Seriously Ill Patients, Temporary Solutions

Working in health policy, I am used to uncertainty. Most of the time, federal policy moves slowly.

There is also inherent uncertainty in all of the CMS Innovation Center models, which are temporary by nature as the R & D arm of CMS. But when models show promising results but the impacts of voluntary selection, attrition, and difficult evaluation methodology show underwhelming technical results, models end and not meet requirements for expansion.

Reminder—CMMI is young-12 years-and is still evolving.

There have been and are now some models that focus specifically on the seriously ill population. This can be specific to a population, like the Kidney Care Choices model for those with end stage renal disease, can be based on overall medical risk and complexity and not a specific condition, and can be for hospice-qualifying individuals, for example.

I wrote about one of the most exciting and promising models from which I hope we can build, the Medicare Care Choices Model. Part One here, Part Two here.

Among some of its remarkable results was a 26% reduction in hospital admissions 👇️ 

These results were achieved even with significant model attrition, mainly due to an under-funded financial incentive that made participation largely unsustainable. The results are so overwhelmingly positive that a new model could be developed that addresses the shortcomings of the first and builds on it to capture not just hospice-level patients, but also the seriously ill population.

High Needs ACO REACH Program

There’s an active model offered by the Innovation Center that includes beneficiaries whose medical and functional risk (*I’m simplifying*) is high enough that they need a higher “dose” of all kinds of care that can’t be done in fee-for-service.

The model assigns risk a bit differently from the CMS HCC risk adjustment model. This model and the KCC model use the CMMI HCC methodology. It involves concurrent risk adjustment and a different weighting of conditions more reflective of the impact of end-stage chronic conditions. It yields higher benchmarks to fund a much greater level of care and intervention.

Most of these entities provide all or most of the care right in the home setting.

Some think of this as “palliative primary care” (more on palliative care’s definitions in my first two articles, linked above). Care is more individualized, well-coordinated, frequent, responsive, proactive, patient-and-family centered, and compassionate than that which can be provided even in other total cost of care, full-risk programs like the Standard ACO REACH entity.

There are so many reasons it makes sense to take care of seriously ill patients differently.

The highest spend in Medicare in chronically ill patients is in the last 1-3 years of life, and one-quarter in the last year of life.

Why?

Exacerbations of chronic illness with poor symptom and often disease management, coupled with a lack of understanding of what their choices are and what they could mean are major causes of spend.

Patients have a common trajectory in the end stages of chronic illness—hospitalizations, post-acute stays, rehospitalizations…and all this often without these providers understanding “what matters” to the patient. And “what matters” to the patient should be at the center of how serious illness is managed by the patient’s medical team.

I can’t find the original quote, but I think it comes from the Institute for Healthcare Improvement:

I found an e-book with the Clinical Practice Guidelines for Quality Palliative Care. There are strict limitations on sharing the actual e-book or any portion of it, but that’s the link to the site and you can click to download the e-book. Palliative care is so misunderstood. This explains it well.

Sorry for that little detour…now back to

High Needs ACO REACH 2023 Performance

I snipped three ACOs’ performance from the CMS Excel public files so you can see the kind of results over one year:

So Bloom Health Network, the first one listed, is a High Needs ACO REACH entity that sees patients at home.

They have a little over 1400 patients and their net savings was almost 11.5 million dollars.

You read that right.

That about $8200 per beneficiary. Where did the savings come from?

Generally, it’s from more days at home vs. the hospital or other settings.

The High Needs quality metric is my favorite quality metric of ALL TIME (see #3) 🤩 

Is it odd to have a “favorite quality metric of all time?” 😁