A pilot collaboration between Bristol Hospice Hawaii and Ohana Health Plan, Inc. to provide interdisciplinary palliative care to complex patients resulted in a 40% reduction in health care costs, as well as substantial reductions in avoidable hospitalizations and emergency room visits. Ohana is a component of WellCare Health Insurance of Arizona, Inc.
The program focused on super-utilizers suffering from chronic or serious illness who had experienced more than three hospitalizations during the prior year, with at least one prolonged length of stay. During the pilot, Ohana service coordinators referred 27 homebound members to Bristol, based on claims utilization data.
The collaboration resulted in a nearly 80% reduction in emergency department visits per thousand patients, with a 75% reduction in hospital admissions.
Participating patients did not enroll in the hospice benefit, but received palliative care from an interdisciplinary team from the hospice while continuing concurrent care. The hospice received payments comparable to the Medicare rate for routine home care.
“We’ve been struggling with this population of people for a while. We as a company tend to get an inordinate number of these folks that sign up with us, so we began to develop different capabilities,” Ed Fess, M.D., medical director for Ohana, said. “We had a longstanding relationship with [Bristol] on a hospice basis. But this is a different population of people, not necessarily at the end of life. They have chronic problems, but may live a long time. The care they had been receiving wasn’t very coordinated. Bristol has the capability of coordinating a lot of this care.”
The hospice teams obtained patient consent and stayed in communication with patients’ primary care providers and specialists. The supportive care team included a physician, nurse practitioner, volunteer a certified nurse assistant, and a social worker and chaplain, as needed.
The median age of participants was 63-years-old, and more than 50% had cardiac diagnoses. Most were Hawaiian, with one other Pacific islander. The patients had a 90-day median length of stay, and 23% enrolled in hospice after receiving this supportive care. The number of patients who completed advance care plans rose to 85%, up from 23%.
Data the hospice collected through the program showed improved patient outcomes as well as cost savings.
“We found that [patients’] pain improved. They got better with shortness of breath and anxiety, and depression also trended in that direction. Some measures, such as their overall well being, did not change,” said Ritabelle Fernandes, M.D., supportive care medical director for Bristol Hospice Hawaii. “When we were tracking these, [an assessment scale] was administered by the nurses at nearly every visit so we could track change over time. We also tracked hospital and emergency room visits. We knew in real time when they went to the hospital or not, but we also got information from the health plan because they were running this claim data.”
Some costs associated with the program did rise, including a 6% increase in outpatient visit costs per member per month, as well as a 27% increase in pharmacy costs, but overall cost savings from reduced emergency department visits and hospitalizations reached nearly 40% even after accounting for these expenses.
These particular cost increases were actually promising signs. Many of these patients had a history of not complying with physician orders, taking medication as prescribed, or following up with physicians in a timely fashion.
“Their medication costs went up, but we expected that because that means that they’re taking their medicines like they’re supposed to,” Fess told Hospice News. “Outpatient costs went up from primary care provider visits, but these are good indicators because that means that they are doing what they are supposed to be doing in terms of their health care.”
Though the pilot project has ended, Bristol and Ohana hope to rekindle this collaboration in the long term. Ohana is a Medicaid provider, meaning they are highly regulated and must undergo a rigorous process to add a new permanent benefit. They have submitted a request for proposal to the state as an important first step moving forward. If approved by regulators the program could continue for an additional five years with the opportunity to renew.
“We have to work with the state when we want to change benefits, because this would be a benefit addition,” Fess said. “We think this program is a worthwhile thing to do, but there are a lot of ramifications in terms of costs and how you allocate them, state approvals and how it meshes with the rest of your benefit structure. So we are kind of holding our breath to see what happens.”