10/24/2018 Removing Obstacles to a Peaceful Death by Revising Health Professional Training and Payment Systems Professor Kathy L. Cerminara Nova Southeastern University Shepard Broad College of Law October 24, 2018 The speaker has no relevant financial relationships to disclose. 1 10/24/2018 How Many Times…? Result: an Unsatisfactory Outcome That Can Be Avoided • The Current Picture • Proposals for Improvement 2 10/24/2018 A Common Patient’s Problem: Thwarted Wishes • Americans overwhelmingly want to die at home, but during the last month of life, about 30 percent of Medicare beneficiaries spend time in ICUs or die in ICUs. • Nearing the end of life creates, highlights, and/or exacerbates the need for psycho‐social support for patients, families, and other caregivers. • Unwanted treatment persists. One‐fifth of heart patients with implanted defibrillators get shocked in the last few weeks of life, 8 percent within hours of death. A Common Provider’s Problem: Cognitive Dissonance • Feelings of failure over inability to cure patients despite doing everything possible. • Reluctance to engage in difficult conversations as patients worsen. • Annals of Internal Medicine study in 2001: • In communicating with terminal cancer patients about expected survival times, physicians were: • Frank 37 percent of the time; • Deliberately inaccurate 40.3 percent of the time; • Not willing to offer an estimate 22.7 percent of the time. • Health Affairs study in 2012: • One in 10 physicians reported lying to a patient about prognosis during the previous year. • More than half reported that they had been “unreasonably optimistic” regarding prognosis. 3 10/24/2018 Even an Economic Problem: Higher Costs of Care for Lower Quality of Life • Approximately one‐third of medical expenses for the last year of life are spent in the last month. • More than 30 percent of Medicare dollars spent each year go to care for the 5 percent of Medicare beneficiaries who die each year. • Journal of Palliative Medicine, 2010: meta‐analysis of 12 studies determined that palliative care intervention significantly reduced ICU utilization across the board. • Journal of Palliative Medicine, 2013: cost savings were greater when palliative care was introduced earlier in a stay. Proposals for Clearing the Path to a Good Death • Training: Conversations and Teamwork • Payment Systems: Facilitate Compensation and Eliminate Dichotomy 4 10/24/2018 Dying in America, IOM, 2014 Response to 2009 & 2011 “Death Panels” Proposals and Controversy IOM recommendations • Delivery of care – comprehensive care, including palliative and hospice, should be covered • Clinician‐patient communication and advance care planning –standards should be developed and integrated into assessments, care plans, and reporting of health care quality • Professional education and development – licensing entities and credentialing bodies, among others, should establish requirements to strengthen palliative care knowledge and skills • Policies and payment systems – medical and social services should be reimbursed/paid for, and public reporting should be required about quality measures, outcomes, and their costs • Public education and engagement – public entities and professional societies should engage the public and provide fact‐based information to encourage advance care planning and informed choices based on the individual’s needs and values 5 10/24/2018 Goal: Effective Communication Barriers Resources • Lack of training in communication skills, in • Materials from Professionals: school or afterward • American Society of Clinical Oncology • Times are changing Provisional Clinical Opinion: The Integration of Palliative Care Into Standard Oncology, Journal • Concern about producing anxiety among of Clinical Oncology, 2012 (best practices patients and families working list of conversation components) • They are already anxious • American Academy on Communication in Healthcare, evidence‐based clinical teaching • Concern about introducing abrupt transitions exercises that might lead to feelings of abandonment • Association of Behavioral Science and Medical • Eliminate confusion over terminology Education, same – information and resources for medical school and continuing education Definitions Palliative Care vs. Hospice Care This Photo by Unknown Author is licensed under CC BY 6 10/24/2018 Palliative care is an approach that improves the quality of life of “ patients and their families facing the problems associated with life‐ threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care . is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such ” as chemotherapy or radiation therapy. World Health Organization: WHO Definition of Palliative Care, 2011. http://www.who.int/cancer/ palliative/definition/en/ For most people, death results from one or more diseases that must be managed “ carefully over weeks, months, or even years. Ideally, health care harmonizes with social, psychological, and spiritual support as the end of life approaches. Hospice is an important approach to addressing the palliative care needs of patients with limited life expectancy and their families. One of the greatest remaining challenges is the need for better understanding of the role of palliative care among both the public and professionals across the continuum of care so that hospice and palliative care can achieve their full potential for patients and their families. ” IOM, Dying in America, 2014 7 10/24/2018 Palliative vs. Hospice Care http://getpalliativecare.org/whatis/faq/#what‐is‐the‐difference‐between‐hospice‐and‐palliative‐care (The Center to Advance Palliative Care) Palliative Care Hospice • Symptom control and pain management • Symptom control and pain management • Care provided by a team of health care • Care provided by a team of health care practitioners practitioners • Usually provided in hospitals but it could vary • Various settings • Not based on life expectancy • Limited life expectancy • Covered by Medicare, Medicaid, and private • Covered by Medicare, Medicaid, and private insurance on same basis as therapeutic care insurance on a per diem basis Goal: Interprofessional Teamwork • Interprofessional teamwork is important in both palliative care and hospice already • Medicare requires hospice to provide physician and nursing services plus drugs; medical supplies; short‐term inpatient and respite care; homemaker and home health aide services; counseling (through chaplains and otherwise), social work services; and physical, occupational, and speech therapy. • Interprofessional education increasingly offered in medical and other health professions schools 8 10/24/2018 Annual survey data, 2007‐2008 to 2016‐2016 Yellow = participated in survey; blue = requires IPE LCME Data, https://www.aamc.org/initiatives/cir/403572/02.html Goal: Facilitate Compensation • Value (lower income, but lower cost) must be recognized in business model • Good first step: two codes for advance care planning discussions (2016) • Needed: fee‐for‐service institutional providers – billing for affiliated professionals such as chaplains and social workers (authorize new codes or bundle in their services) • Needed: ability to simplified billing for palliative care in ICU (CHEST, 2012) • Needed: increased primary care documentation to support billing for palliative care in ED (Annals of Emergency Medicine, 2009) • Needed: billing for affiliated professionals such as nurses, social workers and chaplains in outpatient settings 9 10/24/2018 Goal: Eliminate False Dichotomy in Compensation to Help Combat Late Access • Optimal Time of Access = Three Months to Live • Joan M. Teno et al., Timing of Referral to Hospice and Quality of Care: Length of Stay and Bereaved Family Members’ Perceptions of the Timing of Hospice Referral, 34 J. Pain & Symptom Mgt. 120, 121 (2007). • In Reality, One‐Third = Week or Less to Live • Bruce Jennings et al., Access to Hospice Care: Expanding Boundaries, Overcoming Barriers (2003). • Year 2000 = 63 Percent of Patients in Hospice Less Than 30 Days • B.J. Haupt, Characteristics of Hospice Care Discharges and Their Length of Service: United States 2000, 154 Vital Health Statistics 1, 13 (2003). • Year 2017 = Median Stay of Patients in Hospice in One CT Health Plan 12.9 Days • T.M.Gill, et al., Distressing Symptoms, Disability, and Hospice Services at the End of Life: Prospective Cohort Study, 66 J. Am. Geriatrics Soc’y 41 (2018) How the Law Contributes: Medicare* Hospice Coverage * And Medicaid and Private Insurance, for the Most Part Eligibility for benefits in general Signed “Terminally waiver of ill” curative benefits diagnosis 10 10/24/2018 A New Idea: The Medicare Care Choices Model https://innovation.cms.gov/initiatives/Medicare‐Care‐Choices The model is designed to: •Increase access to supportive care services provided by hospice; •Improve quality of life and patient/family satisfaction; •Inform new payment systems for the Medicare and Medicaid programs. Concurrent Care Projects Multiple Ceritifications Curative? One Certification Optimal Time in Hospice Palliative? Actual Time in Hospice 11 10/24/2018 Concurrent Care Result? More Comfort Earlier Peace Earlier Access and Cost‐ and Comfort Effectiveness Medicare Choices/New Palliative Care Models 12 10/24/2018 Removing Obstacles to a Peaceful Death K.L. Cerminara and B.N. Noah, The Elder Law Journal. 2018: 25(2) 197‐233. 13.