Financing and Payment Strategies
to Support High-Quality Care for
People with Serious Illness
PROCEEDINGS OF A WORKSHOP
Laurene Graig, Elaine Soohoo, and Joe Alper, Rapporteurs
Roundtable on Quality Care for People with Serious Illness
Board on Health Care Services
Board on Health Sciences Policy
Health and Medicine Division
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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This activity was supported by contract No. HHSN263201200074I (Task Order No. HHSN26300096) with the National Institute of Nursing Research/National Institutes of Health and by Aetna Inc., Altarum Institute, American Academy of Hospice and Palliative Medicine, American Cancer Society, American Geriatrics Society, Anthem, Inc., Ascension Health, Association of Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross Blue Shield Association, Blue Cross Blue Shield of Massachusetts, California State University Institute for Palliative Care, Cambia Health Solutions, Cedars-Sinai Health System, Center to Advance Palliative Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced Care, Common Practice, Excellus BlueCross BlueShield, Federation of American Hospitals, The Greenwall Foundation, Hospice and Palliative Nurses Association, The John A. Hartford Foundation, Kaiser Permanente, Gordon and Betty Moore Foundation, National Coalition for Hospice and Palliative Care, National Hospice and Palliative Care Organization, National Palliative Care Research Center, National Patient Advocate Foundation, National Quality Forum, Oncology Nursing Society, Patient-Centered Outcomes Research Institute, Sentara Healthcare, Social Work Hospice and Palliative Care Network, Supportive Care Coalition, Susan G. Komen, UnitedHealth Group, and the National Academy of Medicine. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
International Standard Book Number-13: 978-0-309-47444-3
International Standard Book Number-10: 0-309-47444-2
Digital Object Identifier: https://doi.org/10.17226/25071
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. Financing and payment strategies to support high-quality care for people with serious illness: Proceedings of a workshop. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25071.
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PLANNING COMMITTEE FOR A WORKSHOP ON FINANCING AND PAYMENT STRATEGIES TO SUPPORT HIGH-QUALITY CARE FOR PEOPLE WITH SERIOUS ILLNESS1
MARK B. GANZ (Co-Chair), President and Chief Executive Officer, Cambia Health Solutions
HAIDEN HUSKAMP (Co-Chair), 30th Anniversary Professor of Health Care Policy, Harvard Medical School
ROBERT A. BERGAMINI, Medical Director, Palliative Care Services, Mercy Clinic Children’s Cancer and Hematology, representing the Supportive Care Coalition
PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield
STEPHEN FRIEDHOFF, Senior Vice President, Clinical Strategy and Programs, Anthem, Inc.
LEE GOLDBERG, Director, Improving End-of-Life Care Project, The Pew Charitable Trusts
ANNA GOSLINE, Senior Director of Health Policy and Strategic Initiatives, Blue Cross Blue Shield of Massachusetts
ZIAD HAYDAR, Senior Vice President and Chief Clinical Officer, Ascension Health
JOANNE LYNN, Director, Center for Elder Care and Advanced Illness, Altarum Institute
JAMES MITTELBERGER, Director and Chief Medical Officer, Optum Center for Palliative and Supportive Care, UnitedHealth Group (through July 2017)
SHARON SCRIBNER PEARCE, Vice President, Policy, National Hospice and Palliative Care Organization
LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California
ALLISON SILVERS, Vice President for Payment and Policy, Center to Advance Palliative Care
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
Project Staff
LAURENE GRAIG, Director, Roundtable on Quality Care for People with Serious Illness
SYLARA MARIE CRUZ, Research Assistant
SHARYL NASS, Director, Board on Health Care Services, and Director, National Cancer Policy Forum
ANDREW M. POPE, Director, Board on Health Sciences Policy
Consultant
JOE ALPER, Consulting Writer
ROUNDTABLE ON QUALITY CARE FOR PEOPLE WITH SERIOUS ILLNESS1
LEONARD D. SCHAEFFER (Chair), Judge Robert Maclay Widney Chair and Professor, University of Southern California
JAMES A. TULSKY (Vice Chair), Chair, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Chief, Division of Palliative Medicine, Brigham and Women’s Hospital; Professor of Medicine and Co-Director, Center for Palliative Care, Harvard Medical School
JENNIFER BALLENTINE, Executive Director, California State University Institute for Palliative Care
ROBERT A. BERGAMINI, Medical Director, Palliative Care Services, Mercy Clinic Children’s Cancer and Hematology, representing the Supportive Care Coalition
AMY J. BERMAN, Senior Program Officer, The John A. Hartford Foundation
PATRICIA A. BOMBA, Vice President and Medical Director, Geriatrics, Excellus BlueCross BlueShield
GRACE B. CAMPBELL, Assistant Professor, Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, representing the Association of Rehabilitation Nurses
STEVE CLAUSER, Program Director, Improving Healthcare Systems, Patient-Centered Outcomes Research Institute
JEFF COHN, Medical Director, Common Practice
JANET CORRIGAN, Chief Program Officer, Patient Care Program, Gordon and Betty Moore Foundation
ANDREW DREYFUS, President and Chief Executive Officer, Blue Cross Blue Shield of Massachusetts
CAROLE REDDING FLAMM, Executive Medical Director, Blue Cross Blue Shield Association
STEPHEN FRIEDHOFF, Senior Vice President, Clinical Strategy and Programs, Anthem, Inc.
MARK B. GANZ, President and Chief Executive Officer, Cambia Health Solutions
___________________
1 The National Academies of Sciences, Engineering, and Medicine’s forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published Proceedings of a Workshop rests with the workshop rapporteurs and the institution.
ZIAD HAYDAR, Senior Vice President and Chief Clinical Officer, Ascension Health
PAMELA S. HINDS, Director of Nursing Research and Quality Outcomes, Children’s National Health System
HAIDEN HUSKAMP, 30th Anniversary Professor of Health Care Policy, Harvard Medical School
KIMBERLY JOHNSON, Associate Professor of Medicine, Senior Fellow in the Center for the Study of Aging and Human Development, Duke University School of Medicine
CHARLES N. KAHN III, President and Chief Executive Officer, Federation of American Hospitals
REBECCA A. KIRCH, Executive Vice President of Healthcare Quality and Value, National Patient Advocate Foundation
TOM KOUTSOUMPAS, Co-Founder, Coalition to Transform Advanced Care
SHARI M. LING, Deputy Chief Medical Officer, Centers for Medicare & Medicaid Services
BERNARD LO, President and Chief Executive Officer, The Greenwall Foundation
JOANNE LYNN, Director, Center for Elder Care and Advanced Illness, Altarum Institute
DIANE E. MEIER, Director, Center to Advance Palliative Care
AMY MELNICK, Executive Director, National Coalition for Hospice and Palliative Care
JERI L. MILLER, Chief, Office of End-of-Life and Palliative Care Research, National Institute of Nursing Research, National Institutes of Health
R. SEAN MORRISON, Director, National Palliative Care Research Center
MURALI NAIDU, Vice President, Chief Clinical Officer, Sentara Healthcare
BRENDA NEVIDJON, Chief Executive Officer, Oncology Nursing Society
HAROLD L. PAZ, Executive Vice President and Chief Medical Officer, Aetna Inc.
SHARON SCRIBNER PEARCE, Vice President, Policy, National Hospice and Palliative Care Organization
JUDITH R. PERES, Long-Term and Palliative Care Consultant, Clinical Social Worker, and Board Member, Social Work Hospice and Palliative Care Network
PHILLIP A. PIZZO, Founding Director, Stanford Distinguished Careers Institute; former Dean, Stanford School of Medicine and David and Susan Heckerman Professor of Pediatrics and of Microbiology and Immunology
WENDY PRINS, Senior Advisor, Quality Innovation, National Quality Forum
THOMAS M. PRISELAC, President and Chief Executive Officer, Cedars-Sinai Health System
JOANNE REIFSNYDER, Executive Vice President, Clinical Operations and Chief Nursing Officer, Genesis Healthcare, representing the Hospice and Palliative Nurses Association
JUDITH A. SALERNO, President, The New York Academy of Medicine
KATRINA M. SCOTT, Oncology Chaplain, Massachusetts General Hospital, representing the Association of Professional Chaplains
KATHERINE SHARPE, Senior Vice President, Patient and Caregiver Support, American Cancer Society
JOSEPH W. SHEGA, Regional Medical Director, VITAS Hospice Care, representing the American Geriatrics Society
CHRISTIAN SINCLAIR, Outpatient Palliative Oncology Lead, Division of Palliative Medicine, University of Kansas Health System, representing the American Academy of Hospice and Palliative Medicine
TANYA STEWART, Senior Medical Director, UnitedHealthcare Retiree Solutions
SUSAN ELIZABETH WANG, Regional Lead for Shared Decision-Making and Advance Care Planning, Southern California Permanente Medical Group, Kaiser Permanente
Roundtable on Quality Care for People with Serious Illness Staff
LAURENE GRAIG, Director, Roundtable on Quality Care for People with Serious Illness
SYLARA MARIE CRUZ, Research Assistant
PATRICK BURKE, Financial Associate
ELAINE SOOHOO, Christine Mirzayan Science & Technology Policy Graduate Fellow (January–April 2018)
SHARYL NASS, Director, Board on Health Care Services, and Director, National Cancer Policy Forum
ANDREW M. POPE, Director, Board on Health Sciences Policy
Reviewers
This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process.
We thank the following individuals for their review of this proceedings:
EMILY CHAI, Mount Sinai School of Medicine
JEANNE CHIRICO, Hospice & Palliative Care Association of New York State
TORRIE FIELDS, Blue Shield of California
ROBERT FINE, Baylor Scott and White Health
VICKI JACKSON, Harvard Medical School
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by BETTY FERRELL, City of Hope National Medical Center. She was responsible for making certain that an
independent examination of this proceedings was carried out in accordance with standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies.
Acknowledgments
The National Academies of Sciences, Engineering, and Medicine’s Roundtable on Quality Care for People with Serious Illness wishes to express its sincere gratitude to the Planning Committee Co-Chairs Mark Ganz and Haiden Huskamp for their valuable contributions to the development of this workshop. We also wish to thank all the members of the planning committee, who collaborated to ensure a workshop complete with informative presentations and rich discussions. We are extremely grateful to the speakers and moderators, who generously shared their expertise and their time with workshop participants.
Support from the many annual sponsors of the Roundtable on Quality Care for People with Serious Illness is critical to the roundtable’s work. The sponsors include Aetna Inc., Altarum Institute, American Academy of Hospice and Palliative Medicine, American Cancer Society, American Geriatrics Society, Anthem, Inc., Ascension Health, Association of Professional Chaplains, Association of Rehabilitation Nurses, Blue Cross Blue Shield Association, Blue Cross Blue Shield of Massachusetts, California State University Institute for Palliative Care, Cambia Health Solutions, Cedars-Sinai Health System, Center to Advance Palliative Care, Centers for Medicare & Medicaid Services, Coalition to Transform Advanced Care, Common Practice, Excellus BlueCross BlueShield, Federation of American Hospitals, The Greenwall Foundation, Hospice and Palliative Nurses Association, The John A. Hartford Foundation, Kaiser Permanente,
Gordon and Betty Moore Foundation, National Coalition for Hospice and Palliative Care, National Hospice and Palliative Care Organization, National Institute of Nursing Research, National Palliative Care Research Center, National Patient Advocate Foundation, National Quality Forum, Oncology Nursing Society, Patient-Centered Outcomes Research Institute, Sentara Healthcare, Social Work Hospice and Palliative Care Network, Supportive Care Coalition, Susan G. Komen, UnitedHealth Group, and the National Academy of Medicine.
Contents
PATIENT–CAREGIVER–CLINICIAN PERSPECTIVE ON MANAGING AND PAYING FOR SERIOUS ILLNESS CARE
FRAMING THE CHALLENGES AND OPPORTUNITES FOR FINANCING AND PAYMENT INNOVATION
Taking Care of a Seriously Ill Patient in the Context of the Current Health Care Financing System
Financing Serious Illness Care at Cambia Health Solutions
CompassionNet: Community-Based Pediatric Palliative Care
Anthem’s Enhanced Personal Health Care
Lessons from CMS Demonstration Projects
Box, Figures, and Table
BOX
FIGURES
1 Distribution of out-of-pocket spending in the last 5 years of life
3 Share of regional Medicare beneficiaries cared for under the Medicare Share Savings ACO program
4 Share of members whose care was paid for under a global payment arrangement
TABLE
1 Cost and Location of Death at Five Moments in the Last Year of Life
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Acronyms and Abbreviations
ACA | Patient Protection and Affordable Care Act of 2010 |
ACO | accountable care organization |
AQC | Alternative Quality Contract |
BCBSMA | Blue Cross Blue Shield of Massachusetts |
BCBSNC | Blue Cross Blue Shield of North Carolina |
BPCI | Bundled Payments for Care Improvement |
BSWH | Baylor Scott & White Health |
CHIP | Children’s Health Insurance Program |
CHRONIC | Creating High-Quality Results and Outcomes Necessary to Improve Chronic Care Act |
CMMI | Center for Medicare & Medicaid Innovation |
CMS | Centers for Medicare & Medicaid Services |
COBRA | Consolidated Omnibus Budget Reconciliation Act |
COPD | chronic obstructive pulmonary disease |
CPC Plus | Comprehensive Primary Care Plus |
EHR | electronic health record |
HEDIS | Healthcare Effectiveness Data and Information Set |
I-SNP | Institutional Special Needs Plan |
IMPACT | Improving Medicare Post-Acute Care Transformation Act of 2014 |
MACRA | Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 |
NCQA | National Committee for Quality Assurance |
OECD | Organisation for Economic Co-operation and Development |
PACE | Programs of All-Inclusive Care for the Elderly |
PPO | preferred provider organization |
SNF | skilled nursing facility |
SNP | special needs plan |