Episode 54: MHACO’s Care Variation Reduction Strategies

Heather: This is BACON, brief news from the MaineHealth Accountable Care Organization. A monthly podcast for health care providers. I'm Heather Ward.

Mike: And I'm Mike Clark. Heather and I are practicing physicians who participate in the MaineHealth ACO.

Heather: In this episode, we are joined by MaineHealth ACO Board President Dr. Carl DeMars. With Carl's help, we will explore two projects that the ACO is involved in to reduce care variation.

Mike: That's right. So, let's get to it.

Heather: Care variation reduction is something we've talked about before on this podcast. If you're interested in a deep dive, check out episode 48. And honestly, we're probably going to keep talking about care variation reduction for a while. And that is because it is linked to success in value-based care. And frankly, value-based care is what the ACO is all about.

Mike: That is absolutely right. And the reduction of care variation, or more accurately, unwarranted care variation, has the potential to improve quality while reducing the cost of care. Two things that value based care encourages.

Heather: That is so right. Our guest today is Carl DeMars. He is here to talk about two care variation reduction projects that the ACO is involved in. Carl is the president of the MaineHealth ACO board and VP for physician and APP services for the MaineHealth's coastal region. Carl is somebody that I work with a lot on other projects, so I'm super excited to have him here. And I know that his passion is palliative care. So welcome, Carl.

Carl: Thank you. Glad to be here.

Mike: We're so glad to have you, Carl. And ad as you know, the ACO has named care variation reduction as a priority of the next couple of years. So how about that. Can you tell us what's meant by care variation reduction?

Carl: Thanks, Mike. I will tell you first what it's not. What it's not is standardized medicine. It's not checkboxes and cookie cutter medicine that all of us kind of bristle at. What it really is, is seeing the differences across our system and how we take care of our patients, and then asking the simple question why? Why is the difference there? Not all care variation is bad. In fact, it's kind of the art of medicine that we all practice. But when we find system problems and fix them, we can give better care to our patients.

Heather: That is a really clear explanation. I think you've said it better than I've heard it said before. What exactly are the benefits of variation reduction for ACO, for the ACO and its participants?

Carl: Thanks, Heather. I think that the biggest improvement will be around the care of our patients. When we are able to identify where care variation is leading to less-than-optimal outcomes, and we can correct workflows and different system problems, we're going to give better quality care and better outcomes to our patients. It just so happens that oftentimes these are tied to cost reduction, which is really a very important part of the value equation as we know quality divided by cost.

Mike: So, let's move Carl then from sort of a higher-level view of this down to some more specific strategies. Now as I understand it, the ACO and MaineHealth have named end-of-life care and transitions of care as focus areas for their care variation work, why end-of-life and transitions of care?

Carl: For those of us that have been with the ACO from the very beginning, and I know you are one, Mike. When we sat in a room in Brunswick over ten years ago, we identified end-of-life as really one of those "win-win" situations that are so hard to find. We know that giving better palliative care at the end-of-life leads to improved quality of life, improved symptom control, better support for our patients and their care teams. And really, some studies have shown even an increase in the length of life in lung cancer, a study out of Boston. So, there is lots of good reasons why we have chosen end-of-life care. But with the new robust tools that the ACO has, we can actually look at the cost savings of enrolling patients into hospice in a more timely manner. For patients that come into hospice with less than ten days of life, those are the most expensive patients, costing about $15,000 for the last 30 days of care. Oftentimes, this is a tumultuous time. Patients and families are in the hospital facing hard decisions. The decision to go to quote comfort care is made. And yet we've done a lot to that patient in that hospitalization. For no hospice patients, those that don't have any hospice, it's about $11,000 in that last 30 days. But interestingly, hospice of greater than ten days is associated with a cost of about $6,5000 dollars in the last 30 days of life, which is a significant savings that we are looking for in our value-based work. Transitions of care is another area of focus, because oftentimes our patients coming out of an acute hospitalization are at their most brittle. They really have lots of new medications and new plans around their care and oftentimes end up back in the hospital. So really focusing on that transition of care process, which includes a phone call from a nurse right after discharge, really robust discharge instructions and a relatively quick visit with their PCP or specialist has been shown to really improve care.

Heather: So, I'm really curious about palliative care. And it's something that is kind of new to me. And I'm wondering if you can just help me understand a little bit better the difference between palliative care and end-of-life care. Like a lot of times, I hear those two things used interchangeably, but my understanding is palliative care can go on for a very long time. It's not necessarily end-of-life care.

Carl: Thanks, Heather. I think really end of life care could be maybe synonymous with hospice care when you're trying to explain the differences of those two things. Hospice care is actually a governmental benefit. Also, in a lot of our insurance plans, requiring a physician or APP to say somebody has less than six months of life with their current condition. And really what we do is we stop the curative model of care that we've been doing all along and replace it with truly end-of-life care. Everything is about the symptom control. And more than that, really, the psychosocial issues, spiritual issues that surround a patient and their care team, really supporting all aspects of that through this program that is one of the best things I've ever seen in medicine. Conversely, palliative care really is specialized medical care for people with serious illness. Ideally, it would start while you're still in the curative model at the beginning of your serious illness, really managing symptoms, providing support to the family and caregivers, and really listening to the patient about what their wishes are, what are their goals of care going forward.

Heather: That's great. I really think of that palliative care as an addition to the care team versus transition over from the care team. Yeah.

Mike: Yes, that really does speak to the collaborative aspects, right, of palliative care. And as I understand it, in support of this work, the ACO has set a goal that could spur some real increase in collaboration in it hopes to increase the number of patients with newly diagnosed end stage cancers who are referred for palliative care. How might that happen?

Carl: So, Mike, you know, traditionally most of our palliative care programs have been inpatient, helping patients, as we kind of say, after they fallen off the waterfall. Things are very, very tumultuous at that time. And really, the advent of ambulatory palliative care above where the waterfall is to pull them out of the river, is really the idea here. And so, co-locating palliative care resources in oncology is a tactic MaineHealth is doing right now to great success. Having those patients with their newly diagnosed cancer meet with a palliative care specialist who is in support of the oncological care that we're giving is really the key here. We have partnered with our oncological colleagues at MaineHealth who are really embracing this new initiative and having their patients receive early palliative care in the course of their illness. In addition to that, we are increasing our ambulatory palliative care outside of oncology. This is where I practice my palliative care, and it's incredibly rewarding to see patients in the office who have chosen to interact with myself and my social worker. We even go out to their homes or into the nursing home to see them. It's very rewarding work.

Heather: Okay, that is such helpful information. I would like to shift the conversation from palliative care and end-of-life to transitions of care. Since the ACO goal also centers around increasing the use of transitional care management, can you talk a little bit about what exactly transition of care is and why it's important?

Carl: Transitions of care management, otherwise known as a TCM visit, does have certain requirements for our teams to do with our patients, including a phone call right after discharge and then a pretty quick visit with their primary care or specialist to go over the hospitalization to qualify for the full TCM package that is billable. Quite honestly, primary care has been doing this forever. We know these are our most trying times for patients and their families, and we really try to surround them with care. But sometimes our busy lives do not get the patient in front of us or we don't have complete information when they do come. So this is really a coordinated effort with the nursing and medical assistance staff to call the patient and check in for what the medication changes have been, see if there's any issues going on after the first 24 hours after discharge, and then a quick visit with their PCP or specialist to go over just what happened during the hospitalization. Check for understanding. Do you know what the plan is? Do we know what signs and symptoms to look for that would make you want to call your physician team again so that we can prevent another hospitalization?

Heather: Yeah. I also think to transition of care gives me the opportunity to make sure there's nothing I need to follow up on as well. Yeah. So super important visits.

Mike: Well, thank you, Carl, for highlighting some of these critical areas that both improve value as far as cost, but really these improve care for our patients. And it makes so much sense for us to be focusing on these. So, as we wrap up, what are your hopes as a physician leader and as a primary care provider yourself? What are your hopes for these two areas of focus end-of-life and care transitions? What will be different in the future?

Carl: Well, Mike and Heather, I really think that, you know, looking at these two areas, we can give better care to our patients if we improve the systems at which our providers, our physicians and APPS work. Really helping us do the right thing, at the right time, is the whole key here as our lives become more complex. So, in a nutshell, improve the systems that are surrounding our physicians and APPS, and they'll be able to do this very important work easier.

Heather: Excellent. Thank you so much, Carl, for your time and your insights. It's been great to have you here.

Carl: Thank you for having me.

Mike: Thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we really would love to hear from you. Please email us at bacon@mainehealth.org. That's Bacon@mainehealth.org.

Heather: Bacon is produced by the MaineHealth Accountable Care Organization. Thanks for joining us. See you next time.

Mike: See you next time.