Q: What is ACIStrategies?
A: ACI stands for “Advanced Care Innovation.” ACIStrategies provides solutions to the challenges we face in caring for the growing population with advanced illness. We help health plans, health systems, hospital groups, physicians and others improve the quality of their care and make it more affordable.
Q: What is “advanced illness?”
A: People with advanced illness have at least one chronic disease that is responding poorly to treatment. Their ability to function is declining and their prospects for recovery are poor. They are living in the “gray zone” between treatable and terminal illness, so their needs fall through the cracks between chronic disease management and end-of-life care.
Q: Why is it so important to focus on advanced illness?
A: These are our sickest and most vulnerable patients. Their care needs are not being met, so their families and caregivers are bearing the burden instead. And more importantly, their preferences are ignored. 80 percent of people with advanced illness want to spend their last days at home with loved ones. Yet almost 30 percent of Americans today die in intensive care units. The cost in failed expectations, not to mention dollars, is huge.
Q: Why have healthcare costs near the end of life become such a big issue?
A: Patients undergo treatment that gets more aggressive and more costly the closer they get to the end of life. 28 percent of all Medicare spending goes for treatment in the last year of patients’ lives, and 30 percent of that is concentrated in the last month prior to death, when 80 percent of spending is for hospital treatment. In other words, we are spending a large chunk of taxpayer dollars for treatment that is not doing any good, and in fact may be harmful.
Q: Why is treatment harmful? Aren’t doctors and hospitals trying their best to save lives?
A: There’s no question that the vast majority of clinicians and staff are caring, motivated and conscientious. But when they provide aggressive treatment to people with advanced illness, they’re working against the facts. Research shows that once a person’s illness enters the advanced phase, their survival is limited regardless of what treatment we provide them. Most medical and surgical treatments do not extend life at this stage. In fact, studies show that people with advanced illness survive longer with simple supportive care than with traditional treatment. But our standard practice is to put them in the hospital more and more often, and for longer and longer periods, as they approach the end of life.
Q: If hospital treatment is the standard of care, why shouldn’t we keep doing it?
A: We can’t afford to keep this up. About three quarters of people with advanced illness are over 65, so they are covered by Medicare. The Baby Boomer age wave is causing their numbers to explode. Each day nearly 10,000 Americans age into Medicare. Multiply that growing number of patients by the increasing cost of hospital treatment, and the result is sobering. Within two or three decades the threat to Medicare sustainability, and overall US economic growth, will be obvious.
Q: You can’t stop the population from growing or people going to the hospital when they’re sick. So what’s the solution?
A: Population growth is a given. But hospital treatment for advanced illness is not. New models of care have been developed that shift the focus of care out of the hospital and into home and community. These new models are referred to as “advanced care.”
Q: What is advanced care?
A: Advanced care is a new approach that is more compassionate and effective than traditional treatment, and it also makes care for advanced illness more affordable. It is a system of care management that uses interdisciplinary teams in hospitals, medical groups, home and community along with telephone management to coordinate care across the health system for people with advanced illness. It’s a set of principles, not a model set in stone. It’s an approach that can be customized for the unique attributes of any healthcare setting.
Q: What does advanced care do for patients?
A: The advanced care team makes sure that the transition from hospital to home is smooth, that medications are managed, that the personal physician is fully aware and engaged, that symptoms are controlled, and most importantly that advance care planning takes place over time, at the ill person’s own pace so their values, preferences and care choices are known by the care team and followed by all providers.
Q: Why do you say “ill person” instead of “patient?”
A: The key to success in managing advanced illness is to fully engage the person and their family. When you focus on the needs and goals of the person, and construct a plan of care that follows them, you’re no longer saying, “Here’s what the doctor wants you to do.” You’re saying “We understand what you want in your own life and we’ll help you get it.” After that, adherence goes up, advance care planning goes forward and outcomes improve.
Q: Can you describe the outcomes that improve with advanced care?
A: Not surprisingly, people love the support, guidance and navigation they receive, so patient and family satisfaction go up. Physicians appreciate that they are connected better with the patients who worry them the most, and hospitalists are happy that “frequent fliers” don’t return to the ER. So provider satisfaction scores are very high. Finally, when people with advanced illness come to understand that they can be kept stable and supported at home, they realize that they no longer have to be patients. Data show that a majority stop going back to the hospital. So readmission rates drop, which appeals to hospital leaders. Payer satisfaction is also high, because hospital admission rates are the primary driver of cost. This will become more and more important as the Accountable Care Organization (ACO) model becomes more prevalent, a trend that is accelerating nationwide.
Q: You’re talking about reducing costs for our sickest patients. Isn’t there something wrong about that?
A: With advanced care people have free choice about their care at all times. If they want to go back to the hospital, that’s fine. But two thirds of advanced care enrollees find they can manage just fine at home. When advanced care provides the support people need to stay safe and comfortable at home rather than going back to the hospital, it puts the caring back in health care.
Q: Does advanced care support new healthcare business models?
A: Yes. The Affordable Care Act has spurred innovation to provide care that has more value, in terms of both quality and cost, rather than services that just pump up volume. ACOs are starting to achieve real value-based care. Advanced care supports these efforts by promoting clinical integration of hospitals, physicians and home-based services to prepare these provider groups to accept and share financial risk and to share savings.
Q: How does advanced care contribute to the bottom line in these new ventures?
A: Under traditional fee-for-service reimbursement, hospitals pursue a “heads in beds” strategy to maximize admissions and therefore revenue. Traditionally, hospital administrators have been reluctant to implement interventions that reduce admissions. But margins are decreasing due to reduced Medicare reimbursement, higher cost of care, and readmission penalties that increase each year. Plus the Affordable Care Act (ACA) did more than reform health insurance. It jump-started real delivery reform. Now there are signs of structural change in the system. More leaders are realizing that the key to sustaining margins in the future will be savings as well as revenue, so they are entering ACO-like arrangements in order to align their financial incentives. To the degree that they assume risk, the lower cost achieved by reducing admissions through advanced care goes right to the bottom line.
Q: So in other words, ACIStrategies has developed a solution where everybody wins?
A: That’s a pretty sweeping statement. But we can help get things moving in the right direction. People get to make informed choices and their families get support. Health systems achieve clinical integration. Physicians get teams that leverage their scarce time and expertise to help them care for their sickest patients, which increases their productivity. Payers, including Medicare, see their costs go down and satisfaction with care go up. Some of the pressure is taken off the growth in entitlement spending. Overall, our parents get the care they want and deserve, and we have a more ethical and functional healthcare system to hand off to our children.