By Lama El Zein
There is an increasingly broad push for a movement towards improving the quality of care at a lower cost for everyone, but especially for patients with serious illnesses, given the historically high cost of their care. The waste in the healthcare system in the United States has been estimated to reach as much as $935 billion, with 25 percent appearing to be avoidable (Shrank, et al. 2019). Continuing with this status quo is unsustainable for the future of our healthcare system.
Population health refers to the health outcomes of a specific group or population. In our discipline of palliative care, understanding the unique needs and characteristics of the population is essential for providing effective and high-quality care. Quality in palliative care is multi-dimensional, focusing on various aspects such as pain and symptom management, communication, psychosocial support, and care coordination. By addressing these dimensions, clinicians enhance the quality of care and the overall well-being of patients. And by measuring how well we address what matters to patients in our care, we show payers the value of our services. In addition, different communities may have distinct cultural, social, and economic factors that influence their preferences for palliative care throughout their serious illness journey. Our field’s focus on delivering this type of patient-centric, high-quality, cost-effective care, ideally positions palliative care at the center of discussion in many population health initiatives for health systems, government, and private payers’ programs. The Centers for Medicare and Medicaid Services (CMS), followed by health plans, usually sets the general tone of quality assessment and incentives, thus influencing the allocation of resources to specific programs in the short and long term.
Traditionally, interest and growth in palliative care have been on the hospital side, and hospital quality programs incorporate quality metrics that align with palliative care priorities, such as decreasing ICU stay, decreasing costs of admission, and improving patient and family satisfaction. In recent years, with the rise of value-based care, palliative care has expanded beyond the realms of hospital and immediate cancer pain care. On the other hand, the quality movement has pushed towards the implementation of the quintuple aim in initiatives: improving the health of the population, enhancing the care experience, reducing cost, addressing clinicians’ burnout, and advancing health equity (Nundy, et al. 2022). Thus, palliative care clinicians can play a crucial role in the intersection of quality, value-based care, and population health, given the unique services they provide affecting all aspects of the quintuple aim. However, this workforce needs financial and policy support from public and private payers to succeed. Payers, including health plans, play a significant role in providing incentives to improve quality overall and particularly in support of this focus on palliative care. Here are a few ways in which they can contribute:
Proactive Identification and Measurement: To have a true impact on quality, you need to allocate limited resources to the “right” patients, but who are they? Data have shown that of the top 5% of healthcare utilization in the US, only 11% are at the end of life (Aldridge & Kelly, 2015). Many have persistent unmet care needs leading to high costs with questionable quality outcomes (Salzberg, et al. 2016). This population is most accurately identified with integrated data from claims, prior authorization, pharmacy utilization, clinical feeds from electronic health records (EHR), various functional and SDOH assessments, and vendor information. Payers are in a great position to integrate these data points using newer technology and artificial intelligence to generate a better predictive model of utilization, thus avoiding low-quality care and inappropriate allocation of resources. And for the same reason, they will be able to follow and measure outcome metrics for this population. Payers possesses a lot of data, and it is imperative for the palliative care community to have a seat at the table when creating meaningful outcome measures from this data, focusing not only on cost calculators and regulatory checklists but on the reflection of true high-quality patient care.
Quality Metrics and Incentives: Payers, in collaboration with the palliative care clinical community, can develop and implement quality metrics and incentive programs to encourage healthcare providers to deliver high-quality palliative care. These metrics can focus on various aspects, such as pain management, symptom control, patient satisfaction, and advance care planning. By rewarding providers who meet or exceed the benchmarks of these metrics, payers can drive improvements in the quality of care. As discussed above, the choice of such quality metrics should involve the palliative care workforce. An example of such integrative work is AAHPM’s development of two new Patient Reported Outcome Performance Measures (PRO-PMs) for outpatient palliative care. The new measures assess the quality of care provided by asking how much patients felt heard and understood, and if patients got the help they wanted for their pain. A free measure implementation guide is available on AAHPM’s website. The measures are endorsed by the National Quality Forum, and Feeling Heard and Understood has been proposed for use in CMS’s Merit-based Incentive Payment System (MIPS). The palliative care community should continue testing these measures, publishing results, and pushing these PRO-PMs in CMS and other payers’ quality assessment efforts.
Care Coordination: Given decent access to data, payers can facilitate care coordination between different healthcare entities involved in a patient’s care journey. This includes coordinating with primary care physicians, specialists, hospitals, discharge teams, and home health agencies. This supports seamless transitions and effective communication among all parties. Payers often have internal care management programs, including with in-home care vendors, and some even have special home palliative programs. It is crucial that payers use their data efficiently to decrease fragmentation of care and optimize care coordination.
Coverage, Reimbursement, and Benefits: Payers can ensure that palliative care services are covered and reimbursed appropriately throughout the continuum of care. These covered benefits should include, but are not limited to, professional fee coverage for inpatient, outpatient, home, and skilled nursing facility services for all palliative care clinicians, enhanced rates for interdisciplinary teams, and incentives for coordinating care and engaging in advance care planning, as well as waiving co-pays for some of these services. By doing so, payers can reduce financial barriers, allowing patients to access necessary services without incurring excessive costs.
Provider Networks: Health insurance plans can establish robust networks of palliative care clinicians, ensuring that patients have access to high-quality and comprehensive services. Payers should conduct an adequate screening of the palliative network by sending surveys to identify who provides palliative services and where it is provided, given the vast scope of practice of the available workforce that may not be captured in the standard credentialing process. This can help improve access to primary versus specialty palliative care.
Education and Training: Health plans can support the education and training of members and healthcare professionals, especially when palliative care is provided by someone who is not a palliative care specialist, then called primary or basic palliative care. By collaborating with organizations and institutions to provide free CME and adequate patient resources, payers can help enhance the knowledge and skills of providers, ultimately leading to improved quality in palliative care. Some payors provide an electronic portal for advance care planning to assist providers and patients with education and decision-making tools.
Population health and quality in palliative care are interconnected, with a focus on tailoring care to the specific needs of a sick but diverse population. Public and private payers play a crucial role in improving quality by ensuring coverage, facilitating care coordination, enhancing provider networks, implementing meaningful quality metrics, and supporting education and training initiatives. Collaborative efforts between clinicians and payers can continue to advance the quality of palliative care and enhance the well-being of patients and their families.
Aldridge MD, Kelley AS. (2015). The Myth Regarding the High Cost of End-of-Life Care. Am J Public Health. Dec;105(12):2411-5. doi: 10.2105/AJPH.2015.302889.
Center to Advance Palliative Care (2015). Improving care for people with Serious illness through Innovate Payer-provider relationships- A palliative care toolkit and resource guide. media.capc.org/filer_public/0f/2f/0f2f8662-15cf-4680-baa8-215dd97fbde6/payer-providertoolkit-2015.pdf
Nundy S, Cooper LA, Mate KS. (2022). The Quintuple Aim for Health Care Improvement: A New Imperative to Advance Health Equity. JAMA. 327(6):521–522. doi:10.1001/jama.2021.25181
Salzberg, Claudia A., Susan L. Hayes, Douglas McCarthy, David C. Radley, Melinda K. Abrams, Tanya Shah, and Gerard Anderson (2016). Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences. Commonwealth Fund Issue-Briefs, August 29, 2016.
Shrank WH, Rogstad TL, Parekh N. (2019). Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 322(15):1501–1509. doi:10.1001/jama.2019.13978