assist with formulating an ACD • Review and Revise. Allow patient to review and revise their ACD • Make Aware. Ensure staff are aware of patient’s ACD • Implement. Ensure ACDs are implemented in accordance with law and hospital policy • Educate. Educate patients, staff and community regarding ACDs

14. Current Advance Care Planning is Deficient • Difficult to produce • Strictly defined (AD, proxy and, if appropriate, POLST), approximately 10% of the population has an advance care plan. • Useful advance care planning is complex and time consuming. • Few professionals (lawyers, financial advisors, primary care clinicians) are well-prepared to have an advance care planning discussion. • Advance care planning discussions are usually reserved for people who are terminally ill or whose death is imminent, yet research indicates that people suffering from chronic illness also need advance care planning. Most age >65 die of disease other than cancer. • Less than 50 percent of the severely or terminally ill patients studied had an advance directive in their medical record.

15. Current Advance Care Planning is Deficient • Difficult to store, find, verify and apply at point-of-need • Store and Locate • Between 65 and 76 percent of physicians whose patients had an advance directive were not aware that it existed. • In a jar in the refrigerator? Scanned documents in the EMR? With the health care proxy? • Interpret • Advance directives helped make end-of-life decisions in less than half of the cases where a directive existed. • Value-based directives require interpretation • Disease-specific directives are difficult to create • Physician orders for life sustaining treatment (POLST) are often not created • Surrogates who were family members tended to make prediction errors of overtreatment, even if they had reviewed or discussed the advance directive with the patient or assisted in its development. • Measurement: routine measurement is typically non-existent

16. Luminat Mission and Vision Vision: We envision a day when an individual’s wishes are always understood and consistently honored at end of life. Mission: Lumināt offers a comprehensive solution that allows provider organizations to enhance the effectiveness of advance care planning to improve the patient’s and family’s experience and as a result lower the costs of care.

17. LuminātSolution • Increased adoption of advance care planning: Through an identification and invitation process, increase the number of patients with an advance care plan. • Valid and comprehensive: The Luminātadvance care plan is a valid, certified and thoughtfully constructed advance care plan that allows for a more peaceful and satisfying experience for the patient and the family at end of life. It aligns the complex health care system system around the patients’ wishes eliminating the tendency for the health care system to provide care based based on assumptions and standard operating procedures. • Highly accessible: the Lumināt Registry stores the patient’s ACP, allows the patient to share it with their loved ones and is place for providers and their designees to access the ACP quickly. • Measurable results: combining data from the registry and provider systems allows for measurement of the ACP penetration, effectiveness and cost savings.

18. LuminātSolution Components Identify & Invite Create & Align Store & Access Analyze & Measure IDENTIFICATION CREATION REGISTRY REPORTING • HIPAA certified secure cloud environment • Annual reminders to keep ACP current • Comprehensive audit control • 24/7 secure access to the latest ACP on file • Comparative analytics for patients with and without ACP • Reports on Patients with complete ACPs by value category • Comparative analytics on adoption rates, access rates & satisfaction with other institutions • Estimation of saving opportunities in sum and for each Patient • Cohort sorting by greatest need • Targeted (30%) invitation on Provider’s behalf • Participation open to all patients • Guide Patient with ACP creation • The Plan is • -- Comprehensive • -- Legally Valid • -- Consistent • -- Clinically appropriate • Shared with proxies & Providers

19. LuminātValue Proposition • A complete, provider oriented solution • Less clinician time necessary to create a valid, comprehensive advance care plan • Satisfies certification requirements using a single system • Higher rates of availability and application of AD in the clinical setting • Greater satisfaction of the individual and the family • Lower costs per individual with advance care plan