Tough questions & palliative care

As the cost of delivering quality care for members with a serious or advanced illness continues to strain the resources of government and private health payers, many plans are introducing innovative solutions.  Palliative care programs that effectively address the cost and quality of care for this vulnerable population are beginning to meet wide payer receptivity.

Palliative care is specialized care for members with a serious or advanced illness that provides an extra layer of support for everyday living: relief from symptoms and stress, medication management, care coordination and other support to improve quality of life for both the patient and the family.

With a better understanding of the financial issues, as well as awareness of the new options now available to overcome these problems, brokers and consultants are better prepared to educate customers and offer recommendations that help them make informed decisions.

Whether the client portfolio consists of employers or plan sponsors seeking coverage for health or retirement benefits, or simply includes individuals evaluating options for Medicare Advantage plans, the goal is to help customers choose a plan that best suits their families’ needs.

In this hyper-connected society fueled by media coverage and social communications channels, the challenges of paying for medical care have become top-of-mind in virtually every American household.  Many families are also wondering how they can cover the costs of a relative who already has a serious illness or deal with the medical bills if someone becomes gravely ill or nears end-of-life.

This is precisely where astute benefit professionals can deliver value and help to address these concerns.  Being prepared with answers that reflect a fuller understanding of the issues, as well as the solutions, is a market differentiator that builds client loyalty year after year.

It’s also a good time to challenge health plans and provider organizations to:

• Demonstrate their commitment to members with a serious or advanced illness
• Assess their programs for palliative care
• Evaluate the value that they bring to your customers
• Determine the effectiveness of their focus on delivering quality care while balancing cost

Escalating costs for payers

While the onset and progression of a serious illness can occur at any age, seniors are more likely to experience an advanced illness.  Expense patterns are magnified by the extraordinary growth of the senior population, and by 2050, the number of people on Medicare who are 80 and older will nearly triple, while the number of people in their 90s and 100s will quadruple.

In fact, 1 out of every 4 Medicare dollars — over $125 billion — is spent on services for the 5 percent of beneficiaries in their last year of life. Even more notable is a recent study which looked at 2012 Medicare administrative claims data for older Medicare beneficiaries who died, and identified four unique spending trajectories:

• 48.7 percent (nearly half) of older Medicare beneficiaries were classified as “high persistent,” maintaining high spending throughout the year;
• 10.2 percent showed a “progressive” pattern, starting low but increasing steeply;
• 29.0 percent of decedents were “moderate persistent,” mimicking the “high persistent” pattern except for a spending dip a few months prior to death;
• 12.1 percent of the sample exhibited a “late rise” in the final four months of life after very low spending in the earlier months of that final year.  

Palliative care benefits payers and members

As payers navigate their way to addressing these financial pressures, and with an eye on maintaining high quality care for their sickest members, many are now recognizing the value of palliative care programs. Payers from coast-to-coast — especially Medicare Advantage plans and platforms serving corporate retirees — are now seeing the benefits of this level of care for their members and the positive impact on financial performance.

The most innovative model of palliative care prioritizes the importance of care in the home, with specially trained nurses and social workers providing appropriate social services, clinical assessments and referrals, and partnering with the primary care and provider team.  These palliative care teams are particularly experienced and adept at conducting sensitive, meaningful conversations among patients, families and caregivers.  These discussions result in shared decision-making that helps to align treatments to informed goals of care, averting costly, often unplanned or unwanted interventions and avoiding over-medicalization.

In fact, a study published in the New England Journal of Medicine shows palliative care can also help patients live longer.  Of 151 patients with advanced lung cancer, those given early, concurrent palliative care survived 11.6 months, nearly three months longer than those who received standard medical care. Evidence also shows that, with or without curative treatments, a palliative approach offers the best chance of maintaining the highest possible quality of life for the longest possible time, according to the National Center for Biotechnology Information.

This newer and highly systemized approach, which focuses on care outside the hospital setting, functions as a palliative medical home, addressing disease understanding and symptom control/treatment options that lead to improved member and caregiver satisfaction.  By completing goals of care and advance care planning documentation, clinicians help members to align treatment with individual preferences and manage communications with the member’s treating physician:

• Focuses on care coordination across all settings
• Emphasizes ongoing support at home
• Ensures advance care planning
• Engages physicians and other care providers
• Provides integrated, dedicated, interdisciplinary, team-based care
• Establishes goals of care
• Addresses needs of those who are ineligible or those who refuse hospice
• Identifies gaps in care
• Provides pain and symptom relief
• Facilitates disease understanding and self-management
• Offers psycho-social support

Initial and follow-up home visit assessments include:

• Primary and secondary diagnoses
• Medical and hospitalization/ED history
• Functional status and activities of daily living
• Symptom assessment
• Medication review; adherence assessment
• Adequacy of home, family, safety and financial supports
• Patient’s understanding of illness
• Goals of care/Advance Care Planning
• Services in place or needed
• Patient risk evaluation
• Palliative Plan of Care

Relief for working caregivers

Palliative care is providing welcome relief to working caregivers who add to their work-related responsibilities the duties and commitment that come with taking care of a loved one in need.

Many individuals sacrifice work/life balance and risk losing their jobs, with absenteeism and presenteeism emerging as issues for employers and employees. Among caregivers who are employed or who have been employed during their time as caregivers, some have had to reduce their hours or job responsibilities, take leave from their position, quit their job or retire early to accommodate their caregiving duties.

A study demonstrates the benefits of a phone-based palliative care support program for caregivers of people with advanced cancer. The results suggest that the earlier palliative care services are introduced to caregivers, the better they will be able to cope with the caregiving experience.

Palliative care teams support caregivers

They keep caregivers informed about what to expect, and help individuals prepare for what is happening now and in the future.  This helps the caregiver to anticipate what aspects of their work responsibilities will be impacted.

They equip caregivers with practical tools, including tools to relieve stress.  This allows caregivers to better focus on job responsibilities.

Advance care planning

Advance care planning (ACP) is generally defined as making decisions about the care an individual would want to receive before, and if, he or she loses the ability to communicate. These decisions are based on personal values, preferences and discussions with loved ones.

If an individual is in an accident or has an illness that leaves them unable to communicate their wishes, who will speak for that individual? In advance, that information can be communicated in a document to family, friends and health care providers — wishes and personal beliefs about continuing or withdrawing medical treatments at the EOL. ACP includes:

• Getting information on the types of life-sustaining treatments that are available.
• Deciding what types of treatment one would or would not want if diagnosed with a life-limiting illness.
• Sharing one’s personal values with loved ones.
• Completing advance directives to put into writing what types of treatment one would or would not want should one be unable to speak for oneself.

Source:  National Hospice and Palliative Care Organization; https://www.nhpco.org/advance-care-planning

Value of a specialized solution

To successfully address this vulnerable population, it is necessary to move beyond a focus on disease process to one that emphasizes individuals and their goals of care. Care provided during this timeframe should shift toward a focus on comfort and quality of life.

Specialized palliative care as described above plays a pivotal role in addressing the needs of the whole person and the family to improve quality of life for all.  It can be provided along with curative treatment, offering services that effectively address the symptoms and stress of a serious illness.

Innovate and differentiate services

In today’s dynamic health care industry, brokers and other consultants can demonstrate value to customers by offering information that enhances understanding of market opportunities.  By expressing sensitivity to the challenges confronting individuals with a serious or advanced illness and offering background on specialized solutions — such as palliative care — benefits professionals can demonstrate their value and gain a competitive advantage.  Clients will be appreciative of new ways and perspectives for addressing health care costs and opportunities to access the best possible care during a challenging time of life.

Greer Myers is President, Turn-Key Health and EVP, Chief Development Officer, Enclara Pharmacia. With more than 20 years of health care experience, he joined Enclara Healthcare in 2014, and maintains dual roles as its President of Turn-Key Health and its Executive Vice President of Corporate Development of Enclara Pharmacia. Bringing strengths in post-acute operations, mergers and acquisitions, pharmacy benefits management, strategy and business development, he also has strong vertical experience in payer, provider and healthcare IT verticals.