Numbers are foundational to the algorithms and actuary science which contribute to the creation of healthcare payment models. But increasingly, organizations that are trying to promote optimal care for Americans with advanced illness insist that four words are essential to these equations: What do you want?
When people living with advanced illness are asked what they want, their answer, and the discussion it prompts, yields insight that promotes effective and efficient care.
This is how Dr. Greg Gadbois, Medical Director of Priority Health, a Michigan-based Medicare Advantage (MA) plan sees it. As an MA plan, Priority Health receives a per member per month reimbursement from the Centers for Medicare and Medicaid Services to provide its members with health insurance.
5 percent of Medicare beneficiaries are in their last year of life and they account for 28 percent of Medicare spending. This care is expensive because of the frequency with which Americans with advanced illnesses are hospitalized and receive services they did not necessarily want in their last year of life.
Consider how this overall end of life experience and its corresponding costs would change, if earlier and along the way, a doctor, or nurse, or chaplain, or social worker, or a trusted family member would ask their patient, “what do you want” for yourself at this point in your life?
If that person wants to focus on living the highest quality of life with the lowest degree of pain possible, a caregiver might likely suggest introducing advanced illness management, which provides services to relieve pain and improve the quality of life. Just under half of Priority Health’s members who are living with advanced illness are actively involved in an advanced illness management program.
Dr. Gadbois recounts what a colleague told him of his experience after asking a terminally ill patient what he wanted most for himself at this final stage. “He said ‘My daughter is getting married in three months. I want to walk her down the aisle. That’s what I want to do’. So we said, ‘Alright, let’s set a plan up, so that we can get you to that.’”
An interdisciplinary care team, which contributed to this patient’s clinical, psychosocial and spiritual needs, helped him reach what to him was this most important life milestone.
“He was able to walk her down the aisle. That’s what he wanted,” Gadbois recalls from the conversation. “It really comes down sometimes to some of the simple things. In many, many cases, what’s important to them is how do I move from this stage in my life to the next, wherever it might lead me, with as much dignity and grace as I can.”
But providing team-based advanced illness management to stimulate such solutions, faces problems. Medicare’s fee-for-service payment model does not cover the full range of medical, psychosocial, and spiritual supports which people who live with advanced illness need, if they’re not enrolled in a hospice program.
“Your ability to financially support the team that needs to be in place to do this, even if you were able to find up-front funding to do it, still wouldn’t be sustainable long term,” Gadbois says. “The money is just not there from a reimbursement standpoint.”
As an MA plan, Priority Health is required to provide its members with a defined, baseline level of coverage, but any additional covered services offered remain unreimbursed by CMS, and the plan incurs the cost.
Despite this upfront expense, Priority Health provides its members who could benefit from advanced illness management with a full suite of coordinated services and resources, to address their pain and improve their quality of life.
“It’s worth it because we’re doing the right thing for the patient,” Gadbois says. “Your goal is to improve patient outcomes, improve their experience, and also lower the cost of care.”
Gadbois and other healthcare leaders are working to change the way CMS pays for care to incentivize these types of programs. In March, a panel of experts convened by the U.S. Department of Health and Human Services (HHS) supported two alternative payment models which would promote the full use of care teams to provide advanced illness services to people who need them.
C-TAC and the American Academy of Hospice and Palliative Medicine (AAHPM) submitted the models and are working to secure HHS approval for a combined and funded Medicare payment demonstration project.
HHS’s payment demonstration for an advanced illness management program could be many months away. But concurrently, C-TAC believes it’s imperative to convene stakeholders to make sure they are prepared to implement the model. The organization’s 2018 National Summit on Advanced Illness Care, October 9 – 11 in Denver, will bring together healthcare organizations from around the country to, among other front-burner topics, focus on advanced illness clinical and payment models.
Gadbois hopes to receive from the Summit gathering, greater insight on implementing both advanced care planning and end of life discussions across the broader healthcare community. He also expects to learn how C-TAC’s policy advocacy is making a difference to promote end of life care.
“C-TAC stands as one of the strongest advocates for promoting Advanced Care initiatives,” he says. ‘The Summit gives me the opportunity to hear from national thought leaders.”
The Summit will also address other pressing issues in the movement, such as person-centered care programs, caregiver support, policy reform, state and community organizing, healthcare technology, and indicators of success.
Gadbois’ gauge of success is whether his members receive from their healthcare experience what they want. And when that happens, he says, other stakeholders win as well.
“We see significant savings in the long term,” he says. “Someone has to pay for this care. But when you get better outcomes and better experience, isn’t that what we want to do?”