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A deep dive into Advanced Care Planning (ACP), hospice and expanded senior care in the home
Bambi Francisco Roizen interviews Kumar Dharmarajan, Chief Scientific Officer of Clover Health, a Medicare Advantage company. Dharmarajan is a geriatrician and cardiologist by training. He takes a deep dive into how Medicare Advantage works and Clover Health’s expansion to more services for seniors, such as palliative care, which is estimated to be a $6.1 billion market in 2027. Clover Health began trading in January 2021 through a SPAC (special purpose acquisition company). The company has 58,000 members.
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Here are some takeaways:
-- Medicare Advantage plans are an alternative to Medicare. They are similar to Medicare but are run by private insurers, like Clover Health. A third of seniors choose MA and every year more seniors enroll, largely because of the additional benefits, such as vision, dental, and incentives to stay healthy.
-- While MA networks are traditionally constrained to certain physicians, because they are HMOs, Clover tries to expand the options.
-- Seniors can enroll in MA in their location around October when open enrollment starts.
-- COVID accelerated services for Clover members, such as virtual video visits with the Clover Assistant, Clover’s platform to enable doctors to manage care virtually. This telehealth capability has primarily been used by Clover’s in-home care doctors. Clover helped its members get vaccinated, promoted mail-order medication and sometimes offered 90-day prescription lengths. Clover helped ensure continuity of care for its members by reimbursing physicians for both video and audio telemedicine visits.
-- Advanced care planning (ACP) is an opportunity for people to plan out their healthcare needs before they get sick. Some documents they’d execute include: A living will is a legal document that indicates preferences such as if a person’s heart stops, would they want breathing tubes; Healthcare proxy (essentially a power of attorney); POLST is a portable doctor’s order that outlines a person’s treatment preferences.
-- Only a third of US adults have done any ACP (that is to execute on any of the above documents, such as a living will).
-- Even among people with HIV/Aids, fewer than 1 in 5 people have done advanced care planning. Check out this study: Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care
-- Video-enabled communications make advanced care planning more palatable to seniors. Clover Health is helping to conduct a 5-yr study to show that video-enabled communications can help expand ACP. Because there are few doctors with specialized advanced care planning knowledge, videos scale that knowledge to a broader population. The video empowers providers, social workers, and community health workers to have conversations around end-of-life processes. Check out this study: Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer
-- Palliative care and hospice (go to 31:00). Palliative care is for patients with serious illnesses. Palliative care is assessing someone holistically - behavioral, emotional - to alleviate their illness and improve their quality of life. Hospice is a benefit for people who are expected to live six months or less. It doesn’t try to extend life, but improve the quality of life. It incorporates palliative care principles; and because it’s a Medicare benefit, it can include nurses in the home or access to a chaplain. It’s a set of services offered with limited life expectancy. Studies have shown that patients with advanced lung cancer who are assigned to palliative care /hospice live longer.
-- Palliative care has shown to reduce costs (go to 34:00). Studies have shown patients who do appropriate ACP are likely to have lower costs in the final six months. Hospice generally lowers costs and can sometimes lower costs up to 40% because people tend to elect out of ICU.
-- The goal of Clover’s study on ACP is to understand the effectiveness of using video-based advance care planning resources to optimize serious illness medical care for patients with chronic, life-limiting illnesses receiving home-based primary care. Clover has identified the 2,000 most ill patients out of 50,000 members in NJ. The 2,000 receive home-based primary care. Clover spends up to 90 minutes in their home per visit. In the study, some will receive video-based decision aids to see which patients will opt for ACP. Clover will track to see if they can get information, such as living wills, healthcare proxies, or move patients into hospice.
-- For the Medicare Advantage population in Clover’s home-based primary care program, Dharmarajan believes telehealth visits will comprise a quarter to a third of all doctor visits.
-- How is Clover different from other MA providers? (go to 45:30). Clover doesn’t see itself as an actuary. It views itself as a clinical services organization. The software is designed to help doctors make better clinical decisions. It’s not so much about just pricing risk but helping doctors make real changes in their care plans. Additionally, Clover doesn’t have legacy systems.
-- Clover plans to get into direct contracting as well. Read how hospices are moving into direct contracting.
-- Clover has an advantage over other insurance companies as we transition to at-risk, value-based care models. Since at-risk models require doctors to make different decisions, Clover’s tech platform is already designed to help doctors make those decisions for outcomes vs just helping doctors track services. Clover doesn’t have the baggage of changing its legacy systems.
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