En español | Realizing that seriously ill patients often do better when they can stay in their own homes and receive coordinated and personalized treatment, growing numbers of health plans, physicians and medical facilities are offering pre-hospice, home-based palliative care to their patients.
Home-based plans typically integrate multidisciplinary care teams that include physicians and nurses, social workers, mental health professionals and chaplains who visit patients in their homes and offer tailored treatment plans focused on improving quality of life. The results can benefit patients and their caregivers and are cost-effective for the health care system, according to experts.
Priority Health, which has nearly 800,000 members in Michigan, runs health benefit options for employer groups and individuals, including Medicare and Medicaid plans. About five years ago, Priority Health established the Tandem365 initiative, through which a multidisciplinary team provides free care to patients who are seriously ill and unable to seek outside medical help due to cost or immobility. The initiative has shown promising results, including:
- a 38 percent decrease in inpatient stays
- a 52 percent decrease in emergency department visits
- a 35 percent decrease in total cost of care
- 46 percent fewer specialty care visits
Palliative care combined with traditional care
“Most people lump palliative care in with hospice, but there are distinct differences between the two,” says Greg Gadbois, Priority Health's medical director. “With palliative care, curative care is also OK. The big goal is to have that discussion with the patient of: 'What is important to you? What do you want us to do, or what don’t you want us do?' Most say they want to be home with their family and in peace. Palliative is the low-tech, high-touch opportunity to learn what the patient wants and needs."
Having a home-based team also offers a new level of understanding for a patient’s situation, he says. “For doctors, they see a patient in their office for 20 minutes and don’t get a full picture. I‘m a family doctor, and when elderly patients come to see me, they are dressed in their Sunday best and will say that everything is fine. They want to impress their doctors. But in home settings, you can’t hide those issues and problems.”
Members of a palliative care team may see that the patient is in financial trouble and deciding between paying for medications or their heat bill. Or that the patient is a hoarder with a fall risk when walking through the house. These social determinants of health can provide important context to their overall health care plan, Gadbois says.
Palliative care also offers medical professionals the opportunity to discuss risks and benefits of traditional treatment plans, Gadbois says, noting that a study published in the New England Journal of Medicine showed that lung cancer patients who received early palliative care lived longer than those who didn’t. “It speaks to the fact that some treatment can be pretty toxic.”
Stereotypes remain that palliative care means giving up on extending life, but that perception is changing with increased use of the programs, Gadbois says. Retraining doctors to talk to their patients about end-of-life options is crucial. "We never received training on end-of-life discussions, and we are not comfortable talking about it. Death is seen as a failure. But the end is part of our journey. It is important to do a good job helping the person to transition from this world to the next with as much dignity as possible.”
Barriers to palliative care
Reimbursement issues can make palliative care tricky for doctors, who are paid based on productivity. “Taking 45 minutes to talk to a patient about palliative care is a lifetime in their world,” Gadbois says. However, the Center for Medicare and Medicaid Services is now paying for advanced care planning discussion, and some health plans are moving towards adopting a palliative care system.
For managed care plans, palliative care hits the Institute for Healthcare Improvement’s “Triple Aim” of health care:
- improving the patient experience of care (including quality and satisfaction)
- improving the health of populations
- reducing the per capita cost of health care
“We aren’t denying care. We are eliminating unwanted care, and we see fantastic outcomes. Patient satisfaction rates are through the roof,” Gadbois says. However, he recognizes that doctors' offices are losing revenue, so a better way to reimburse delivery systems must be found so that the right care is incentivized. “That is the bigger lift right now. We are in the process of moving in that direction, but no where near where we need to be.”
Support for caregivers
“Caregiver burnout is a challenging issue for many families, and having access to home-based care provides another layer of direct support, along with professional-level advice. Social workers and others on the care team play a crucial role in coordinating community support options," says Bruce Smith, executive medical director for Regence BlueShield in Washington state.
“We believe caregiver support is so essential for the patient that our palliative care benefit offers caregiver support whether the person is a Regence member or not,” Smith says.
Regence, which offers coverage in Idaho, Washington, Oregon and Utah, launched a palliative care program in 2015 that includes advance care planning, collaborative care coordination and in-home counseling. It is open to anyone with a serious medical illness and provides caregiver and psycho-social support, as well as non-medical needs such as transportation and food.
“Having the ability to bring a coordinated model of care to a person in their own home can be a godsend for those who may have difficulty getting to an office appointment due to their health condition or other barriers,” Smith says. “Home-based programs take on the responsibility of meeting the patient’s needs rather than asking the patient to meet the doctor’s needs.”
The trend toward palliative care is growing in part because health insurers and medical groups are being held accountable for both quality outcomes and costs, Smith says. “Since a well-run home-based care program can improve quality of care and reduce overall costs, more and more organizations are offering home-based care.”
California leading the charge
The Hill Physicians Medical Group in San Ramon, Calif., has partnered with Blue Shield of California and Snowline Hospice on a home-based pre-hospice plan, which they say has numerous benefits.
“When people have a serious illness, they and their families often have a host of questions and needs that are best addressed by an interdisciplinary team,” says Terry Hill, vice president for performance strategy at Hill Physicians. “There's a world of difference between trying to identify those questions and needs in a physician's office versus at home, where the patient and family feel more in charge and the clinicians can take in the whole picture.”
Word of mouth is helping palliative care to grow, Hill says. “People who have experienced or heard about home-based palliative care tend to be enthusiastic and vocal, so word is getting out, and health care delivery systems are beginning to realize that these programs can reliably yield positive clinical and financial outcomes.”
Many of the top palliative care programs are located in California. “California is blessed with a number of factors that facilitate innovation in palliative care," he says. "It helps to have medical groups with a long-standing commitment to population health and leaders from the state's medical and public health schools who are palliative care champions. The Coalition for Compassionate Care of California facilitates a shared community for palliative care learning, and foundations have provided strategic support.”
Paying for palliative care
Barriers to wider implementation of palliative care nationwide include lack of reimbursement by Medicare, says Torrie Fields, senior program manager of palliative care for Blue Shield of California. "While many commercial health plans and Medicaid plans, like those in California, have begun to innovate and finance palliative care programs, the majority of those who would benefit from palliative care are still covered under Medicare fee-for-service."
Palliative care can reduce expensive and unwanted emergency department visits and hospital admissions, so it makes financial sense for a payer, health plan or delivery system with responsibility for the total cost of care, Hill says. “But high-touch services such as those provided by palliative care teams are themselves costly and beyond the resources of most organizations that do not share in the cost savings that palliative care makes possible.”
However, all patients and caregivers can have advance care planning conversations, starting at their doctor's office. "Not all health plans have palliative care programs, but some do — including access to multidisciplinary care teams and even extra covered benefits. Patients and caregivers should ask whether or not palliative care is covered by their health plan and whether it requires a copay. This will allow patients and families to make the most informed choice about how to access palliative care," Fields says.