Palliative Care Key Part of Berkeley Forum's Prescription

by Mari Edlin, California Healthline Regional Correspondent

TOPIC ALERT:

The Berkeley Forum, a task force of private and public sector health care leaders convened by UC-Berkeley's School of Public Health, is taking what it calls a new "bottom-up" approach to addressing health care costs and population health in California.

"We support risk-adjusted, global health budgets to pay for integrated care," said Stephen Shortell, chair of the Berkeley Forum and dean of the School of Public Health. "We want to pay by the package, not by the piece."

In a recently released report, the Forum suggested seven initiatives to help reduce health care spending in California by $110 billion over the next decade.

Palliative care was a key area specifically highlighted by the Forum as having great promise in generating significant savings and improving the quality of care in California.

Palliative Care at the Forefront

The Forum supports widespread access to high-quality, patient- and family-centered, holistic palliative care that emphasizes quality of life and autonomy and includes curative therapies.

Three Northern California health care organizations -- Partnership Health Plan of California in Fairfield, Sutter Health and UC-San Francisco -- already are aggressively involved in palliative care and in some cases are expanding those services.

Shortell said current medical practices place too much emphasis on invasive procedures, such as chemotherapy, hospitalization, and time spent in the intensive care unit without considering the wishes of patients and their caregivers or the effect of such interventions on quality of life.

About 10% of seriously ill patients receive community-based palliative care, according to the Berkeley report. The Forum envisions an increase to 50% by 2022.

Most California acute care hospitals (53%) offer inpatient palliative care, according to the California HealthCare Foundation.

Although the Affordable Care Act does not explicitly address palliative care, it mandated a three-year hospice concurrent care demonstration project that allows hospice-eligible patients to receive aggressive treatment and hospice care at the same time.

Richard Fleming, regional medical director for Partnership Health Plan of California, said palliative care's contributions to society and the general health care system are a work in progress.

"As a fairly new concept, palliative care is still in the process of establishing its role in the health care system," Fleming said. "But its importance is becoming more clear as a health care service which can improve quality of life for those approaching the end of life and for their caregivers, while also reducing health care costs by avoiding unnecessary, futile and often expensive interventions."

Gordon Hunt, chief medical officer and senior vice president for Sutter Health, along with Shortell and other experts and stakeholders agree that the 2009 debate about "death panels" put a crimp in the discussion of palliative care.

Hunt predicts embracing a collaborative palliative care model will result in better information flow to patients and their families leading to informed decision-making and better choices.  "When cure is unlikely, patients tend to select less aggressive therapies with fewer complications," he said.

These interventions also are less costly, Hunt said.

"The reduction in hospital admissions and shorter stays in the ICU and in the hospital overall result in less demand for hospital services and result in lower costs," said Hunt, noting that a large percent of health care expenses occur in the last year of life.

Hunt believes palliative care could lead to a reduction in the hospital workforce -- and an increase in the unemployment rate -- if the trend becomes widespread.

"But the overall benefit to society might far exceed the costs in jobs and services in health care," he said. 

Health Plan Embarks on 'New Specialty'

Partnership Health Plan of California in Fairfield started a palliative care program March 1. "Since this is a new specialty for the plan, we expect it will take some time before primary care physicians and other clinicians incorporate this service into their workflow and management of patients," Fleming said.

Partnership serves Medi-Cal (California's Medicaid program), Medicare and commercial patients in Solano, Yolo, Napa, Sonoma, Marin and Mendocino counties.

The program, Fleming said, targets the frail and elderly prior to moving into hospice care and will focus on symptom management and access to resources, such as transportation, mental health services and community- and religious-based programs.

"Equally important is communicating with patients about their diagnoses and prognosis," Fleming said. "Specialists understand end-of-life issues and have the forte and diplomacy to help patients accept their situations and better select therapy options."

Under the program, Partnership Health Plan reimburses primary care physicians on a capitated basis for making referrals to the plan's eight licensed, board-certified palliative care specialists, who are paid on a fee-for-service basis.

Fleming said the plan is marketing the new services to primary care physicians, specialists and hospitalists throughout its network. The campaign aims to inform providers about the availability of palliative care consultations for patients, which patients are most likely to benefit, what kinds of services are provided and that prior approval is unnecessary.

Sutter Expands Palliative Care Offerings

With a $13 million grant from the Center for Medicare and Medicaid Innovation in hand, Sutter Health revamped its Advanced Illness Management Program, expanding it to more counties and enhancing features. Early versions of the program started in 1998.

Sutter anticipates 3,175 patients in its palliative care program this year.

"The essence of the program is meeting the health care needs of seriously ill patients before they enter hospice," Hunt said. "It's difficult to accept you might only have six months to live."

Hunt said as soon as patients are diagnosed with a serious illness such as cancer, an integrated care team offers transition from hospital to home care and eventually into hospice, education and counseling.

Sutter's Advanced Illness Management program has increased use of hospice care, generated high levels of patient, caregiver and physician satisfaction, and reduced inpatient and ambulatory care utilization and overall care costs. It produced an average savings to Medicare of $760 per enrollee per month, according to preliminary unpublished data.

UC-San Francisco's Palliative Program a Decade Old

UC-San Francisco started its Symptoms Management Service, an outpatient palliative clinic, about a decade ago.  

The program created an infrastructure that complements what Eric Widera, associate professor at the UC-San Francisco Division of Geriatrics, and other experts agree are important features of palliative care:

  • Improved quality of life through a multidisciplinary team approach.
  • Combination of symptom relief and reduction of stress from living with a serious illness with curative treatment.
  • Access to palliative care specialists through referrals from primary care physicians and oncologists.
  • Established goals of care based on priorities and values.

Although Widera said there is no conclusive evidence that palliative care improves quality of life, studies show improved pain and symptom control, patient and family satisfaction, a decrease in time spent in intensive care and cost reduction.

He considers a study published in the Aug. 19, 2010 issue of The New England Journal of Medicine, "Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer," to be the clearest evidence to date of palliative care's value in the health care system. The study indicated that patients with metastatic non-small-cell lung cancer who received palliative care showed improvement in quality of life and mood, less aggressive care at end of life and longer survival than patients receiving standard care.

Challenges to Outpatient Palliative Care

The Forum report attributes a lack of access to palliative care to fee-for-service reimbursement, fragmented care systems, insufficiently trained workers and a lack of mandatory quality standards.

Judy Citko, executive director of the Coalition for Compassionate Care of California, agrees that workforce and reimbursement issues are  challenges, but she's optimistic that palliative care could succeed if it follows the path set by the Berkeley Forum.

If Congress passes the Palliative Care and Hospice Education and Training Act (S 641), introduced by Sen. Ron Wyden (D-Ore), it should expand opportunities for interdisciplinary education and training in palliative care, Widera said. The bill, which has been referred to the Senate Committee on Health, Labor, Education and Pensions, supports the development of faculty careers in academic palliative care and promotes education in the discipline.

Fernando Petry
The problem is that the Academy of Hospice and Palliative Medicine has now closed the door on certification for physician without having to do a formal fellowship. We currently have around 8,000 phyisicans certified but that doesn't mean that they all practice palliative care. The AAHPM should have waited to increase the numbers and pushed for more doctors to certify through work experience so that we can satisfy the growing need for palliative care certified physicians. Many of the fellowships throughout the nation have 1-2 fellows and are not sufficient to increase the numbers within the amount of time to fill the need. There needs to be another pathway to certification that doesn't involve formal fellowship training.
Robert E. Edmondson
The Program of All-inclusive Care for the Elderly [PACE] is presently providing truly integrated care, including palliative care, for frail seniors in over 30 states. In California there are six PACE organizations including On Lok Lifeways which was the designer of the model of care based on an integrated team model. This proven model is more than 20 years old.

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