Dying in America: A Comprehensive Review of End-of-life Care LeadingAge Annual Conference Panel Discussion November 2, 2015

Panel Patricia Bomba MD, FACP, VP & Medical Director Geriatrics, Excellus BlueCross BlueShield Naomi Karp, JD, Consumer Financial Protection Bureau/Senior Policy Analyst Judith Peres, LCSW-C, Independent Consultant Moderator: Karen Lipson, EVP for Innovation Strategies, LeadingAgeNY

Introduction: Why the IOM Report is Important to LeadingAge Members Karen Lipson, JD EVP for Innovation Strategies LeadingAgeNY

Objectives Review the findings of the IOM’s report on end-of- life care delivery in the U.S. Assess the knowledge gaps, structural problems and financial disincentives that exist in end-of-life care Discuss key recommendations for improving quality of care for people nearing the end of life across all care settings

IOM Report: Current State and Opportunities Patricia Bomba MD, FACP VP & Medical Director Geriatrics, Excellus BlueCross BlueShield Committee Member, IOM Report Dying in America

How Americans Die

How Americans Wish to Die

Medicare payments in last year of life account for ¼ of all Medicare spending Data from: Riley G, Lubitz J. “Long-Term Trends in Medicare Payments in the Last Year of Life.” Health Services Research, 2010;

“30% of health care is unnecessary or harmful” How do we shift the cultural mindset from “more treatment is better” to “the right treatment and care, and no more?” Triple Aim, IHI Choose Wisely Campaign

Palliative Care Interdisciplinary care – aims to relieve suffering and improve quality of life for patients with advanced illness and their families – offered simultaneously with all other appropriate medical treatment from the time of diagnosis – focuses on quality of life and provides an extra layer of support for patients and families Three Key Pillars with Psychosocial & Spiritual Support – Advance Care Planning and Goals for Care Discussions is process Step 1: 18 and older - Choose a Surrogate/Decision Maker Step 2: Seriously Ill Persons: Medical Orders – Pain and Symptom Management – Caregiver Support

Impact on Survival and Quality of Life: Early Integration of Palliative Care Randomized study of 151 patients with newly diagnosed non- small cell lung cancer – Early palliative care plus standard oncologic care or standard oncologic care – Quality of life and mood assessed at baseline and at 12 weeks – Primary outcome: change in quality of life at 12 weeks Outcomes – Fewer patients in early palliative care group received aggressive end- of-life care (33% vs. 54%, P=0.05) – Median survival longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02) Early Palliative Care for Patients With Metastatic Non-Small Cell Lung Cancer NEJM. 2010;363:

Palliative Care and New Value-Based Accountable Care Models Palliative care aligns with new care and innovative payment models – Helps to reduce avoidable hospitalizations & ED use – Strengthens person-centeredness, consumer engagement and satisfaction – Improves coordination along the continuum – Avoids unnecessary and unwanted service utilization and expense

IOM Report: Recommendations Naomi Karp, JD Consumer Financial Protection Bureau/Senior Policy Analyst Committee Member, IOM Report Dying in America

IOM 2013 Committee on Approaching Death: Addressing Key End of Life Issues Current state of end of life care with respect to Delivery of medical care and social supports Patient-family-provider communication of values and preferences Advance care planning Health care costs, financing, and reimbursement Education of health professionals, patients and loved ones, and the public at large

Dying in America: Key Conclusions Major gaps in care near end of life Urgent attention needed from numerous stakeholder groups Person-centered, family-oriented approach to care near the end of life should be a high national priority Compassionate, affordable, and effective care is an achievable goal Released September 17, 2014 Report available:

Dying in America: Five Recommendations 1.Person-centered, family-oriented (palliative) care 2.Clinician-patient communication and advance care planning 3.Professional education and development 4.Policies and payment systems 5.Public education and engagement

Key Recommendations 1. Person-centered, family-oriented (palliative) care All insurers should cover comprehensive care for individuals with advanced serious illness who are near the end of life. “Comprehensive Care” – Seamless, high quality, consistently accessible around the clock; – Consider evolving biopsychosocial/spiritual needs; – Coordinated –across all sites of care; – Consistent with person’s values goals and INFORMED preference.

One Solution: Palliative Care

Key Recommendations 2. Clinician-patient communication and advance care planning Professional and quality organizations should develop standards for clinician-patient communication and advance care planning that are measurable, actionable, and evidence based. Adherence to these standards should be tied to credentialing, licensing, and reimbursement.

Workbooks, tools

Key Recommendations 3. Professional Education and Development Establish training, certification, and licensure requirements that strengthen the palliative care knowledge and skills of all clinicians who care for individuals with advanced serious illness…

Key Recommendations 4. Policies and Payment Systems Federal, state, private insurance and health care delivery programs should integrate the financing and delivery of medical and social services; And require public reporting of quality and costs for care near the end of life.

Key Recommendations 4. Policies and Payment Systems Require the use of interoperable electronic health records that incorporate advance care planning to improve communication of individuals’ wishes across time, settings, and providers. Encourage states to develop and implement a Physician Orders for Life-Sustaining Treatment (POLST) paradigm program in accordance with nationally standardized core requirements.

Key Recommendations 5. Public Education and Engagement Every element of society should engage their constituents and provide factual information about care of people with advanced serious illness to encourage advance care planning and informed choice based on the needs and values of individuals.

Report and Dissemination Report available Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx Free slide deck for download IOM will engage in 12 month dissemination phase o Developing materials o Engaging relevant stakeholders and key audiences o Evaluating tactics to inform future activities