Cheat Sheet

C-Suite Cheat Sheet Series: Hospice and Palliative Care

    Overview

    Hospice care provides comfort to patients during the last months of life through comprehensive services and a care team of clinicians (i.e., physicians, nurses, and therapy providers), social workers, spiritual care providers, and volunteers. Palliative care focuses specifically on pain management and symptom relief and is administered to those in hospice, but may also be used to support patients who are not receiving hospice care. Though hospice and palliative care can significantly lower health care costs while improving quality of life, research indicates the benefits have been under-utilized in the care delivery system.

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    What are hospice and palliative care?

    What types of patients are served using hospice and palliative care?

    Hospice services are intended for patients with a life expectancy of six months or less. Patients who suffer from a severe illness, but have a longer life expectancy, can benefit from palliative care services as they continue to receive curative treatment. Palliative care patients often suffer from illnesses such as congestive heart failure, progressive pulmonary disorders, or progressive neurological disorders such as multiple sclerosis and amyotrophic lateral sclerosis (ALS).

    What services are offered during hospice and palliative care?

    hospice and pallative care services

    While hospice and palliative care are related services, they can serve different patients and have different goals. One important difference is timing. Palliative care can be provided at any stage of illness and focuses on relieving symptoms of chronic illness and making patients more comfortable. Hospice care is provided to patients whose illness has advanced to a point where the patient no longer benefits from or desires curative treatment. The other critical difference is the range of services offered. Palliative care offers symptom management and psychological support while hospice care additionally fulfills holistic patient needs as patients near the end of life.

    What is the role of hospice and palliative care in a value-based delivery system?

    Hospice and palliative care services play an essential role as providers transition from fee-for-service to value-based payment because of their effectiveness in reducing unnecessary health care spending and patient mortality. Studies have shown hospice improves satisfaction for the patient and reduces Medicare spending, resulting in $2,300-$10,800 savings per enrolled beneficiary compared to traditional care at the end of a patient’s life. This reduced spending is mostly attributed to fewer hospitalizations, re-hospitalizations, and emergency department visits for patients accessing comprehensive hospice services, which is essential as providers look to strengthen population management.

    Moreover, hospice patients and their families experience enhanced medical and social outcomes, particularly for pain and symptom management. However, the utilization of hospice and palliative care is often delayed because of costs and patient and physician attitudes towards hospice and palliative care.

    To overcome these hurdles, some providers are implementing a concurrent care model, which allows a patient to receive palliative care services from hospice providers while simultaneously receiving treatments provided by their curative care providers. The concurrent care model removes financial and psychological barriers for patients opting into hospice care and results in a more gradual transition, since patients do not choose hospice, palliative care, and curative treatments in isolation. Concurrent care programs are structured to advance the same goals supported by population health management (i.e., improving care quality and reducing costs).

    What are the key priorities and opportunities for hospice and palliative care?

    Providers are increasingly recognizing the value of hospice and palliative care services in filling care delivery gaps. Many providers view these services as potential drivers for financial and quality improvement, especially as organizations shift from volume-based to value-based business models and face aging, chronically-ill populations. Those providers under risk-based contracts have seen up to a 40% reduction in total cost of care. Meanwhile, providers operating under fee-for-service models may see savings in the inpatient setting and experience a reduction in readmissions.

    For patients and providers to realize the full value of hospice care, hospice length of stay (LOS) must increase. Even though more patients are enrolling in hospice, median length of stay has remained largely unchanged since 2009, with 19 days in 2012. A third of hospice stays are shorter than one week and more than 60% of hospice users only access hospice within the last month of life. Studies indicate that Medicare spending is lowest when a patient receives hospice care for 80-90 days. This means that hospice providers want to prioritize early enrollment, to increase LOS and allow patients the full benefit of hospice care.

    In an effort to improve early enrollment, hospice providers are looking to increase consumer and clinician awareness of hospice services. Seventy percent of consumers report that they are not at all knowledgeable about palliative care. Only a quarter of physicians caring for cancer patients express a willingness to discuss hospice with patients have a four-to-six month terminal prognosis.

    Although current Medicare policies do not support concurrent models, there is potential that this will change. Some organizations are piloting concurrent care services with select patients to capitalize on potential future grants to expand access to comprehensive hospice services. CMS has recently begun accepting applications from hospices for the Medicare Care Choices Model, under which beneficiaries can continue to receive coverage for curative treatment even after beginning hospice care. CMS expects to enroll 30,000 beneficiaries over a three-year trial period to evaluate utilization and effectiveness.

    What are the challenges hospice and palliative care faces?

    Patient and physician attitudes toward hospice care often delay hospice utilization. Another barrier to increased utilization is the structure of the Medicare Hospice Benefit. Medicare requires that patients forgo curative treatment related to their hospice diagnosis to be eligible and does not reimburse hospice providers for palliative treatments. As a result, physicians often wait to communicate with a patient about hospice care only after exhausting all curative options, delaying access to hospice services.

    Factors limiting hospice utilization

    How are your relationships with providers offering hospice and palliative care changing?

    Hospice and palliative care providers are navigating a changing health care landscape just like their acute care partners.

    Assist in hospice and palliative care education

    Hospice providers need to keep pace with demanding industry expectations and customize value messaging to a widening variety of payer types while also engaging communities in end-of-life care awareness.

    Conversation starters with the hospice c-suite

    1. How is your organization increasing patient and community awareness of the benefits of hospice care?
    2. What reimbursement or delivery reform challenges is your organization experiencing?
    3. How is your organization educating clinicians about hospice and palliative care services?

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