Palliative Care Opportunities and Ethical Dilemmas Created by the

Affordable Care Act

Jan Slater JD, MBA

The Current Healthcare Delivery System

Healthcare consuming 18% of the US GDP is unsustainable

The US spends 34% more per capita on healthcare than Denmark, the next highest country

Health indicators place the USA 38th healthiest country

Volume driven reimbursement is unsustainable

People do not change until the pain of staying the same…

… exceeds the pain of changing.

Anonymous

So What’s New in Health Care Reform?

Affordable Care Act; One Year Later

• Partisan lines are drawn.

• Should we repeal or leave it alone?

• A middle position; keep the good things and re-engineer the components that fail.

Goals of Healthcare Reform

• Improve quality of healthcare• Reduce Costs, and• Improve population health

Palliative care naturally advances all three goals

Price Transparency

QualityTransparency

The Role of TransparencyTransparency; An Innovation encouraged by the ACA and demanded by Consumers

The “Viral” Influence of Transparency:

In the future the consumer will make health care decisions on the basis of VALUE

VALUE = Outcomes + Satisfaction CostThe CONSUMER ultimately determines which of

these elements constitute VALUE

Read all about it !! April 2005

Price Transparency

QualityTransparency

The Role of TransparencyQuality Transparency

2011-2013 Core Measures:

Heart Attack Heart Failure Pneumonia Surgical Care Improvement

HCAHPS

2014 Clinical Quality Measures: Emergency Department Throughput Stroke VTE AMI

CAP Surgical Outcomes

New Born Care

More HCAHPS

Transparency of Cost and Quality

Transparency is the best thing that’s happened to cost and quality since antibiotics...by decreasing variance and improving results

Dr. Steven Berlowitz

That which is measured, tends to improve. That which is measured publicly, tends to improve faster.

“What we concluded was that even when hospitals know their performance is not good, that's not sufficient motivation for them to do something. Making it public

made a big difference in motivating them to improve”.

Dr. Steven Berkowitz

What is “Quality” to the Healthcare Consumer?

More responsive and patient centered healthcare

• Treatments at home and in out-patient settings:– Enabled by technology and home health care

• Fewer inconveniences and cost related to illness • Less disability, pain and discomfort due to interventions

Palliative care is already focused on these attributes

QualityTransparency

The Role oPriceansparency

PriceTransparency

Price Transparency

Price Transparency

Healthcare providers will compete by offering value– Cost conscious healthcare providers– P4P will become the rule– Cost saving measures that improve patient

satisfaction will be in demand

Opportunities for Palliative Care will be significant

If the other guy’s getting better, then you’d better be getting better faster than that other guy’s getting better… …Or you’re getting worse.

Tom Peters

The Increasing Trend of Higher Deductibles

From 1999 to 2013, average annual employer and worker contribution for health insurance increased 300%

Out-of pocket cost for healthcare increased from $500 in 2006 to $1100 in 2013

Greater costs will be pushed to consumers who will become more:– health literate – responsible purchasers of healthcare

Influence of Cost on the Purchase of Healthcare

Tom has the flu and feels bad!Tom has great insurance but a $3,000 deductible

What does he do? Treatment Options: Approximate* Out of Pocket Wait Emergency Department $ 500 2-3 hrsUrgent Care 150 1 hrPCP visit 120 1 hr (if available) Local Pharmacy 80 30 minSelf Treat.. rest, OTC meds... 10 ? None

* The actual cost may not be known until the evaluation is completed.

Price Transparency; Opportunity for Palliative Care

Currently: – Physician discomfort speaking about costs– No access to cost information to make informed decisions

Future:– Cost information will be available – Discussion of cost will be part of every informed consent

discussion.– Cost information will facilitate more honest discussions

when consumers demands futile care

More rational decisions will be made by all

Current System vs New Models

Currently patients with chronic conditions:

• See several physicians

• No coordination of care

• Leads to repeated hospital admissions

One Successful Model: Patient Centered Medical Home (PCMH)

PCMH: short waits, responsive primary care, team based care, high tech solutions– Team make up: PAs, RNs, pharmacists, dietitians,

mental health professionals and case managers – Emphasis on care coordination and preventive

medicine– Use of data bases of medical information to screen

for diseases and flag needed preventive measures– Great improvements in patients’ and healthcare

professionals’ satisfaction

Examples of Quality Improvement

Healthcare providers take on the problem of patient non-compliance

• Reduce readmissions of CHF patients with at-home technology

• Reduce diabetic amputations with frequent visits to wound clinics

• Specialty teams to care for high risk, high cost patients

Examples of Quality Improvement continued

• Chronic disease specific clinics• Alignment of rural and urban hospitals for care

coordination• “Choosing Wisely” initiative to legitimized our ability to cut

back on what's unnecessary.

• Information technology– EMR– Health Information exchanges– Evidence based protocols– Genomics will permit development of personalized medicine

Won’t All This Run Up Costs?

• Skeptics doubt it is possible to improve quality and reduce costs

• Without financial reform the pressure of P4P requires keeping a foot in both the volume boat and the value boat which are traveling in opposite directions

• How to retool the organization to jump entirely into the value boat but keep it steadfast on the volume course?

The American Healthcare System is Repair-Centric and NOT Prevention-Centric.

We wait for train wrecks and then clean them up.

What if we prevented the train wreck in the first place??

“You can fix a problem at step 1 for $1 or fix it at step 10 for $30.”

W. Edward Deming

How to Cut Costs

• Focus on what costs the most:– Hospitalizations, – ED visits, – care for the frail, high-risk elderly and patients

with multiple high-risk chronic conditions. • Use "upstream" interventions, to save on

"down-stream" costs. • Invest in future wellness to prevent train

wrecks.

You can always count on Americans to do the right thing…

…after they’ve exhausted all the other possibilities !!”

Winston Churchill

Implications of Innovation for Palliative Care

• There was a time when death was a part of every day life • Today we are strangers to death• What has changed from days past?

1. The power of advanced technology2. Most injuries and infectious diseases are curable3. Less emotional closure and peace with the death of a loved one4. We don't know what to expect when someone is dying

Monica Williams-Murphy M.D. and Kristian Murphy It’s OK to Die

Should we use technology because we have it?

Carotid endarterectomy in a bed bound 91-year-old?

Ventilator for a patient speechless for 10 years with a peg tube?

CPR on 75-year-old with end-stage diabetes in cardiac arrest?

Emergency evacuation of brain hemorrhage for patient with advance dementia?

Lessons for doctors:

When physicians feel compelled to cure illness and families press for “everything to be done” for a dying patient:

• Comfort care should replace cure focused medicine.

• Death is not "failure ". We all die. • “Artificial life-support "may be "artificial death

extension.” • Monica Williams-Murphy M.D. and Kristian Murphy It’s OK to Die

What is a “Good Death "?

Attributes of a "good death“ as identified by healthcare professionals:

• A sense of control and honoring wishes of one who is dying

• Assuring comfort and dignity• A sense of closure• Affirming unique personal qualities of the dying• Trust in the healthcare providers• Acceptance of impending death• Honoring the dying persons beliefs and values

Monica Williams-Murphy M.D. and Kristian Murphy It’s OK to Die

Advance Care Planning • An ongoing process of planning for future

medical care• Identify who to speak on your behalf • Describe decisions you want them to make • Ensure wishes, values and goals are honored • Two documents that assist Advance Care

Planning:– Advance Directive,– OkPOLST document.

Advanced Directive (“AD”) Act, 63 OS §3101

Provides a statutory form to document medical care the “declarant”wishes to receive when incompetent.

• Declarant may request or refuse life-support under four conditions: – terminally ill, – persistently unconscious, – has an end-stage condition, – or “other” as described by declarant.

• Declarant may appoint a primary and a secondary proxy

• Declarant can choose to be an organ/ tissue donor

Advanced Directive (“AD”) Act, 63 OS §3101

• The AD must be signed by the adult declarant when competent –witnessed by two witnesses who are not

legatees, devisee's or heirs of the declarant. • Requirement for physicians to comply with AD

or arrange care by another physician or healthcare provider willing to comply with the AD.

63 OS §3101: Useful Tips for Advising Patients regarding ADs

• Appointment of co-proxies complicates medical decision making• A Proxy’s duty to make decisions based on known wishes of the

declarant is often misunderstood• If declarant desires a trusted Proxy to make all medical decisions ,

advise the declarant to: – leave section 1. Living Will blank and complete remainder of AD; – make clear in Living Well subsection (4), that declarant wishes the

proxy to make decisions that are in the best interest of the family, however, the declarant would not want his/her life artificially prolonged and consents to withdrawal of life-sustaining treatment and AAHN

• Families need permission to permit a loved one to die naturally

63 OS §3101: Useful Tips for Advising Patients about ADs continued…

• At least one proxy should be younger than the declarant • Copies of executed ADs should be given to the proxies,

key family members, the attending physician and hospital

• Failure to have an advance directive can cause family strife

• Oklahoma law only permits a healthcare proxy, an attorney-in-fact, or a guardian (“Legal Representative”) to make decisions to withdraw or withhold life-sustaining treatment on behalf an incapacitated person

Physicians Order for Life-Sustaining-Treatment (POLST)

Physician’s order form that outlines wishes for medical treatment and goals of care for patients with life limiting and irreversible conditions;

• Translates and advance directive or durable healthcare power of attorney into a physician’s order

• Can stand alone without an advance directive• Lists choices of medical treatments.• Can be completed by Legal Representative if patient

is no longer able to communicate

POLST Document continued..

• Becomes valid, when discussed with a patient and/or Legal Representative and appropriately completed. It must be signed by a physician.

• Combining the OkPOLST with an AD is more likely to ensure patients’ wishes are honored at end-of-life – it is a physician’s order and – travels with the patient across health care settings

• OkPOLST form becomes effective at the time the order is signed

• Use of OkPOLST is always voluntary • More information at www.okpolst.com

OkPOLST Form