R. Sean Morrison of Mount Sinai Medical Center agrees that care for patients with serious illness and their families is in much need of improvement. He explains that palliative care provides interdisciplinary care coordination and team-driven continuity of care that best responds to the episodic and long-term nature of chronic, complex disease. While the prevalence of these programs in hospitals grew from 5 percent in 2000 to 50 percent in 2008, palliative care still falls far short of being accessible to all who need it. For palliative care to be accessible to all patients with serious illness and their families, he urges consideration of a number of key policy initiatives, including education of patients, families, and healthcare professionals about the benefits of palliative care; additional resources for workforce development to train sufficient numbers of specialists to effectively provide palliative care to patients and families in need; patient-oriented and health services research; and reimbursement structures that promote team-based care.

Ronald A. Paulus of Geisinger Health System suggests that value-based payment models must move beyond payment for units of work or effort and instead reward demonstrated patient- and population-level clinical impact and outcomes. Paulus explains that care gaps are evidence- or consensus-based patient clinical needs as informed by age, gender, comorbidities, physiological parameters, and other factors. Primary care teams of practitioners, nurses, and specialists at Geisinger Health System work in closing these gaps for their patients. When supplemented by an electronic health record with enhanced decision support, population-level data, and integrated analytics, he explains, this approach can produce marked progress in patient and population outcomes. For example, among diabetic patients, this clinical care-based process has resulted in continuous stepwise improvement in the percentage of patients who have completed all nine care bundle components of evidence-based care, producing a fourfold percentage increase over 24 months for a group of more than 22,000 patients. He suggests that this model could also serve as a point of reference for those seeking to develop value-based payment models structured to encourage innovation, enhance patient experience, improve clinical quality, and contain costs.

Lastly, Anand K. Parekh of the U.S. Department of Health and Human Services identifies several policy areas that could further support tertiary prevention in individuals with multiple concurrent chronic conditions. Since medically complex patients have often been excluded from participation in randomized controlled clinical trials, he suggests that the external validity and generalizability of these studies to this population are limited. While identifying the importance of health professional training in the care of medically complex patients, he explains that many current evidence-based

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