Paying to Keep Seniors Out of the Hospital
How smarter economics could make for better medicine
(reprinted with permission from author)
By Diane Meier | 01/11/17 05:31 Am EST
I met Mr. B in the emergency room. He was 88 years old with dementia and severe arthritic pain. His wife called 911 when a lower back spasm made it impossible for him to stand up from the toilet. She tried to pull him up but he screamed at her to leave him alone. No neighbors were home to help. She called their doctor, but it was 5:30 p.m. and she got a tape saying “If this is a medical emergency, hang up now and call 911.” As she said to the ER nurse, “It was a medical emergency to me.”
Mr. B curled up on his stretcher, refusing to speak to his wife or answer questions. As it turned out, this was his fourth visit to the ER in four months; previous visits were caused by back pain and by an episode of confusion and agitation caused by constipation. On each of those visits he was hospitalized, developing an infection, worsening confusion and incontinence. He was furious to be back. Frustrated, the Emergency Department doctor paged me, the attending physician on the palliative care team, saying “Nobody’s been able to get his back pain under control, so I figured we’d try you guys.” His chart showed that high doses of Tylenol had failed to help, and that he couldn’t take anti-inflammatory medicines because of poor kidney function. Opioids were the next step, but no one had tried it, in part because they feared censure from the Department of Health for prescribing opioids for “chronic pain.” Instead, he and his wife were using 911, the ER and the hospital—arguably the least safe of his pain management options—for his chronic and recurrent back pain.
All too often, people like Mr. B stay on that costly and stressful merry-go-round—home, ER, hospital, home, ER, hospital—accompanied by a gradual decline in health and quality of life, and mounting strain on family caregivers. But bit by bit, our health care system is getting smarter. Partly because of new payment incentives and partly because of a growing recognition of the challenges of caring for complex older patients—we’re learning that it’s better medicine, better economics and more humane to treat people at home rather than in institutions, and to understand and address their unmet social needs as well as their strictly medical ones.
As a palliative care physician and geriatrician, I practice in a setting where that kind of care is our goal. That wasn’t always the case, and it’s not the approach everywhere. But I was able to start by treating Mr. B’s physical pain—and then branch out. I tried him on a low dose of morphine and watched to see whether it affected his pain or had any adverse side effects. After 40 minutes, no change. I gave him slightly more and watched as he began smiling, holding his wife’s hand and flirting with the nurses. He asked to go to the bathroom and was able to walk there with minimal assistance. His pain was pretty much gone, and not only had the drug done him no harm, he was able to function normally. We taught Mrs. B how and when to give the pain medicine (only when needed—not a constant stream of opioids), how to prevent the constipation that those drugs cause. Then we sent them home in a taxi.
But that wasn’t the only new approach we took. Worried about their safety at home, I called my colleagues in our medical House Calls program and asked whether they could visit the Bs the next morning. When they got there, they found loose throw rugs, electrical wires crisscrossing the floor (putting both of them at risk of serious falls), a refrigerator empty except for old Chinese food containers, and no grab bars or elevated toilet seat in the bathroom. Mrs. B could not get out to the grocery store because Mr. B could not be left alone. Their only daughter lives in California; they did not tell her what was going on because they didn’t want to worry her (a story I’ve heard countless times). They had stopped going to church a year earlier because of Mr. B’s decreasing mobility. As a result, they lost their social supports and network of friends. Loneliness and isolation may not be “medical conditions,’’ but they can be devastating to health.
The house calls team fall-proofed the home. They arranged meals on wheels and asked the Bs’ daughter to order them groceries online. They called the couple’s minister, who hadn’t known why the couple had stopped attending church but now arranged a “friendly visitor” program for them three afternoons a week. That allowed Mrs. B to get out to shop and see her friends, while providing Mr. B company to watch a game or tell war stories. The church also sends a car to pick them up every Sunday for services, gives them lunch and takes them home again, restoring their place in their community.
The house calls team has 24/7 telephone coverage so that when a crisis develops, Mrs. B reaches a real person, not a taped message. In the three years since we began palliative care, Mr. B’s digestive problems have gotten under control, and his back goes out a lot less now that he has a raised toilet seat, grab bars and a chair in the living room that helps him stand up. When his back pain does flare, about two times a month, Mrs. B gives him a dose of liquid morphine, getting his pain under control in about half an hour. Mr. B is now 91 years old. He is frailer and uses a walker to get around his apartment, but otherwise he is stable. They have not once called 911 or been back to the ER or the hospital.
Mr. B’s story exemplifies the kind of high-value care that a growing functionally impaired and frail older population must have if we are to prevent unnecessary, costly and harmful use of emergency and hospital services. Given the cost of health care in America—it’s nearing 20 percent of GDP—and the upcoming wave of elderly baby boomers, we need to figure out how to provide that kind of high-value, lower-cost care across the board.
But this kind of care, though gradually becoming more common, is still not the norm, and the payment system is largely to blame. Fee-for-service still dominates our health care payment system, and it’s tied to providing medical services, not to the kind of social and home-based needs that can be identified in a couple like Mr. and Mrs. B during a comprehensive medical, social and psychological assessment.
So how do we make this kind of care more common? How do we scale reliable access to such services across the country? Some of it’s happening because financial incentives are changing under a Medicare law called MACRA and the Affordable Care Act—and many of these payment shifts are expected to survive Republican efforts to replace Obamacare. Those changed incentives mean health care providers and insurance plans are taking on more financial risk. And when they bear more financial risk, they have more reason to identify the highest need patients and intervene to support them in ways that keep them out of emergency rooms and hospitals.
It is important to note that Mr. B was and is not eligible for hospice—he is not dying, and the care he needs is not “end-of-life” care. He needs palliative care—care that addresses the symptoms that accompany decline and serious illness, but also takes into account the social, spiritual and emotional needs. He is eligible for palliative care because of need and complexity; for hospice he’d be eligible only if he had a prognosis that he’s likely to die within a few months. A landmark report by the Institute of Medicine found that only about one-tenth of the costliest 5 percent of U.S. patients are actually in their last year of life. About 40 percent, like Mr. B., are high-cost year after year because of the high burdens of chronic disease like dementia.
Programs that are part of the Affordable Care Act (not the politically controversial coverage expansion but the parts of the law that address payment and risk) have jump-started similar models. Like the care my colleagues and I were able to provide to the Bs, these programs include 24/7 availability (since most crises occur after hours); attention to both social and medical needs; family caregiver assessment and support; training in safe and effective pain and symptom management; care continuity and coordination over time and across settings; and skilled communication abilities.
We’re getting better at providing this continuum of care. Here are three examples, drawn from a report published last month by the Center to Advance Palliative Care, which I direct. They illustrate clearly that this approach can work in a range of settings. They are financed in different ways, but most are based on a set payment per patient with providers and payers bearing the financial risk but also sharing any savings with Medicare.
ProHEALTH in Queens, New York: ProHEALTH Care Associates is a large, multispecialty physician group practice with more than 200 locations in Long Island and Queens. ProHEALTH employs social workers and nurses who make home and telephone visits with strong physician oversight. They serve about 500 people, mostly frail and homebound older people with multiple conditions including heart failure, pulmonary disease and memory loss. To avoid unnecessary trips to hospitals and ERs, they make innovative use of telemedicine and local urgent care centers. Early findings demonstrated high levels of patient and family satisfaction and dramatic savings; the cost per patient during the final three months of life was $12,000 lower with than with a more traditional approach, and hospital admissions were reduced 34 percent.
OACIS Palliative Home-Based Consult Service in Allentown, Pennsylvania: OACIS, which stands for Optimizing Advanced Complex Illness Supports, is a home- and assisted-living-based palliative care consultation service that is part of the Lehigh Valley Health Network. It’s aimed at seriously ill adults who can no longer make regular visits to their primary physician’s office. Social work, physician and volunteer support (through a community time bank) are core elements of the program, which is financed by a combination of fee-for-service billing and bonus payments from the health system linked to quality metrics such as reduced hospital mortality and 30-day readmissions.
Home Connections in Buffalo, New York: Home Connections is part of an independent community hospice in the Buffalo region, providing (non-hospice) care in people’s homes as well as in assisted living and skilled nursing facilities. Eligibility is based on claims data from participating health plans and is limited to frail and complex older people with multiple chronic conditions who are members of a health plan that contracts to pay a per-member per-month rate for these services. The patients showed marked improvement in symptom burden, advance care planning and satisfaction. Substantial cost savings were apparent in the last three months of life—$6,804 per member per month cost for palliative care versus $10,712 for usual care.
What is striking about these innovators is their success and sustainability despite the perverse incentives of our health care financing system. With just a little help from new payment models, there is every reason to hope that much-better and much-lower-cost care in homes and communities will soon be available for everyone who needs it. And that will be many of us.
Diane Meier, a geriatrician, is director of the Center to Advance Palliative Care in New York.