Telehealth Advance Care Planning Cost Effectiveness

Marvin J. Gordon M.D.^*, Tao Le M.D, Ferdous Kabir

Department of Medical Affairs Health Net, Inc, Cypress, California, USA

*Corresponding Author: Marvin J. Gordon, Department of Medical Affairs Health Net, Inc, Cypress, California 90630, USA

Received: 28 March 2023; Accepted: 12 April 2023; Published: 27 April 2023

1. Introduction

Multiple studies of cost savings from advance care planning vary in their conclusions as well as in the design of the study. A review of seven studies [1] showed cost savings in six studies [2-7] and no savings in one [8]. However, the authors conclude that “The studies… in this review allow only preliminary conclusions regarding the cost implications of ACP because of poorly designed and heterogeneous interventions and incomplete cost assessments.” [1]. Other studies support cost savings from ACP [9-10] while other studies do not find significant cost savings [11-13]. Conclusions about cost savings vary: “cost savings due to changes in practice at the end of life are not likely to be substantial” [14], “Little evidence supports the hypothesis that advance care directives reduce resource use by hospitalized patients” [15], “Despite the intrinsic logic of advance care planning, the evidence suggests it does not have the desired effect.” [16]. Explanations as to why ACP cost savings studies vary in their conclusions. “ACP is complex and trial characteristics were heterogenous” [17], “only preliminary conclusions can be made owing to poorly defined and heterogeneous interventions”, and “there are no clear, widely accepted guidelines on how to implement ACP “ [18]. Similar disparities are seen in studies of the use of ACP in nursing homes. Studies may show cost reductions [6] or decreased utilization [19], while other studies may not [20-21]. Even studies using POLST orders have varying results with some showing savings [22], while other studies of the POLST do not show decreased utilization [23]. Even POLSTs with limitations on interventions may not show decreased utilization or in-patient cost [24-25].

The current study is a retrospective controlled study in California, focused on high-cost and high-risk adults, across multiple insurance products, employing a telehealth approach, using an advance directive and or POLST for documentation, in an out-patient setting, and measuring health care cost as the outcome.

2. Materials and Methods

Health Net LLC of California, a California health maintenance organization, identified 7,089 members as high-cost and high-risk members using Impact Pro© (I Pro©) risk stratification tool, Charlson Index, and claims data. These members were referred to a telehealth based advance care planning vendor with instructions to enroll members up to a maximum of 300 commercial, 300 Medicare, and 300 Medicaid members in the calendar year 2020. Patients were initially contacted through printed mail which referenced the partnership of the vendor with Health Net LLC of California. The program uses education, documentation, and goal setting to influence care. The vendor utilizes physicians, nurses, and social workers to contact members for potential enrollment in an advance care planning program that included an explanation of the process, the options for choices in interventions, and the documents available. The process included the members making choices for end of life (EOL) interventions, generating documents, signing the document, and distributing the documents as directed by the member. Caregivers, family, and significant others were welcome to join the telehealth sessions at the discretion of the member or Power of Attorney for Health Care. Periodic follow ups were done after signing. Copies of the ACP documents were available online and were distributed according to the member’s wishes. Members understood that all aspects of the program were voluntary and ACP documents could be revoked.

Health Net analyzed all medical costs including pharmacy and behavioral health for calendar years 2020 and 2021. Cost was further evaluated for in-patient acute care and emergency room visits.

3. Statistical Analysis

The enrolled population was compared with the control population (Table 1) for various cohorts including age group, race/ ethnicity, sex, line of business and diagnosis. The result of that analysis indicates that the enrolled and control population are comparable among those demographic and clinical characteristics with higher R-Value (>0.90), which is statistically significant (p > 0.05). A chi-square test of independence was performed to examine the relation age group and ACP enrollment. The relation between these variables was significant, Chi-SQR=32.3982, p = .00001. (Table 1) Cost data was analyzed using a two-tail analysis for a significant difference.

Table 1: Statistical analysis of the intervention group compared to the control group.  The results of this analysis indicates that the enrolled and control population are comparable among those demographic and clinical characteristics with higher R-Value (>0.90), which is statistically significant (p > 0.05).

4. Results

Of the 314 members enrolled, 39.2% disenrolled prior to completing their preferences. Of the 191 members (60.8%) who completed their preferences, 36 (11.4%) generated a living will only, 14 (4.5%) generated a POLST only, and 14 (4.5%) generated a living will and a POLST. Therefore, a total of 64 unique members (20.4%) generated an ACP document. Only 9 of the 14 members generating a POLST document actually signed the document (Table 2).

Table 2: Intervention group completion of documents.

The length of stay in the enrollee group was 19.9 months in the program while what would have been the length of stay in the control group was 21.6 months. The two-year decrease in total medical per member per month (PMPM) cost was $951.20 (30.3%) in the enrollee group compared to the control group. The in-patient cost decrease of $709.60 PMPM was the main driver of the total decrease. Decreases were seen in the admits per thousand members, the bed days per thousand members, and the length of stay over the two-year period. Emergency room visits per thousand members for two years increased by 10.2% in the enrolled group compared to the controls (Table 3).

Table 3: Mean PMPM cost and two-year utilization data comparing the intervention group to the control group.

The enrollee median PMPM cost decreased by 40.2% in year one and 61.3% in year two. The mean PMPM cost decrease was 31.0% in year one and 35.7% in year two (Table 4).

Table 4: Median and the mean PMPM Cost Data for 2020 and 2021 for a high-cost high-risk population enrolled in 2020.

5. Discussion

The current study does show significant cost savings from a telehealth advance care planning program for high-cost and/or high-risk patients. This study focuses on cost although other outcomes have been considered in other studies, such as utilization and quality of life [17]. Telephonic ACP sessions have been successfully used previously [10, 17]. Some studies have focused on end of life but trying to prospectively focus on end of life is difficult since end of life unpredictable [14]. Total cost may reflect the quantity of life-sustaining interventions being provided or simply different kinds of medical care being provided [14].

Most striking in this study is that the savings were significant despite only 60.8% of the enrollees completing their preferences for interventions and only 20.4% generating an advance care planning document. The savings were greater in calendar year one, the year in which they were enrolled, compared to calendar year two, the year after enrollment. This supports the suggestion that the conversation itself has a greater effect on cost savings than the generation of a document alone [26].

The success of advance care planning depends on multiple elements of the total process. Advance Directives (AD) are not always adhered to by doctors in clinical practice. Reasons may include inability to verify that a “proper” AD discussion had occurred, whether the patient fully understood the consequences of their decisions, AD was outdated, or the need for confirmation of the validity of the document [27]. Preferences may change over time. Over a 1 year follow up, preferences for CPR or mechanical ventilation changed in 38.3% of the patients. The most common causes of changing preferences included health status, mobility, anxiety, depression, and marital status [28]. Memory of what preferences were chosen may fade over time. Interviews with proxies showed that only 5% had a recall period greater than 2 years [29]. Documents may not be distributed to all parties involved or documents may not be honored even if presented to current providers. [30-31]. Preferences for life-sustaining treatment are different when patients are healthy as opposed to when they are ill (prior to, soon after, and several months after a hospitalization) [32]. Advance Directives (AD) completed within 3 months of death or greater than two years before death will reflect preferences for more aggressive care [29].

Stage of illness, mental status, and surrogate/family concordance may all play a role in the outcomes from advance care planning. Patient designated and next-of-kin surrogates incorrectly predicted patients’ end-of-life treatment preferences in 32% of the cases. Two studies have shown that patient designation of decision makers does not appear to improve surrogate accuracy. Three other studies were unclear on the impact of patient designation on surrogate accuracy, and two other studies had shown that prior discussions did improve surrogate accuracy. Further limitation is that studies are based on hypothetical scenarios [33]. Timing of completing advance directives also affects choices. Factors include overall health status, mild-moderate chronic diseases, and advanced life-threatening illness with a risk of imminent death [34].

The current study does support the proposition that ACP does result in total medical cost savings. However, this support is specific to a high-cost high risk population in a relatively younger population, predominately Medicaid patients, in an out-patient setting. Other factors such as physician behavior, timing of ACP relative to hospitalization, death, or exacerbation of chronic illness were not evaluated. The data does confirm that the savings are predominately from lower in-patient utilization. The current study does support the use of telehealth. The current study does suggest that the ACP discussion may play a larger role than the documents alone. Future studies do need to address all variables in the heterogeneity of ACP to compare outcomes with existing literature.

6. Conclusion

Despite only generating advance care planning (ACP) documents in 20.4% of those enrolled in a telehealth ACP program in 2020, a significant decrease in total medical cost of 33.3% was seen in 314 high cost and high-risk patients followed in 2020-2021 compared to a control group of 6,775 patients also identified as high-cost and high-risk and followed over the same period. This would suggest that telehealth advance care planning can be accomplished, and cost savings appear to be more likely driven by the ACP conversation more than by the completion of documents. A larger volume study would be required to confirm this.

Conflicts of Interest

None. All authors have no financial nor personal conflicts of interest.

Drs. Gordon and Le are Regional Medical Directors and Ferdous Kabir is a Director of Healthcare Analytics for Health Net, LLC a wholly owned subsidiary of Centene Corporation

This manuscript is not being submitted to any other journal for consideration for publication.

Funding

The palliative care program is funded by Health Net LLC, a wholly owned subsidiary of Centene Corporation. No additional funding was required for this retrospective study

IRB

IRB was not required for this study.

References

1. Klinger C, Jurgen in der Schmitten, Marckmann. Does facilitated Advance care Planning reduce the costs of care near the end of life? Systematic review and ethical considerations. Palliative Medicine 2015, 30: 423-433.
2. Chambers CV, Diamond JJ, Perkel RL, et al. Relationship of Advance Directives to Hospital Charges in a Medicare Population, Arch Intern Med 1994, 154: 541-547.
3. Edes TE, Lindbloom EJ, Deal JL, et al. Improving care at lower cost for end-stage heart and lung disease: integrating end of life planning with home care. Mo Med 2006, 103: 146-151.
4. Hamlet KS, Hobgood A, Hamar GB, etal. Impact of Predictive Model-Directed End-ofo-Life Counseling for Medicare Beneficiaries. Am J Manag Care 2010, 16: 379-384.
5. Zhang B, Wright AA, Huskamp HA, et al. Health care Costs in the last Week of Life. Arch Intern Med 2009, 169: 480-488.
6. Molloy DW, Guyatt GH, Russo R, et al. Systematic Implementation of an Advance Directive Program in Nursing Homes. JAM, 2000, 283: 1437-1444.
7. Engelhardt JB, McClive-Reed KP, Toseland RW, et al. Effects of a Program for Coordinated Care of Advanced Illness on Patients, Surrogates, and Healthcare Costs: A Randomized Trial. Am J Manag Care 2006, 12: 93-100.
8. Connors AF, Dawson NV, Desbiens NA. A Controlled trial to improve Care for Seriously Ill Hospitalized Patients. The Study to understand Prognoses and Preferences for outcomes and risks of treatment (SUPPORT) JAMA, 1995, 274: 1591-1598.
9. Patel MI, Sundaram V, Desai M, et al. Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer A Randomized Clinical Trial, JAMA Oncology 2018, 4(10): 1359-1366.
10. Colaberdino V, Marshall C, DuBose P, et.al., Economic Impact of an Advanced Illness Consultation Program within a Medicare Advantage Plan Population, J Palliat Med 2016, 19 (6): 622-625.
11. Schneiderman LJ, Kronick R, Kaplan RM, et al. Effects of offering advance directives on medical treatments and costs. Ann Intern Med 1992, 117: 599-606.
12. Korfage IJ, Carreras G, Amfeldt Christensen CM, et. al., Advance care planning in patients with advanced cancer: A 6-country, cluster-randomized clinical trial. PLoSMed 2020, 17 (11): e1003422.
13. Gabbard J, Pajewski NM, Callahan KE, et. al., Effectiveness of a Nurse-Led Multidisciplinary Intervention vs Usual Care on Advance Care Planning for Vulnerable Older Adults in an Accountable Care Organization, JAMA Int Med 2021, 181 (3): 361-369.
14. Emanuel EJ, Emanuel LL. The Economics of Dying The Illusion of cost Savings at the End of Life. NEJM 1994, 330: 540-544,
15. Taylor JS, Heyland DK, Taylor SJ, How advance directives affect hospital resource use, Canadian Family Physician 1999, 45: 2408-2413.
16. Morrison RS, Meier DE, Arnold RM, What’s Wrong With Advance Care Planning, JAMA 2021, 326: (16): 1575-1576.
17. McMahan RD, Tellez I, Sudore RL, Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review, J Am Geriatr Soc 2021, 69 (1): 234-244.
18. Jimenez G, Tan WS, Virk AK, et al. Overview of Systematic Reviews of Advance Care Planning: Summary of Evidence and Global Lessons. J Pain Symptom Manage 2018, 56:436-49.
19. Tolle SW, Tilden VP, Nelson CA, et. al., A Prospective Study of the Efficacy of the physician Form for Life-Sustaining Treatment, J Am Geriatr Soc 1998, 46 (9): 1097-1102.
20. Mitchell SL, Volandes AE, Gutman R, et.al., Advance Care Planning Video Intervention Among Long-Stay Nursing Home Residents, JAMA Int Med 2020, 180 (8): 1070-1078.
21. Overbeek A, Polinder S, Haagsma J, et. al., Advance Care Planning for frail older adults: Findings on costs in a cluster randomized controlled trial. Palliative Medicine 2019, 33: 291-300.
22. Lin AL, Newgard C, Caughey AB, et al. End-of-Life Orders, Resource Utilization, and Costs Among injured Older Adults Requiring Emergency Services. The Journals of Gerontology: Series A 2021, 76: 1686-1691.
23. Fromme EK, Zive D, Schmidt TA, et. al., Association Between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and In-Hospital Death in Oregon. J Am Geriatr Soc, 2014 62 (7): 1246-1251.
24. Vranas KC, Lin AL, Zive D, et. al., The Association of Physician Orders for Life-Sustaining Treatment With Intensity of treatment Among Patients Presenting to the Emergency Department, Annals of Emergency Medicine 2020, 75 (2); 171-180.
25. Halpern SD, Small DS, Troxel AB, et. al., Effect of Default Options in Advance Directives on Hospital-Free Days and Care Choices Among Seriously Ill Patients, JAMA Netw Open 2020, 3 (3): e201742.
26. Brinkman-Stoppelenburg A, Rietjens JAC, van der Heide A, The effects of advance care planning on end-of life care: a systemic review, Palliat Med 2014, 28 (8): 1000-1025.
27. Moore N, Detering KM, Low T, et.al., Doctors’ perspectives on adhering to advance care directives when making medical decisions for patients: an Australian interview study, BMJ Open, 2019, 9: e032638.
28. Janssen DJA, Spruit MA, Schols JMGA, et. Al., Predicting Change in Preferences for Life-Sustaining Treatment Among Patients With Advanced Chronic Organ Failure, Chest 2012, 141 (5): 1251-1259.
29. Enguidanos S, Ailshire J, Timing of Advance Directive Completion and Relationship to Care Preferences, J Pain Symp Manage 2017, 53 (1):49-56.
30. Tolle SW, Teno JM. Lessons from Oregon in Embracing Complexity in End-of-Life Care. N Engl J Med 2017, 376: 1078-1082,
31. Malhotra C, Sim D, Jaufeerally FR, et. al., Impact of a Formal Advance Care Planning Program on End-of-Life Care for Patients With Heart Failure: Results From a Randomized Controlled Trial, J Card Fai 2020, 26 (7); 594-598.
32. Ditto PH, Jacobson JA, Smucker WD, et.al., Context Changes Choices: A Prospective Study of the Effects of hospitalization on Life-Sustaining Treatment Preferences, Med Decis Making 2006, 26: 313-322.
33. Shalowitz DI, Garrett-Mayer E, Wendler D, The Accuracy of Surrogate Decision Makers A Systematic Review, Arch Intern Med 2006, 165 (5): 493-497.
34. Sedini C, Biotto M, Crespi Bel’ski LM, et.al., Advance care planning and advance care directives: an overview of the main critical issues, Aging Clinical and Experimental Research, 2022 34: 323-330.