by: Beth Berselli

How our health care is provisioned and paid for has been much in the news lately, and here at the foundation, it’s something we’ve been paying attention to too — particularly as it relates to improving the experience and outcomes of care for elderly, high-need patients.

In the U.S. today, we are experiencing a “silver tsunami” — referring to the elderly segment of the population that has been growing significantly and will continue to do so. By 2050, one-fifth of the total U.S. population will be elderly (that is, 65 or older), up from 12 percent in 2000 and eight percent in 1950, according to the Congressional Budget Office.

That growth in the elderly population will bring a corresponding surge in the number of seniors with both serious health conditions and functional limitations. Many of these projected 84 million seniors will be “high need” — meaning they have serious chronic conditions such as diabetes, heart disease and chronic obstructive pulmonary disease, and they are also limited in their ability to perform everyday tasks such as eating, bathing and walking.

Our Patient Care Program has been investigating how best to provide high-quality care for these elderly, high-need patients in the places most want to receive it: in the community and in their homes. 

Over the last year, we have particularly focused on the development of a robust accountability system for community-based serious illness care. Currently, a strong consumer protection system does not exist for this kind of care. Such an accountability system could include: 

  • Performance measures for use in public reports that help people select high-quality health care providers 
  • Value-based payment programs that link payment to the quality of care, not just volume of services provided
  • Accreditation and/or certification programs that signal the presence of a high-quality, community-based program 

We commissioned Discern Health, a health policy consulting firm that focuses on enhancing health care value, to review available measures and payment programs for serious illness care. The resulting two reports were recently published and include many important lessons. 

Here are the highlights of each report:

Building Additional Serious Illness Measures into Medicare Programs: In support of an expert convening activity co-sponsored by the foundation and The Pew Charitable Trusts, Discern identified a small number of setting-specific, serious illness care measures that could be immediately implemented by the Centers for Medicare & Medicaid Services (CMS) for relevant Medicare quality programs. A panel of 16 experts reviewed measures currently in use by Medicare for the home health, hospice, hospital and nursing home settings, and recommended steps that Medicare can take to strengthen quality oversight. The expert panel’s specific recommendations for CMS were:

  • Implement two existing quality measures that assess whether Medicare beneficiaries in hospitals have completed advance care plans. 
  • Capture the experiences of patients who have died or are unable to speak for themselves through surveys of their family members. 
  • Collect data (including on functional status) about seriously ill patients in a standard way across all care settings, because functional status is key to understanding patients' service needs. 
  • Create new measures to assess whether a patient's care was consistent with his or her goals. 

The expert panel also recommended that CMS pay careful attention to incorporating meaningful measures into new payment models that aim to control costs. Aligning financial incentives with measures of patient outcomes and experience of care is one way to make sure that efforts to make care more affordable do not result in reduced access to necessary services.

Read and download the Discern/Pew measures report.

Payment Models for Advancing Serious Illness Care: In a second project, Discern identified key characteristics of payment programs that enable the provision of high-quality serious illness care (e.g., coverage of home-based visits and telehealth, supports for family caregivers), and assessed the alignment of 31 existing alternative payment models offered by public and private payers with these characteristics. Discern’s findings underscore the fact that making serious illness care broadly available depends on the continued transitioning of health care payment programs from traditional fee-for-service that emphasizes physician office visits to more flexible global payment models linked to outcomes. Without more flexible payment arrangements, providers will struggle to launch and sustain high-quality, affordable serious illness programs in communities across the U.S., and so access to this kind of care will be limited to those patients who can afford to pay for it out of pocket. See the payment report and also a blog the authors wrote for Health Affairs.

These two new reports serve as valuable resources for health care providers and payers as they seek out the best ways to offer high-quality, affordable care to high-need patients. In addition, all of us at the Patient Care Program are grateful to have the benefit of this new knowledge; it has helped us pinpoint the areas of greatest need and potential impact for the foundation’s philanthropic dollars. We are currently working with grantees on several projects related to serious illness care measures and accountability programs. We look forward to updating you on this work in the future.

Beth Berselli is a program officer for the Patient Care Program at the Gordon and Betty Moore Foundation


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