On June 10-11, the Technical Advisory Committee (PTAC) held a public meeting focused on “Addressing the Needs of Patients with Complex Chronic Conditions or Serious Illnesses in Population-Based Total Cost of Care (PB-TCOC) Models.” PTAC was created under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). PTAC reviews proposals for physician-focused payment models (PFPMs) and makes comments and recommendations to the Secretary of Health and Human Services (HHS) regarding the extent to which such proposals meet criteria established by the Secretary.
The convening was intended to build upon PTAC’s ongoing series on designing and implementing PB-TCOC models. At the June meeting, the following topics were covered:
- Care delivery needs of high-cost patients with complex chronic conditions or serious illnesses who account for the top five percent of Medicare spending;
- Strategies for providing patient-centered care for this patient population;
- Opportunities for improving care delivery and health outcomes for this patient population;
- Optimizing the use of post-acute care, palliative care, and end-of life care for this patient population in PB-TCOC models;
- Approaches for measuring performance and quality of care for patients with complex chronic conditions or serious illnesses in PB-TCOC models; and
- Best practices for incentivizing improved outcomes and delivery system transformation for this patient population in PB-TCOC models.
Highlights from day 1 of the meeting included a presentation by the Preliminary Comments Development Team (PCDT) covering the challenges and opportunities present in caring for those with serious illness or complex chronic conditions. Challenges were related to patient identification and prevention (e.g., how to prospectively identify patients, risk stratification approaches, and changing cohorts), provider challenges (e.g., clear clinical guidelines and goals of care and sufficient time with patients), clinical care needs (e.g., care coordination and integration, team-based care, and appropriate care), patient engagement (e.g., engaging patients and caregivers in care delivery), and health equity (e.g., health-related social needs and disparities in health outcomes). Opportunities discussed were broken out by beneficiary type; for those with serious illness, the quality and cost of care for many patients can be improved through an increased focus on palliative care and/or hospice, whereas those with complex chronic conditions may benefit from intensive outpatient team-based medical care and/or formal disease-management programs.
Highlights from day 2 of the meeting included two Listening Sessions. The first focused on “Optimizing the Mix of Palliative Care and End-of-Life Care in PB-TCOC Models.” Of note, Kurt Merkelz, MD, FAAHPM, Chief Medical Officer of Compassus, discussed the need for integrating palliative care throughout the continuum of care. Doing so addresses the challenges that current models of care are not designed to meet the needs of frail, seriously and chronically ill individuals and the over-emphasis in medicine on symptom management and acute medical care. Palliative care providers are well positioned to be integrated into treatment teams and quarterback care plans and outcomes, while a model of community-based palliative care shifts the focus away from prognosis and onto the patient’s success in critical areas including Medical Condition Management, Safety, Autonomy, Burden of Care, Aging in Place, and Quality of Life.
The second Listening Session focused on “Best Practices for Incentivizing Improved Outcomes for Patients with Complex Chronic Conditions or Serious Illnesses in PB-TCOC Models”. Diane Meier, MD, Icahn School of Medicine at Mount Sinai, reviewed best practices for integrating palliative care into population models including systematic and proactive identification of patients most in need via EHR, having a care manager assessment for symptom, functional, and caregiver burdens, communication with treating clinicians or connection to specialty palliative care, as warranted, specialty palliative care services tailored to patient and family need, and having a 24/7 meaningful clinical response. Meier also emphasized that value-based payment models are not alone sufficient to motivate providers to ensure access to high-quality palliative care services, necessitating additional payment and explicit requirements to ensure the integration of palliative care.
Having advanced palliative care through its various policies, state, federal, and clinical initiatives, C-TAC is pleased to see the needs of the seriously ill population and how to address them being discussed by PTAC. This is a big area of opportunity, and C-TAC will continue to lend its voice and work to the movement to ensure all persons impacted by serious illness, especially those who are underserved and under-resourced, have a high quality of life – on their own terms.
