Four Ways ACOs Can Achieve Success in Home-Based Palliative Care

Myers

Amid growing pressure from CMS to take on additional risk, as a condition for ongoing participation, Medicare Shared Savings Program (MSSP) ACOs must contend with the rising cost of providing quality care while generating cost savings. This challenge is especially pronounced within the fast-growing senior population, the group most likely to experience a serious or advanced illness.

One-quarter of all Medicare dollars are spent on treatment during the final year of life. Moreover, one-third of the final-year expenditures are squeezed into the last month before death. Over that period, 80% of spending is for hospital-based treatment, much of it in intensive care units (ICUs).  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. As a result, organi¬zational leaders are beginning to recognize that this fragile, vulnerable population requires a more focused approach to effectively address the enormity of the issues impacting cost and quality of care.
 
According to a recent study which looked at 2012 Medicare administrative claims data for older Medicare beneficiaries who died, researchers identified four unique spending trajectories: 

- Nearly half (48.7%) of older Medicare beneficiaries were classified as “high persistent,” maintaining high spending throughout the year;
- 10.2% showed a “progressive” pattern, starting low but increasing steeply;
- 29.0% of decedents, were “moderate persistent,” mimicking the “high persistent” pattern except for a spending dip a few months prior to death;
- 12.1% 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.

Ironically, what has been the highest-cost population may now represent the greatest opportunity for ACOs to remain viable in the revised MSSP environment. Innovative models leveraging structured community-based palliative care deliver a high return on investment in both cost and quality. ACOs are discovering the benefits of moving patients with a serious or advanced illness out of the hospital and into the home environment.

Related: Anthem-Aspire Acquisition: 5 Takeaways

Four necessary conditions to remain in the game

To deliver positive ROI in both cost and quality, any form of home-based palliative care strategy must be highly structured in its approach. ACOs must:

• Employ AI and sophisticated predictive analytics to identify members earlier in order to get ahead of the curve. The passive referral-based model, under which members/patients are caught in final safety nets, is insufficient. That model delivers last two-week improvement in cost and quality but misses the mark for truly improving the quality of end-of-life.
• Keep all eyes on the patient, caregiver, and environment, in their home. The traditional model engaging with patients during an 11-minute PCP visit in the office is insufficient to manage a patient population. The patient-centered medical home cannot exist without someone in the home. For this population, the serious and advanced ill, this represents the difference between significant unplanned care and non-beneficial treatment versus aging peacefully at home.
• Engage palliative clinicians act as extensions of the medical practice for those with a serious or advanced illness. Siloed approaches don’t work. Fragmentation of care remains rampant and the dream of integrated EMRs, tests, and data is elusive. Palliative clinicians are remarkably adept at identifying gaps in care, caregiver breakdown, psychosocial issues, etc. They are also best equipped and communicate gaps in care, advance care plans, and related caregiver burden. They are at the front line of identifying the potential for unplanned care and non-beneficial treatment.
• Assume a population health approach to manage not only at a macro level, but also at an individual level. The traditional approach of palliative care in the home does not provide for consistency in approach or longitudinal progress tracking. EMRs built for billing purposes and checking boxes for billing Medicare are insufficient for managing a population of individuals suffering from a serious or advanced illness. Systems must be in place to inform and guide clinicians as to the next steps required to ensure the best possible quality of remaining life outcome.

Identify. Engage. Support. Guide. None of these elements can be effective on their own and are only fully accretive when combined. However, there are specialized approaches that solve for this problem, virtually guaranteeing significantly positive ROI. ACOs choosing to stay in the MSSP program are faced not with whether to tackle end-of-life care and quality, but how.

Greer Myers is president of Turn-Key Health.