Palliative care model meets goals of health care reform

All of the accountable care principles that are integrated into the Affordable Care Act (ACA) require a clinical approach to the sickest, most complex and costliest patients, says Diane E. Meier, MD, FACP, director of the Center to Advance Palliative Care at the Mount Sinai School of Medicine in New York City, because they all begin to move the system away from the fee-for-service model.

"Health care groups, providers, hospitals and multiphysician practice groups will need to function in an environment that involves various forms of capitation, where payment is linked to quality and not quantity of care," she says.

Palliative care is one of very few interventions that has repeatedly been shown to save money by improving the quality of care, Dr. Meier says. "It doesn't save money by rationing care, but by helping to avoid preventable crises," she says.

For this reason, says Dr. Meier, the new delivery and payment models called for in health reform have the potential to "enormously increase" attention to access and capacity for palliative care in Medicaid. "It's not explicitly called for in the law, but I don't see how any of these models can survive without it," she says.

A missed opportunity

The ACA's failure to mandate that palliative care be included in accountable care organizations (ACOs) was a "missed opportunity," says R. Sean Morrison, MD, a professor of geriatrics and palliative medicine at Mount Sinai School of Medicine in New York City.

"Within ACOs, it's going to be the 5% to 10% of the seriously ill patients that will account for the majority of health care spending," he says.

Including palliative care teams within the ACOs would ensure that a vulnerable population would receive the best quality care, says Dr. Morrison, and would also ensure that ACOs would be sustainable moving forward. "One of the things that states should be cognizant of is to make sure that ACOs and Medicaid medical homes include palliative care," he says.

Dr. Morrison says the "last untouched frontier" where palliative care has not been developed is long-term care facilities such as assisted living and nursing homes. "Right now, many Medicaid regulations are designed to encourage a system where seriously ill patients from nursing homes are transferred back and forth to hospitals to receive unwanted and unnecessary interventions, then sent back to the nursing home," he says.

For this reason, says Morrison, palliative care needs to be developed for the dually eligible elderly and disabled population residing in nursing homes. "This is a generalizable model that really meets the goals of health care reform," says Dr. Morrison. "It improves quality and reduces costs at the same time."

Barriers still exist

Dr. Morrison notes that only 60% of U.S. hospitals have some sort of palliative care program currently. "We need to move to fully integrating this into the fabric of our health care institutions," he says. "If we can do that, we improve care for our most vulnerable and costly population. We also have more dollars to go around."

One key barrier is reimbursement, says Dr. Morrison, as the physician and nurse practitioner are the only providers on the palliative care team who are currently reimbursed. "The other barrier is a workforce issue," he says. "It is a relatively new specialty. There need to be training opportunities for health care professionals to enter the field."

There is currently a cap on the number of graduate medical education trainees, he explains, and since palliative care is a new specialty, there are no new open training slots.

Some providers wrongly believe that palliative care is the same as end-of-life care, says Dr. Morrison, when in fact it's provided at the same time as disease-directed and curative treatments. Due to that misconception, he says, many patients are never referred.

"If I was a Medicaid director, I wouldn't want any of my beneficiaries being cared for in a hospital that doesn't have a palliative care program," says. Dr. Morrison. "State Medicaid directors can have a huge role in promoting education on palliative care for practitioners, as part of licensing requirements, for example."

Dr. Meier notes that Medicaid redesign laws were recently passed to require hospitals, home care agencies, assisted living facilities and nursing homes to ensure access to palliative care in New York state, adding that almost all payers who participate in Medicaid also participate with other payers such as Medicare and commercial insurance.

"By saying , 'If you want to participate in Medicaid, you must assure access to this kind of care for patients,' it's the same thing as saying that every health care institution needs to do this," she says.

Dr. Meier adds that the budget crisis was a key motivator for the legislation. "Everybody knows we are in a cost crisis," she says. "That has a way of overcoming a lot of barriers that ordinarily would prevent this kind of law from passing."

Contact Dr. Meier at (212) 241-6796 or Diane.meier@mssm.edu and Dr. Morrison at (212) 241-1466 or sean.morrison@mssm.edu.

Reference

1. Morrison RS, Dietrich J, Ladwig S, et al. Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff 2011: 30(3);454-463.