Making a Business Case for End of Life in ACOs

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Billie Whitehurst By Billie Whitehurst, MS, RN 
Senior Vice President, Extended Care and Care Operations, Change Healthcare
End-Of-Life Care and ACOs

A new article on the Health Affairs Blog makes a strong case to extend accountable care organizations (ACOs) to include end-of-life (EOL) care. And it begs the question: Is your hospice organization ready to participate in such an organization?

Authors of the post are Julia Driessen, an assistant professor of health policy and management in the Graduate School of Public Health at the University of Pittsburgh, and Turner West, the director of education and the director of the Palliative Care Leadership Center at Bluegrass Care Navigators.

The authors outline hospice benefit usage among Medicare patients, which shows a median length-of-stay of 17 days, but an average length-of-stay of 72 days. Such a wide variation of lengths of stay brings questions about both the underutilization and the overutilization of hospice care.

In suggesting inclusion of hospice and/or palliative care services in an ACO bundle, the authors outline three strategic approaches:

  1. Selective focus on quality hospice providers. Under current regulations, ACO participants are free to leave the ACO for whatever services they may desire. However, the authors suggest that ACO providers could weigh in on the hospice question by learning which local providers provide the best quality care. The start of Hospice Quality Reporting will provide much more information to both patients and their families, as well as providers who could make referrals to your organization.
  2. Expanding access to palliative care. The lines between palliative care and hospice care can be blurry for most patients and their caregivers. And there remains a dearth of palliative care programs in the country. But by focusing earlier on relieving pain and lessening the symptoms of many chronic illnesses that will eventually lead to death, a patient’s quality of life can be greatly improved. The authors note the established efficacy of palliative care across the Triple Aim of better individual and population health at a reduced cost, including a reduction in hospital readmissions. Expanding palliative care programs is one of the recurring trends in hospice care.
  3. Condition-specific EOL care pathways. The wide variation among hospice stays can be attributed, in part, to the one-size-fits-all nature of the Medicare hospice benefit, the authors argue. Those with dementia, for example, stay in hospice nearly three times longer than those being treated for cancer. Tailoring hospice services to the type of end-stage illness would help right-size care and reduce inefficiencies. The authors propose reimagining hospice “as a suite of services tailored to beneficiary needs.”

The need for more palliative care and hospice services will grow as the American population continues to age. Four in five Americans say they do not want to go to the hospital or to intensive care during the end-stage of an illness. However, a longitudinal study of emergency department use among older adults showed that more than half visited the ED in the month prior to death. When looking six months before death, that figure was 75%. In contrast, few hospice patients visit the ED in the months prior to death.

Payers and the government will continue to look for ways to provide high quality, lower cost care that resonates with patients through satisfaction scores. Hospice and palliative care are services that home health and hospice organizations should monitor closely in their markets to determine whether there is unmet demand.

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