The Magic Pill

As a new medical intern, Christopher Meeusen didn’t consider himself an interventional guy. The thought of inserting needles into the arms of patients left him uneasy.

But one thing that left his fellow interns—and many doctors—feeling unsettled felt to Meeusen more comfortable. Even in the midst of the fast-paced, revolving-door hospital environment, he found himself wanting to linger and talk in-depth with patients, especially the seriously ill.

“Quite often,” Meeusen says, “when it comes to serious illness, the first questions I ask are, ‘What do you understand about what’s going on with your illness? Or your body? Or your disease?’ You’d be surprised as to the answers that people give versus what providers believe.”    

These days Dr. Meeusen, an internist in Grand Rapids, Michigan, specializes in palliative care. The field takes a holistic, quality-of-life approach to managing the symptoms and stresses of a terminal illness. As a relatively new area of study, palliative is often considered synonymous with hospice, a specific type of palliative care that requires a prognosis of less than six months to receive Medicare reimbursement.

But the space between hospice and palliative continues to grow—offering rich opportunity for compassionate understanding, more effective healthcare delivery, reduced medical costs and greater patient satisfaction. Payers and providers alike are exploring new options. The result? Fewer deaths in area hospitals, higher enrollment and longer lengths of stay in hospice programs, lower medical costs, and greater knowledge and awareness among those providing care.

In other words, the terminally ill are living longer and better lives at less cost—a health insurer’s dream.

“There’s more and more research coming out extolling the benefits,” Meeusen says. “It keeps piling up. Earlier involvement is better.”

Meeusen is, in many ways, a product of his environment. He grew up in Grand Rapids, coming of age in an area nationally recognized for its collaborative, multi-disciplinary approach to palliative and hospice care. Meeusen received his residency through Grand Rapids Medical Education Partners and his education through Michigan State University College of Human Medicine.

Moving far beyond its storied “West Michigan nice” congeniality, the region started putting gold-standard initiatives in place years ago that other areas are just beginning to explore: professional collaboration between acute care hospitals, hospice and others; training programs and fellowships for those interested in the field; regular informal gatherings of those in practice to share information and encouragement; educational offerings for nurses, counselors, assistants, volunteers and others; and programs that provide chronic disease management, decision-making support, caregiver support and individualized help for patients who are seriously ill—but not yet ill enough for hospice.

In addition, this summer, Hospice of Michigan and Spectrum Health Hospice and Palliative Care—both are agencies based in Grand Rapids serving west Michigan—were chosen among 140 hospices nationwide to participate in the Medicare Care Choices Model. Traditionally, beneficiaries have had to relinquish curative efforts to receive hospice coverage, but the model allows for both.

“The ‘H’ word—hospice—has developed kind of a negative connotation,” says Mike Jasperson, vice president of marketing and business development for Hospice of Michigan. “Unfortunately, people incorrectly equate accepting it with giving up hope or any prospect of curative care. We’ve developed programming that allows patients and their families to receive some of the benefits traditionally associated with hospice care but not covered under the formal Medicare benefit. It’s designed around meeting people where they are in terms of their end-of-life journey. We can begin to work with them and give them navigation and guidance so that when they come to making a decision, they feel more prepared and comfortable and less resistant to the idea of moving to a formal hospice service. Because there are a lot of wonderful things about hospice care. It’s very comprehensive in its scope.”

Closing the Gap

It wasn’t that long ago that Dr. Diane Meier, director of the New York-based Center to Advance Palliative Care, was given the monumental task of increasing the number and quality of palliative care programs across the country. Back then, in 1999, there were “probably 10 to 15” such programs based in hospitals, Meier says, and large gaps existed between care for the seriously ill and the dying. Today, more than 90% of the large hospitals in the United States with more than 300 beds—and 80% of all nonprofit hospitals—have palliative programs. The challenge, she says, is serving the many people with serious and complex illnesses who are not being treated in a hospital, so that’s the emphasis for the next 10 to 15 years.

“Most people with serious, complex illness are at home,” Meier says. “An even more vulnerable subset live in nursing homes or assisted living facilities, and many are receiving care from multiple specialists. No one is attending to the whole person and the whole-family needs in that situation.”

Five percent of the country’s patients account for 50% of healthcare spending, Meier says, with the top 1% accounting for 22% of costs.

“And the current healthcare system is more focused on the 95% than the 5%,” she says. “The question is, how can payers, how can actuaries, how can brokers help providers and payers to focus on that high-cost, high-risk population in an effective, comprehensive manner, as opposed to letting them be an afterthought that is bankrupting all of us and providing very poor quality of care to that particular group?”

Without partnerships with payers, she says, healthcare providers are unable to meet the need. And as the population ages, those needs will only increase.

To highlight innovations in the space—and to help focus on that 5%—the Center to Advance Palliative Care offers a Payer-Provider Palliative Care Toolkit as a resource on its website. There are numerous ways that payers and providers can better collaborate for more effective services overall. First, Meier says, payers have the best data on patients, and the effective sharing of that data can provide the best holistic view of treatment. Payers can also incent different values-based insurance design approaches to care for this population; can identify and refer high-risk members to appropriate palliative care services; can support the training of physicians, nurses, social workers and case managers; can reward physicians and nurses who receive advanced training and can work with community organizations such as churches, senior centers and schools to increase awareness and acceptance of advance care planning.

It might sound like a lot, but Meier remains optimistic. “More and more people are recognizing we’re all in this together,” she says. The Affordable Care Act helped by increasing awareness that everyone is responsible for improving value, improving quality “and meeting people’s needs in the community so they don’t have to call 911,” Meier says.

This shift in access point is considered moving healthcare “upstream.” In Michigan, that happens in numerous ways. Hospice of Michigan, for example, has programs that target different segments of the marketplace. At Home Choices is a community-based program that allows patients to receive palliative care, such as assistance navigating the healthcare system, decision-making support and evaluation by a nurse, at the same time as curative treatment. There’s also a social work navigational program for children born with life-limiting illness. Another program, At Home Support, provides patients with interdisciplinary collaboration, chronic disease management, individualized care, decision-making support and caregiver support.

A three-year study of patients enrolled in At Home Support saw an average decline of 36.8% in monthly spending for inpatient and outpatient health services; a decrease in hospitalization rates of 34.9%; a decrease in length of hospital stays of 24.6% and a total cost savings of 44%.

Spectrum Health, meanwhile, has seen success with its Home Based Primary Care program and Tandem365, an integrated care model aimed at patients ages 55 and older with complex health issues and little or no social support. It covers services not typically reimbursed by insurance, such as transportation to and from medical appointments, adult daycare and maintaining compliance with medications, all with the aim of improving quality of life and reducing unnecessary escalation of symptoms. These costs currently are covered by Michigan insurance provider Priority Health, the payer arm of Spectrum Health.

“Within Spectrum Health Medical Health Group, which did not exist about seven years ago, we have 1,300 providers, with strong leadership from the top down who have been very clear about the way we expect medicine to be delivered,” says Chad Tuttle, president of Spectrum Health Continuing Care. “One of our core initiatives is what we call ‘heal the whole person.’ When we talk with our providers, staff and team, that doesn’t just necessarily mean treat, treat, treat. It’s intended to really dive down to understand the patient’s wishes and expectations, make sure they have the information to make an informed choice, and then let’s honor that choice, whatever it is.”

Tuttle concedes that some providers still struggle with understanding and/or valuing palliative care. But overall, he says, “we’ve seen leaps and bounds in improvement in creating awareness about what palliative care can do for patients.” 

On the payer side, a handful of innovative organizations and programs are doing the same. First, there’s the Aetna Compassionate Care program, which was launched as a pilot in 2005 to provide additional support to patients with advanced illnesses and their families. It has since grown alongside the field’s focus on interdisciplinary teams and been underscored by the Affordable Care Act’s shift from fee-for-service to value-based offerings.

“There is good evidence that we can achieve better outcomes, not only in overall quality of life, but in specific things that matter to people—pain control, symptom management, their ability to deal with life-threatening conditions—when we put programs into place,” says Dr. Joe Agostini, the national medical director for Aetna Medicare. “There are health plans and provider groups that should be evaluated based on their ability to support this segment of the population. The ability to provide services to coordinate care, to address the needs of people with advanced illness, is something that purchasers of healthcare should be looking for to make sure that this part of the population, just like any other, has access to more supportive-type programs.”

Cambia Health Solutions, which has been actively engaged in palliative care since 2008 through its charitable foundation, is another frontrunner. Cambia’s regional health plans in Washington, Oregon, Idaho and Utah recently announced they would begin reimbursing beneficiaries for palliative care services such as home health aides and advance care planning. In addition, Cambia Health Foundation continues to fund programs and initiatives that provide training for clinicians, caregivers, individuals and families in facilitating conversations about end-of-life care. (The Centers for Medicare and Medicaid Services also proposed a rule this year including reimbursement for advance care planning, with payment expected to start in 2016.)

Jennifer Danielson, the president of Regence BlueCross BlueShield of Utah and a member of the Cambia Health Foundation board of directors, says her company has been contacted by other insurance carriers about the decision to offer such benefits. Time is of the essence: 14% of the U.S. population was over 65 in 2013.

That number is expected to reach almost 22% by 2040.

“We do get asked about ROI on it, but it’s too new for specific numbers,” she says. “We do know, from lots of other research in healthcare, that when you create a mechanism to help support people to be as healthy as they can be outside the hospital setting—the most expensive setting—that you get a great benefit from that, from the mindset and morale of the patient to the cost aspect.”

Typically, insurers will pay for physician and advance practice nurse services. “Yet what we know is that supportive whole-person care, palliative care, requires attention to the emotional, psychological and spiritual needs of patients in addition to their medical and physical needs,” says Judith Skretny, director of palliative care for the National Hospice and Palliative Care Organization. The goal of pilots and programs from Aetna, BlueCross BlueShield and other insurers and ACOs is to reduce emergency room visits and hospitalizations and provide a full range of services in patients’ homes.

“This is the best possible model of care for patients with a serious illness,” Skretny says. “It creates an easy process for end-of-life decision making and facilitates admission to hospice. While the goal of palliative care is not to save money, it is an important secondary benefit, saving providers the cost of very expensive hospital services.”

In the meantime, Tim Cousounis, managing director of the national consultancy DAI Palliative Care Group, would like to see brokers asking insurance carriers what they offer to cover those with advanced and terminal illnesses. There’s more to consider than the Medicare hospice benefit, and as the field continues to grow, competition will continue to grow with it.

Cousounis, who studies “exemplar” hospice and palliative care communities like Grand Rapids, is most excited about the ability to “enable people’s preferences and values to be honored and fulfilled.” Greater awareness of options, easier conversations, improved coverage and increased participation help everyone win.   
Meeusen, right in the thick of it, agrees. Though some head-butting still exists between providers, he says, “We all want what’s best for the patient…. One of the benefits of palliative care, as a mentor told me, is that it’s a better quality of care at a price we can afford.”