Duke University Healthcare Policy Research Report Highlights Value of Turn-Key Health Model
Innovations in Medicare Advantage to Improve Care for Seriously Ill Patients
For organizations attempting to solve for the problem of high cost, poor quality end of life care, this report signals an inflection point that has been experienced by other adjacent healthcare solution providers, such as telehealth or urgent care. This benchmark study confirms growing interest in palliative care to address serious illness among providers and payers – and the members they serve. It speaks to strategic and financial objectives, calling for increased changes that will further impact the cost and quality of care.
Moreover, it is recognition of the significance of newly finalized guidance and policies for the Medicare Advantage program from the Centers for Medicare & Medicaid Services (CMS). These changes will expand the supplemental benefits afforded to beneficiaries to include items and services that address certain “Social Determinants of Health” (SDoH). SDoH refers to a wide range of factors and conditions that are known to have an impact on healthcare, ranging from socioeconomic status, education and employment, to one’s physical environment and access to healthcare. Previously, CMS did not allow an item or service to be eligible as a supplemental benefit if the primary purpose was for daily maintenance. CMS’ reinterpretation of the statute to expand the scope of the primarily health-related supplemental benefit standard is an important step in encouraging value-based care.
This latest development aligns Medicare Advantage with commercial payers and states across the country that recognize the importance of addressing SDoH in achieving better health outcomes and lower costs. The Turn-Key model, as described in the report, leverages SDoH in its proprietary Palliative Activation Scale (PAS™): the measure of a patient’s propensity to adopt a palliative care approach, to improve quality of life and outcomes.
More Changes Needed
Duke researchers, however, are mindful to point out that more change is needed to effectively manage the care of seriously ill patients. They express the hope that policymakers and other health system stakeholders will utilize this information and examples of industry leaders to accelerate progress, better estimate the cost and quality impact of solutions, and share that evidence broadly.
This report is a stepping stone to making meaningful progress for sharing information with a greater number of payers, providers, and patients. It is also an opportunity to recognize and help overcome existing barriers to care and accelerate the “diffusion of innovations” in serious and advanced illness care.
- Provide incentives, through payment and delivery models, to encourage innovation in serious or advanced illness care for the traditional fee-for-service Medicare population.
- Rigorously study these new serious or advanced illness programs to expand the evidence on utilization, quality, and cost effects.
- Support workforce development initiatives that train clinicians for roles in alternative payment model care teams.
Characteristics of Exemplary Models
Authors examined features of exemplary models that consistently deliver results in these areas:
- Analyzes claims data received from plans in order to identify patients that meet the eligibility requirements for services. This process is often more sophisticated than simply applying certain diagnosis and utilization criteria to patients based on their current health status, but instead entails predictive analytics that can identify patients who will incur increasing utilization and costs in the near-term as their illness progresses.
- Members of the care team conduct their own health and functional assessments of patients when they enter their cohort and update them regularly while patients are in their care. These assessments enable the teams to gain a more comprehensive understanding of patients’ health and risks by evaluating and recording factors such as safety concerns in patient homes and any issues related to social determinants of health. Information recorded in these assessments may then be used to inform risk stratification within patient cohorts, to prioritize resour ce needs for patients, and to tailor care plans.
- Aggregates assessment data along with claims into software platforms where it can be analyzed to monitor the health status and risk of patients in their cohorts. These systems generate dashboards and regular reporting on measures related to patient engagement, quality of care, utilization, and outcomes that are utilized by their care teams to flag when they should proactively intervene to prevent high-cost encounters like emergency department visits and hospital admissions.
- Care teams deliver care to patients in their home or residence in facility settings, providing round-the-clock accessibility to patients, which is critical for quickly addressing patient concerns and needs in order to prevent or divert emergency visits and hospital admissions.
- Providers conduct advance care planning discussions with patients and their families and caregivers in order to help them consider and plan for decisions that will need to be made as the patients approach the end of life. Care teams also work to refer patients to hospice when it becomes appropriate for their disease progression and when it aligns with patient and family goals of care and preferences.
- Specific payment and performance metrics often vary across their contracts with different plans, emphasizing the degree of flexibility in contracting and payment structure that the organizations have while still making their model work for all parties.