BY JON STONE | JANUARY 17, 2019
The notion of ‘change’ and ‘healthcare’ might seem contradictory to people who believe that change is long overdue in the administration of healthcare.
But outcroppings of institutional change are developing at all levels of the U.S. healthcare system.
Consider a hospital being seen not as a revenue maker, but as an entity designed to minimize admissions and billings for the greater good of its patients and the community.
That’s the philosophy and practice of Sharp HealthCare, a nonprofit, San Diego-based integrated delivery system, which includes hospitals, medical groups, a health plan, and other practice areas like community-based palliative care.
The highest healthcare costs for Medicare beneficiaries in the U.S. involve people who are in their last year of life. These costs are most directly tied to services which they receive in a hospital. But generally, when a patient’s overall health is managed within an integrated system, intervening early before a trip to the hospital reduces costs for both the patient and the health system.
Sharp is achieving such success through its Sharp Transitions program, which provides care for qualifying patients who have advanced illnesses. Through this program, the patient’s existing care team is expanded to include a palliative nurse, social worker and chaplain, who focus on pain management and the psycho-social effects of their advanced illness. Often, this enables them to be cared for in their homes.
“If you can engage your patients upstream, they do better, the costs go down, they live longer, and they experience the entire end of life years in their home,” says Dr. Daniel Hoefer, associate medical director for Sharp Hospice Care.
Sharp says that its Sharp Transition program has contributed to a drop of up to 65% in patient emergency room visits, and that if these patients are admitted to the hospital, they’re 1/3 less likely to be readmitted. Sharp’s data also shows that only 8% to 11% of Sharp Transition patients die in the hospital compared to more than 50% of advanced illness patients who are not in the program. This combines to yield an average cost savings to the system per patient of $24,000, and a high family satisfaction rating.
Many palliative care programs that provide these services struggle to sustain themselves because Medicare doesn’t pay for the full care team. The challenge is particularly profound for these programs with a high percentage of patients insured by Medicare’s traditional fee-for-service (FFS) model.
“You don’t get the coverage you need for social workers, chaplains, nurses. It is a cost-ineffective service from that perspective, if you try to run it in fee-for-service,” says Hoefer. “Virtually all these programs have to have subsidies or donations or some other service to make them run well.“
Medicare Advantage (MA) offers a different payment and incentive structure than traditional fee-for-service. MA plans compensate providers on a per-member, per-month basis, and attach incentives to boosting the health outcomes and satisfaction of the people they serve. Nearly 50 percent of Sharp’s patients are covered under MA and if the palliative care program keeps them healthier and out of the hospital, the system enjoys the resulting cost savings and better patient outcomes.
But regardless of whether its Medicare patients are enrolled in MA or FFS, it’s still up to Sharp to fund its palliative care team at the point where Medicare stops. Hoefer believes full government support for these services makes complete sense.
“There’s a huge cultural change that needs to occur in the United States, starting from the top, recognizing that the best care is keeping patients so healthy that they need no care,” he says.
Two evidence-based proposals under consideration by the U.S. Department of Health and Human Services (HHS) – introduced by C-TAC and the American Academy of Hospice and Palliative Medicine — are paving a path for Medicare payment reform by allowing Medicare to fully fund palliative care programs. This would allow Sharp to sustain and scale its community-based primary care program by being compensated from both MA and FFS.
The result would provide current and prospective patients with broader access to these programs and the confidence to know they’ll be available to maintain and offer their services. The support to health systems –large and small—would promote better health outcomes and the corresponding saving of money.
“We’re eager for solutions for people who live with advanced illness that coincide with their values and preferences,” says Hoefer. “Inclusive and innovative care models that show promise for future, wide-scale implementation, taking into consideration quality, cost, and accessibility.”