Improving oncology care with more integration of palliative care

Thomas J. Smith, MD FACP Harry J. Duffey Family Professor of Palliative Medicine

Director of Palliative MedicineJohns Hopkins Medical Institutions

Professor of OncologySidney Kimmel Comprehensive Cancer Center

tsmit136@jhmi.edi

Objectives1. Reasons why.2. Smaller fixes within reach.

a) More use of palliative care consultation services.b) More “primary palliative care” in oncology practicesc) More and earlier use of hospice (live better and longer)

3. Big fixes.a) Insurance: Aetna’s Compassionate Care Programb) Sutter Health Advanced Illness Model

Medical care costs 2-fold more in the US than any other country

OECD Health Data 2011

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Belgium

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Finlan

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Cancer care costs are rising exponentially- $173 billion at 2% growth rate

1990 1995 2000 2005 2010 2015 20200

20406080

100120140160180

Cancer Care Costs (Billions)

Year

Mariotto AB, et al. Projections of the cost of cancer care in the United States: 2010-2020. J Natl Cancer Inst. 2011 Jan 19;103(2):117-28.

Claxton G, et al. Health Aff (Millwood). 2010 Oct;29(10):1942-50.

Care patterns for cancer patients who died at a major medical center, Summer 2011 (see Dy S et al, JPM 2011; *Dow and Smith, JCO 2010)

Process measure N (%) Targets

Seriously ill 61

Use of ventilator 16 (26) 10%

Deceased 35 (57)

Any goals of care discussion 26 (43) 95%

Advance directives on file 4 (7) 90%

Oncologist brought up Ads* 2/75 (1%) 100%

Death in hospital 21 (34) 10%

Discharged with hospice 14 (23) 60%

Chemo with 2 weeks of death, solid tumor patients

28-35% <10%

Quality of care is not optimal

We are still hospital oriented and not hospice oriented near the very predictable end of life.

Medicare Patients, Unadjusted Cancer Care Measures, By Hospital Characteristics, Morden, Health Affairs 2011

Measure AllNCCN cancer centers

Academic hospitals

Community hospitals

Death in hospital (%) 30.2 32.6 33.8 29.7Hospice use, last month of life (%) 53.8 53.4 50.3 54.2

Days in hospice, last month of life (per decedent)

8.4 8.6 7.6 8.5

Hospitalized, last month of life (%) 64.9 60.2 64.4 65.1

ICU use, last month of life (%) 24.7 23.3 26 24.6

QOL concerns are not raised or discussed in cancer clinical settings.

2010 ACS CAN National Poll on Facing Cancer in the Health Care System (www.acscan.org)

Q: After diagnosis and before starting treatment, did anyone on care team ask what is important to you/family in terms of QOL?

3/4s of patients with lung and colon cancer think they could be cured with chemo (Weeks J, et al. NEJM 2012)• Half of all lung cancer patients have had NO discussion with any of their

doctors about hospice 2 months before they die. Huskamp HA, et al. Arch Intern Med. 2009

• Only 37% of patients have any conversation about dying. (Wright AA, JAMA 2008)

• 60% of us prefer not to have “hard conversations” (DNR, AMDs, hospice) until “there are no more treatment options left”. Keating NL, et al. Cancer. 2010

• Telling some one they are “incurable” is not enough – people want information about prognosis, what will happen to them, and their options.

Definition of palliative care“Palliative care is specialized medical care for people with

serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness - whatever the diagnosis.

The goal is to improve quality of life for both the patient and the family.

Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient's other doctors to provide an extra layer of support.

Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.”

– Diane Meier, MD, Director, Center to Advance Palliative Care, July 1, 2011

Palliative care in addition to usual oncology care allowed lung cancer patients to live almost 3 months longer than those who got usual oncology care. Temel J, et al. NEJM 2010; Temel J, et al, JCO 2011

Longer and better survival Better understanding of

prognosis Less IV chemo in last 60 days Less aggressive end of life

care More and longer use of

hospice $2000 per person savings to

insurers and society

The American Society of Clinical Oncology now recommends “…combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden.”

- Now 5 randomized trials showing the same results.- No trials showing harm or increased costs.

Hospice in the United States• Hospice is defined as a Medical Benefit• Truly managed care:

– $150 a day outpatient, $500 a day inpatient– Everything must be paid from that

• Must have a 50/50 chance of death in the next 6 months if the disease runs its natural course

• Hospice eligibility: Hospice in a Minute

How do we better integrate palliative care into our care?

• Primary PC: every oncologist should be able to do.– Communication (ask, tell, ask)– Symptom Assessment and management (ESAS, MSAS)– Spiritual assessment (FICA, SNAP, AMEN)– Hospice referrals

• Secondary PC: referral, just like referral to cardiologist.• Tertiary PC: specialized inpatient and research programs.

• Need more PC people– Fellowships– Advanced training (EPEC-O, ELNEC, OncoTalk)

How to do palliative care in the office.Cheng J, King L, Alesi ER, Smith TJ. J Oncol Practice, 2013

Table 1: Components of Office-based Primary Oncology Palliative Care 1. Ask, Tell, Ask.

Always ask people how much they want to know, and what they do know.Then tell them, in understandable words.Ask “What is your understanding of your situation?”

2. At each transition point (when changing treatments or prognosis) ask, tell, ask. “What are you hoping for?” and “What is your understanding of your situation?”

3. Always do a symptom assessment. 4. At least some of the time, do a spiritual assessment. 5. Make a “hospice information referral” when the patient still has 3-6 months left to live.

6. Audit hospice referrals, like QOPI does. 7. Set up “best practices” for seriously ill patients who have less than a year to live. 8. Take advantage of decision aids to help those patients who want to know their prognosis. Use www.Eprognosis.org

9. Use some “palliative care pearls” in your practice, such as olanzapine for nausea, ginger for nausea, ginseng or dexamethasone for fatigue and better quality of life.

10. Use chart prompts in your EMR.Advance Directive __Yes __ No __ Not discussedCode status __Full ___DNR Other _______________DPMA ___________________________________

There are opportunities to improve our practice on hospice referrals

Medicare Patients, Unadjusted Cancer Care Measures, By Hospital Characteristics, Morden N, Health Affairs 2011

Measure AllNCCN cancer centers

Academic hospitals

Community hospitals

Death in hospital (%) 30.2 32.6 33.8 29.7

Hospice use, last month of life (%) 53.8 53.4 50.3 54.2

Days in hospice, last month of life (per decedent)

8.4 8.6 7.6 8.5

Hospitalized, last month of life (%) 64.9 60.2 64.4 65.1

How do we better integrate hospice into our care?

• Have a “hospice information visit” when we think the person has 3-12 months to live.

• Can’t hurt. OK to predict wrongly.• Can dramatically help

– Makes us address difficult issues like “code status”– Informs family that the situation is serious and their loved

one is dying– MOLST– Will, Living Will, DPMA, Life Review, Dignity therapy

Smith TJ, Longo DL. Talking with patients about dying. N Engl J Med. 2012 Oct 25;367(17):1651-2. doi: 10.1056/NEJMe1211160.

Hospice eligibility is straightforward

• The SURPRISE QUESTION: “Would you be surprised if this person were to die in the next 6 months?”

• Failure to thrive: BMI < 22, involuntary weight loss

• CHF NYHA Class IV, EF < 20%• COPD: hypoxemia at rest, FEV1 < 30%• Dementia < 6 words• Liver disease: INR > 1.5, albumin < 2.5• Cancer – much easier. Salpeter et al. J

Palliat Med. 2012 Feb;15(2):175-85– Hypercalcemia, any malignant effusion, spinal

cord compression, ECOG PS 2 or higher

The benefits are straightforward…better care, and people who use hospice for even one day live longer.

Connor SR, et al. J Pain Symptom Manage. 2007 Mar;33(3):238-46.

We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more.

U of Iowa Hospitals. • 688 in-hospital deaths • 209 decedents had preceding admission • 60% of decedents were eligible for hospice on the

penultimate admission, based on NHPCO, National Hospice and Palliative Care Organization worksheets.

-Only 14% had any discussion of hospice, despite being eligible; 14 of 17 enrolled, all from ONE service

- Hopkins among the lowest of UHC Hospitals for hospice discharges from Cardiology, some other services

Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.

We miss opportunities to recognize hospice-eligible patients, they are readmitted, and cost more.

Table: Comparison of Cost and Length of Stay Between Patients Enrolled and Not Enrolled in Hospice During a Terminal Hospital Admission

Enrolled in hospice before last admission n = 7/14

Not enrolled in hospice, all diagnoses, n = 202/209

Cost Mean $4963 $52 219 Median $3690 $23 322 Standard deviation

$3250 $85 101

Standard deviation

4.47 25.05

Palliative Care Consultation YES, $41,859 NO, $58,386P<0.04

Freund K, et al. J Hosp Med. 2012 Mar;7(3):218-23. doi: 10.1002/jhm.975. Epub 2011 Nov 15.Weckmann MT, et al. Am J Hosp Palliat Care. 2012 Sep 5.

People who use hospice are re-admitted less often, use less medical resources, and get better care.

Enguidanos S, Vesper E, Lorenz K. 30-Day Readmissions among Seriously Ill Older Adults. J Palliat Med. 2012 Dec;15(12):1356-61. doi: 10.1089/jpm.2012.0259. Epub 2012 Oct 9.

Table 2. Readmission Rate by Post-discharge Medical Service Use Post-discharge medical services Ratio of readmissions Percent Hospice 11/240 4.6 Home-based palliative care 5/60 8.3 Home health 2/15 13.3 Nursing facility 14/58 24.1 Home no care 9/35 25.7

Hospice saves Medicare $2309 per decedent, and the longer the hospiceLength of stay, the bigger the savings. Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length of hospice use maximizes reduction in medical expenditures near death in the US Medicare program? Soc Sci Med. 2007 Oct;65(7):1466-78. Epub 2007 Jun 27.

Better care, consistent with what people would choose. Smith TJ, Schnipper LJ. The American Society of Clinical Oncology program to improve end-of-life care. J Palliat Med. 1998 Fall;1(3):221-30.

Identifying hospice eligible patients makes a difference

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Fig 1. Increase in GH Referrals Since JH PC Program Started Oct 2011

PC program

Change our standards of care to incorporate national guidelines and best practices about palliative care.

7. Set guidelines like the U S Oncology pathways that preserve survival, reduce cost by 35% in lung and colon cancer

For NSCLC and colon cancer, equal results, less toxicity, less cost.Neubauer M, et al. J Oncol Pract. 2010 Jan;6(1):12-8. Hoverman JR, et al. J Oncol Pract. 2011 May;7(3 Suppl):52s-9s

Equal survivalWith no 3, 4, 5th

Line chemo

GenericsLimit to 3 “lines”Of chemo

Less chemoLess hospital

More hospice2x↑ LOS, use

Someone in the office- AMDs- DPMA- Hospice info visit

Advanced Care:

How choice, comfort and dignitycan drive cost reduction

in a shared risk/shared savings world

Brad Stuart MDstuartb@sutterhealth.org

“Bending the Cost Curve for Seriously Ill Patients” Annual Assembly of AAHPM & HPNA

March 8, 2012

Moving Care Out of the Hospital

HOSPITALS• Emergency Dept.• Hospitalists• Inpatient palliative care• Case managers• Discharge planners

MEDICAL OFFICES• Physicians• Office staff

HOME-BASED SERVICES• Home health• Hospice

• Telesupport Center

New Advanced Care staff & services

EHR• Patient Registry

911

• Care Liaisons

• Care managers• Telesupport

• Transitions Team

CRITICAL EVENTS• Acute exacerbation• Pain crisis• Family anxiety

CRITICAL EVENTS• Acute exacerbation• Pain crisis• Family anxiety

Tracking the Process of Personal Choice

HOSPITALS

PHYSICIANOFFICES

HOME-BASED SERVICES

TELESUPPORTEHR

Shared decisionsmade over timeat the patient’s

own pace

Start the conversation• Inpatient PC• Hospitalist• PCP

Handoff

Trained teamlinked acrossall settings

Continuityat high or lowacuity

Advanced Illness Management (AIM) 90 Days Pre/Post Enrollment

– Hospital• 54% reduction in admissions• 80% reduction in ICU days• 26% reduction in inpatient LOS (2

days/case)– Physicians

– Home• 52% reduction in MD visits

• 60% increase in hospice enrollment• 49% increase in home health enrollment

Net System, Payer SavingsPayer Mix = 71% Medicare

• Per Beneficiary Per Month:

312 million x 10% = $ 14.2 billionPotential Medicare Savings:

– System savings $1125– AIM rollout expense ($ 912)– Net system gain $ 213 PBPM

Total payer savings $ 760 PBPM

x 5% x $760/mo.

x 12 mo/yr.

Lessons Learned in Advanced Care

• Re-engineer, re-brand, integrate– Add services people, clinicians want &

need– Integrate MDs, AC, PC & Hospice

• Personal goals drive cost savings– Person-centered trumps “patient-

centered”– Seriously ill people don’t want to be

patients

• Turn the business model upside down– Get the heads out of the beds– Invest in home and community

1. Palliative care alongside usual care is now the accepted best practice.

2. All the evidence suggests equal or better quality of life, fewer symptoms, equal or better survival, and less cost, with no harms.

3. There is still a LOT of research to be done to improve “trigger points”, symptoms, integration of PC into usual care, identification of patients and families who can benefit, and communication.

4. Advanced Illness Management Models improve care and save money but require an integrated health system.

Conclusions