By Allison Silvers, MBA, Diane E. Meier, MD, Center to Advance Palliative Care; Emily Jaffe, MD, HM Home and Community Services; and Robert Krebbs, Anthem, Inc.
The value of hospital-based palliative care — specialized care teams focused on the relief of symptoms and stresses of serious illness — is well documented, having lasting effects on quality-of-life and symptom burden, reducing caregiver distress, reducing readmissions, and improving patient and clinician satisfaction. The essential value of hospital-based palliative care has only been underscored in this COVID era, as clinicians, patients, and families struggle with complex decisions and distressing symptoms. Yet despite this evidence, reliable access to palliative care remains highly variable, with stark differences in palliative care availability based on geographic location, hospital size, and tax status. Payers seeking to ensure high-value care should focus on consistent access to high-quality palliative care services across their network hospitals.
Two health plans — Anthem, Inc. and Highmark Blue Cross Blue Shield — are at the forefront of driving palliative care capabilities in their network hospitals. Both organizations introduced a palliative care measure into their hospital value-based payment programs and facilitated opportunities to improve quality through network education and implementation support. Their efforts led to significant improvement in access to palliative care for their seriously ill members.
Highmark Quality Blue Hospital Program
In 2011, Highmark introduced a measure of palliative care access into its value-based program, Quality Blue Hospital Program. The measure sets a target proportion of hospitalized patients with serious illness who should receive at least one palliative care consult, either two weeks prior to the hospital stay, during the stay, or within two weeks after discharge. Originally an optional, self-report measure, the measure of palliative care access is now fully embedded in Quality Blue. Since 2015, Highmark has used a claims-based methodology that flags certain diagnoses to define the denominator – including metastatic cancer, end-stage renal disease, oxygen-dependent COPD, and others. It currently employs ICD-10 Z code Z51.5 to identify palliative care consultations in the numerator. If a hospital discharges an appropriate patient to Highmark’s home-based palliative care program, that home-based visit counts toward the discharging hospital’s compliance.
Highmark updates the palliative care target goals each year, leveraging penetration of the top 30 percent of performers, thus encouraging continuous improvement in the network. In addition to setting the standard, Highmark provides support to its network hospitals with clinician education and the assistance of Clinical Transformation Consultants. “Originally, there were a lot of misconceptions around palliative care and what was meant by a palliative care consult,” said Mary Blank, a Value Based Implementation Specialist at Highmark, but the education has paid off. Palliative care clinicians are now seeing an increasing proportion of Highmark members with serious illness, growing from 11 percent in year in 2015 to 50 percent in 2018. Highmark has seen further benefits of including hospital palliative care standards in the Quality Blue program, such as more appropriate utilization of its home-based palliative care program.
Anthem Quality In-Sights Hospital Incentive Program
Anthem’s Quality In-Sights Hospital Incentive Program (“Q-HIP”) partners with its network hospitals and subject matter experts to continually evolve and improve. In 2014, Anthem’s leadership recognized the need to include a palliative care measure in the program as an essential element of patient-centered care. The Anthem team worked collaboratively with both Bon Secours and its National Advisory Panel on Value Solutions to create a palliative care measure that was both feasible for hospitals to achieve and aligned with best practice. The result is a four-part bonus measure that includes:
- A written palliative care policy;
- A process to identify patients in need of palliative care services;
- A palliative care team staffed by at least two disciplines, with specialty certification in palliative care; and
- A staff training program on palliative care.
Hospitals with Advanced Certification in Palliative Care from the Joint Commission automatically earn points for all four measures. The percentage of hospitals meeting all four components has grown from 20 percent in 2015 to almost 45 percent by 2018. During this time, Anthem’s program managers worked closely with hospital staff to understand how to improve measure performance.
Network Hospitals’ Response
Why did hospitals respond to these standards and incentives? First, payer incentive programs get the attention of hospital chief financial officers, which helps drive resources to improve performance. In addition, as learned through interviews with five participating hospitals, these payer-led standards have provided both validation and a blueprint for palliative care champions within hospitals.
“We knew we had to do better for our patients with serious illness, but couldn’t quite agree on how to go about that. When the Anthem Q-HIP palliative care measure was introduced, we then had the standards to strive for,” said Brian Madden, MD, palliative care lead at Providence St. John’s Hospital. The multi-fold benefit of reducing hospital readmissions, achieving inpatient cost savings, and also meeting the Q-HIP palliative care standard was an important motivator at Dignity Health’s Mercy Medical Center.
Highmark’s program was equally compelling to its network. At Cabell Huntington Hospital in West Virginia, the Highmark standard and its financial implications caught the attention of the Director of Quality, who supported the implementation of new patient identification and consultation processes. “We built a report with diagnoses pulled from the nursing notes, date of admission, and insurer, to guide us to the right patients,” say Shannon Runnels, Palliative Care Nurse Practitioner at Cabell Huntington. “All patients in the report have their charts reviewed, and if appropriate, the palliative care clinician sees patients to assess if they can address any gaps in care or assist with advance care planning conversations.” This assessment process, defined as a “Highmark Initiative,” quickly won the appreciation of the attending physicians. At Cabell Huntington, implementing the report and the assessment visit allowed them to exceed the target within three months.
All five of the hospitals interviewed noted that they had implemented or are pursuing the three key strategies recommended by the Center to Advance Palliative Care (CAPC): (1) proactive patient identification; (2) interdisciplinary palliative care teams; and (3) all-staff training in palliative care – all explicitly because of their participation in the Anthem or Highmark incentive programs. For example, Stamford Hospital created a screening tool for older adults upon admission in the emergency room, added staff to their interdisciplinary palliative care team, and included palliative care in its mandatory nurse education program.
Of note, these payer palliative care measures are structure and process and not outcome measures, despite a general movement toward outcome measures in U.S. health care. Anthem was clear about the need for structure and process measures: there are certain patient-centered capabilities that should be expected, including palliative care. Hospitals also appreciate the yes/no nature of the measures: If they follow the standards, they can earn the reward, and that certainty is welcome.
Broader Adoption to Promote New Palliative Care Standards
Other payers also find the straightforward measures appealing. For example, Blue Cross Blue Shield Massachusetts has successfully adopted the Q-HIP measure in its Hospital Performance Incentive Program. The clinical, financial, and satisfaction results that both Highmark and Anthem have seen are consistent with the results from other payer strategies that advance access to palliative care for their seriously ill members. The basic structure of these hospital palliative care incentives are easily replicable and flexible enough to fit within a broad range of value-based strategies that health plans may be pursuing. CAPC is now working with a small group of Medicare Advantage plans to introduce them to these effective strategies and support broader adoption.