A Value-Based Payment Model for Palliative Care: An Analysis of Savings and Return on Investment.

Five percent of the US population accounts for 50% of total health expenditures. This "5%" problem requires moderating Medicare cost trends. SPARK, a community-based palliative care program, focused on its costliest Medicare Advantage patients. This cohort's projected costs were 280% higher than average beneficiaries, based on Medicare's risk model. Despite significant losses during enrollees' first year, a positive 5.1% ROI was found over the program's 4 years when stop-loss insurance payments were included. SPARK demonstrates that a high-quality, community-based palliative care program can be financially self-sustaining using a value-based payment model with premium plus stop-loss income exceeding actual costs.

New arrows in the quiver for targeting care management: high-risk versus high-opportunity case identification.

"Care management" purposefully obscures the distinctions between disease and case management and stresses their common features: action in the present to prevent adverse future outcomes and costs. It includes identifying a high-need population by referrals, screening, or data analysis, assessing those likely to benefit from interventions, intervening, evaluating the intervention, and adjusting interventions when needed. High-risk individuals can be identified using at least 9 techniques, from referrals and questionnaires to retrospective claims analysis and predictive models. Other than referrals, software based on the risk-adjustment methodology that we have adapted can incorporate all these methodologies. Because the risk adjustment employs extensive case mix and severity adjustment, it provides care managers with 3 innovative ways to identify not only high-risk individuals but also high-opportunity cases.

Successful Strategies for Reducing Disparities in Quality of Care: Lessons From Dual-Eligible Special Needs Plans.

Identifying strategies to reduce health care disparities is a national priority. This study examines factors within higher performing Medicare Advantage dual-eligible special needs plans (SNPs) that contribute to improved diabetic control. These structural and process elements include nonprofit status, interdisciplinary care teams, medication management, home visiting clinicians, and motivational interviewing. We suggest further research into the value of requiring all Medicare plans serving duals comply with standards for the SNP Model of Care. Finally, we recommend that all plans with dual and nondual members report scores separately to demonstrate the quality provided to the dual population.

Whole-patient assessment, goal planning, and inflection points: their role in achieving quality end-of-life care.

This article provides a framework for performing whole-patient assessment and goal planning. These clinical tasks involve a multidisciplinary, multidimensional, patient-centered approach to care and a deep appreciation for the complex interplay between the physical, psychological, social, and spiritual aspects of the human experience of dying. This article stresses the iterative nature of whole-patient assessment and goal planning, both of which should be conducted at certain important junctures in a patient's progression to manage effectively the evolving challenges faced by terminally ill persons and their families. This article also provides suggestions on successfully managing the communication challenges in caring for patients near the end of life and their family.