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    Five strategies to improve care for members with advanced disease


    Serious illness is becoming serious business for our nation’s healthcare payers.

    By 2030, an estimated 72 million Americans will be aged 65 years or older, nearly one-fifth of the U.S. population, according to U.S. News and World Report.  Unfortunately, approximately 92% of older adults have at least one chronic disease, and 77% have at least two, with chronic diseases accounting for 75% of the money our nation spends on healthcare, according to the National Council on Aging.  Mean capita spending in the last year of life in the U.S. is high, reaching $80,000, with hospital spending accounting for much of these costs (44.2%), despite peoples’ desire to reduce burden on families, avoid futile care, and die at home, according to Health Affairs.

    Given the enormity of the socioeconomic burdens associated with serious illness, and the fact these are the sickest and most fragile members of a health plan, managed care decision-makers are seeking proven strategies to deliver excellent care and improve quality of life for these individuals, at lower total cost.

    Below are key strategies to improve care and outcomes for members with advanced illness:

    Strategy 1.  Utilize a specialized population health management (PHM) solution.

    There are two important components for a successful PHM solution: sophisticated predictive analytics and capabilities to deploy a clinically driven approach:

    First, Sophisticated predictive analytics can identify members with advanced illness well before they experience a costly over-medicalized or inappropriate death. For example, some companies now offer highly specialized predictive analytics and proprietary algorithms that use historical data to proactively identify members who will benefit most from specialized case management and home-based palliative care.  

    Too often, a generalist population health approach lacks specificity with unrefined analytics that simply track the member’s disease process rather than placing a specialty focus on advanced illness and end-of-life as they relate to the individual’s goals of care. The majority of current solutions miss the mark when it comes to forecasting what will actually happen to the patient, and fall woefully short in transitioning from disease or event-specific care management to a patient-centered approach that addresses individual needs. 

    Rather than simply tracking disease progression, the optimal analytic model will project future medical events so that care management resources are targeted appropriately. Some predictive models are capable of forecasting which of their members with advanced illness are more likely to experience avoidable hospitalizations, readmissions, ICU days or other interventions in the next six to 12 months.

    Combining these data driven approaches with referrals from case managers, discharge planners, and others, improves the ability to identify those who would benefit from specialized services compared to relying on referrals from clinicians alone.   

    Second, the other critical PHM success factor is developing and deploying a clinically-driven approach such as a specialized palliative care program designed specifically for this fragile population.

    Without the proper care management infrastructure, appropriate staffing, and resources to intervene when something is predicted to happen, the potential of improving care outcomes for members identified through data will fall short. To achieve goals, data analytics must be combined with best practices supported by evidence, clinical protocols and patient outcomes—which lead us to the next strategy.

    Strategy 2.  Introduce a specialized palliative care program.

    Based upon timely and accurate identification of members with advanced illness, payers can introduce a specialized palliative care program that engages with patients and caregivers to provide: relief from symptoms and stress, medication management, care coordination and other support that are frequently missing from traditional care. 

    As palliative care evolves from an end-of-life modality to a PHM strategy, a growing number of payers are introducing these specialized services. Introduction of palliative care earlier increases the likelihood of improving quality of life while avoiding burdensome hospitalizations, skilled nursing stays and treatments that frequently result in more suffering without meaningful life prolongation.

    In fact, a study in the New England Journal of Medicine shows palliative care can also help patients live longer.  In a study of 151 patients with advanced lung cancer, those given early, concurrent palliative care survived 11.6 months, nearly three months longer than those who received standard medical care. Evidence also shows that, with or without curative treatments, a palliative approach offers the best chance of maintaining the highest possible quality of life for the longest possible time, according to the National Center for Biotechnology Information.

    Next: Strategy #3



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