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Palliative Care 2012: Matching Care to Our
Patient’s Needs
Diane E. Meier, MDDirector
Center to Advance Palliative Care
www.getpalliativecare.org
Core Principle
1. “The secret of the care of the patient is caring for the patient.” Francis Peabody, Harvard University, 1921
The Ends of Medicine: Our Professional Obligations
“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients”
-Oath of Hippocrates, 400 BC
“May I never see in the patient anything but a fellow creature in pain.”
- Maimonides, 12th century AD
Objectives
1. What’s wrong with the U.S health care system?
2. How can it be fixed?3. How is palliative care important to
improving value (quality and cost) in health care reform?
4. Changing the delivery system to improve access to quality palliative care in and beyond the hospital
Health care in the U.S.
• What are the ends of medicine?– What are they in the U.S.?
• What should they be? “To cure sometimes, relieve often, comfort always.”
• The problem: “The nature of our healthcare system- specifically its reliance on unregulated fee-for-service and specialty care- …explains both increased spending and deterioration in survival.” Muenning PA, Glied SA. What changes in survival rates tell us about
U.S. health care. Health Affairs 2010;11:1-9.
How They Think About it in Washington:
The Value Equation-1Value of health care = Quality CostNumerator problems
– 100,000 deaths/year from medical errors– Millions more harmed by overuse, underuse, and
misuse– Fragmentation– Medical practice based on evidence <50% of the time– 50 million Americans (1/8th) without access– U.S. ranks 40th in quality worldwide
The Value Equation- 2
Value of health care = quality costDenominator problems• Insurance premiums increased by 181% in the
last 10 years.• U.S. spending 17% GDP, >$8400 per capita/yr • Nearing 30% of total State spending• Despite high spending, 15% of our population
has no insurance, and half are underinsured in any given year.
• Health care spending is the #1 threat to the American economy and way of life.
International Comparison of Spending on Health, 1980–2009
* PPP=Purchasing Power Parity.Data: OECD Health Data 2011 (database), version 6/2011.
Average spending on healthper capita ($US PPP*)
Total expenditures on healthas percent of GDP
8Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
EFFICIENCY
8
Sun Sentinel (Broward County edition)Tuesday, August 9, 2011
Health Care vs Determinants of HealthGrowth in Massachusetts State Budget Spending FY2001 to FY2012
(Inflation adjusted)
Source: Massachusetts Budget & Policy Center Budget Browser
-60%
-40%
-20%
0%
20%
40%
60%
80%
100%
Health Care Primary-SecondaryEducation
Law andPublic Safety
Public Health Environmentand
Recreation
HigherEducation
Local Aid
%
What is this money buying us?
Organization for Economic Development and Cooperation
Among OECD member nations, the United States has the:
• Lowest life expectancy at birth.
• Highest mortality preventable by health care.
Cost: Hospital Spending per Discharge, 2009Adjusted for Cost of Living
17,206
12,163 11,988
9,398 9,131 9,026
7,312 7,312 7,295
4,667 4,527
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
US* CAN* NETH SWITZ NOR* SWE NZ OECDMedian
AUS* FR GER
Source: OECD Health Data 2009 (June 2009).
Dollars
Wall Street
Journal page 1
Sept. 18, 2003
Medical Spending in the U.S.$2.9 trillion in 2010
The costliest 5% account for 50% of all healthcare spending
Medicare Payment Policy: Report to Congress. Medpac 2009 www.medpac.gov
Health Affairs 2005;24:903-14.
CBO May 2009 High Cost Medicare Beneficiaries www.cbo.gov
nchc.org/facts/cost.shtml
Copyright 2008 Center to Advance Palliative Care. Reproduction by permission only.
Target Population for Palliative CareDistribution of Total Medicare Beneficiaries and Spending,
2009
10%
63%
37%
90%
Total Number of FFS Beneficiaries: 37.5 million
Total Medicare Spending: $417 billion
Average per capita Medicare spending (FFS only): $7,554
Average per capita Medicare spending among
top 10% (FFS only): $48,220
NOTE: FFS is fee-for-service. Includes noninstitutionalized and institutionalized Medicare fee-for-service beneficiaries, excluding Medicare managed care enrollees. SOURCE: Kaiser Family Foundation analysis of the CMS Medicare Current Beneficiary Survey Cost & Use file, 2009.
Palliative Care is Central to Improving the Value Equation
• Because our patient population is driving most of the spending
• >95% of all health care spending is for the chronically ill
• 50% of all healthcare spending goes to the sickest and most complex 5% of patients- those in need of palliative care.
Why Palliative Care is Important to Improving Value in Health Care
• Improves patient quality/length of life– Reduces pain, depression and other symptoms;
in several studies prolongs life• Improves family satisfaction and well-being• Reduces resource utilization and costs
….and does so for the sickest 5%-10% of the population driving over half of total healthcare costs.
Conceptual Shift for Palliative Care
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
Palliative care is specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.
The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.
Palliative Care Language Endorsed by the Public
95% of respondents agree that it is important that patients with serious illness and their families be educated about palliative care.
92% of respondents say they would be likely to consider palliative care for a loved one if they had a serious illness.
92% of respondents say it is important that palliative care services be made available at all hospitals for patients with serious illness and their families.
Once informed, consumers are extremely positive about palliative care and want access to this care if they need it:
Exceptionally High Positives
Palliative Care Teams Address 3 Domains
1. Physical, emotional, and spiritual distress2. Patient-family-professional
communication about achievable goals for care and the decision-making that follows
3. Coordinated, communicated, continuity of care and support for practical needs of both patients and families across settings
Palliative Care Improves Value
Quality improves– Symptoms– Quality of life– Length of life– Family satisfaction– Family bereavement
outcomes– Care matched to
patient centered goals
Costs reduced– Hospital costs
decrease– Need for
hospitalization/ICU decreases
Palliative Care Improves Quality in Office Setting
Randomized trial simultaneous standard cancer care with palliative care co-management from diagnosis versus control group receiving standard cancer care only:
– Improved quality of life – Reduced major depression – Reduced ‘aggressiveness’ (less chemo <
14d before death, more likely to get hospice, less likely to be hospitalized in last month)
– Improved survival (11.6 mos. vs 8.9 mos., p<0.02)
Temel et al. Early palliative care for patients with non-small-cell lung cancer NEJM2010;363:733-42.
Palliative Care at Home for the Chronically Ill Improves Quality, Markedly Reduces Cost
RCT of Service Use Among Heart Failure, Chronic Obstructive Pulmonary Disease, or Cancer Patients While Enrolled in a Home Palliative Care Intervention or Receiving Usual Home Care,
1999–2000
13.211.1
2.3
9.4
4.6
35.0
5.3
0.92.4
0.90
10
20
30
40
Home healthvisits
Physicianoffice visits
ER visits Hospital days SNF days
Usual Medicare home care Palliative care intervention
KP Study Brumley, R.D. et al. JAGS 2007
RCT of Nurse-Led Telephonic Palliative Care Intervention
• N= 322 advanced cancer patients in rural NH+VT• Improved quality of life and less depression
(p=0.02)• Trend towards reduced symptom intensity
(p=0.06)• No difference in utilization, (but v. low in both
groups)• Median survival: intervention group 14 months,
control group 8.5 months, p = 0.14
Bakitas M et al. JAMA 2009;302(7):741-9
Consequences of Late Referral to Palliative Care
Serious Adverse Outcomes for Bereaved Caregivers:
Compared to care at home with hospice, • Care in ICU associated with 5X family risk
of Post Traumatic Stress Disorder; and • Care in hospital associated with 8.8X
family risk of prolonged grief disorder
Wright A et al. Place of death: Correlation with quality of life of patients with cancer and predictors of bereaved caregivers mental health. JCO 2010; Sept 13 epub ahead of print
Effect of Palliative Care on Hospital Costs
How Palliative Care Reduces Cost
• Improved resource use• Reduced bottlenecks in high cost units• Improved throughput and consistency
The Conceptual Model: Dedicated medical team =
Focus + Time = Decision Making / Clarity / Follow
through
Source: Center to Advance Palliative Care, 2011 capc.org/reportcard
Palliative Care Growth
America’s Care for Serious Illness
A State-by-State Report Card on
Access to Palliative Care in Our Nation’s Hospitals
Source: Center to Advance Palliative Care, 2011 capc.org/reportcard
NYS Palliative Care Programs by Hospital Type
New York (2008) New York (2011) United States (2011)
% (#) ALL hospitals w/PCPs
56% (75/134) 72% (106/147) 47% (1894/3989)
% (#) > 300 Bed hospitals w/PCPs
77% (30/39) 89% (55/62) 85% (597/699)
Public hospitals 25% (2/8) 89% (17/19) 54% (192/356)
Sole Community Provider
50% (7/14) 53% (8/15) 37% (151/406)
Dartmouth Atlas Data and NY State Ranking, 2009
Medicare reimbursement last 6 months of life
$9384 51st
ICU admission during last hospitalization
19% 45th
Medicare deaths in hospital
37% 51st
ICU days/decedent last 6 m.
3.2 30th
Hospital admits/1000 decedents
1532 43rd
New York State Summary
• 147 Hospitals• 72% (106/147) have a palliative care program. • Grade of “B” on the CAPC State-by-State Report
Card up from “C” in 2008• NY State costs are among the highest in the
nation. www.dartmouthatlas.org
• NY State palliative care programs see <1% of admissions – huge opportunity for growth, since goal is 4-6%
Hope for the Future: Younger physicians exposed to palliative care more than their predecessors.
− 37 −
% “Great Deal” or “Some” Exposure to Palliative Care by Physician Age
National Quality Forum: Palliative Care is One of Six National Priorities for Action
http://www.nationalprioritiespartnership.org/Priorities
38
National Recognition of Importance of Palliative Care to
Healthcare Value
• MedPAC: Called a meeting of national experts in palliative care in May 2011 to understand what Medicare payment policies might advance access and quality
• The Joint Commission: Announced September 2011 release of a Palliative Care Advanced Certification Program.
41
Palliative Care: “on the map” with IHI
http://www.ihi.org/IHI/Programs/ImprovementMap
Strategic Partnerships
New Delivery and Payment Models + Palliative Care
Accountable Care Organizations?
Patient Centered Medical Homes?
Bundled payments?
Adding palliative care targeted to the highest cost + risk populations to the specifications for these strategies is key to their success at improving quality and reducing cost.
Major Health Systems Get It
Making multimillion dollar investments in palliative care integration across settings:
•Partners Health System/ Harvard Medical School
•U. of Pittsburgh Health System
•Duke U. Health System
•North Shore-LIJ Health System
Payers Get It
Examples of private sector approaches to community-based
palliative care
Matching (Payer) Resources to Needs
Demand Management DM/CM CCM-palliative care
RE
SO
UR
CE
S
NEEDS
Payers Have Skin in this Game
Resources: Don’t Waste Time Reinventing the Wheel
• www.capc.org• www.getpalliativecare.org• Registry https://registry.capc.org/
• Audioconferences http://www.capc.org/support-from-capc/audio-conf/
• E-learning via CAPCcampus on-line http://campus.capc.org/
• CAPCconnect forum http://www.capc.org/forums/
• Joint Commission technical assistance http://www.capc.org/palliative-care-professional-development/Licensing/joint-commission
• Palliative Care Leadership Centers http://www.capc.org/palliative-care-leadership-initiative/overview
Although the world is full of suffering, it is full also of the
overcoming of it.
Helen KellerOptimism 1903
