Saturday, November 28, 2009

Palliative Medicine - Undercapitalized and Overcommitted

The practice of palliative care, by physicians and advanced practice nurses, has gradually moved into the mainstream of American health care. While there is little debate over the need to improve late-life care, especially within acute and long-term care institutions, there continues considerable discussion over how to best improve it. Unlike most other medical specialties, palliative care is not reliant upon the effective formation of physical capital (diagnostic and therapeutic equipment using advanced technology) for its practice –to the contrary, it is totally reliant upon the effective formation of intellectual capital. Its effective formation is integral to the success of palliative medicine practices.
You’re thinking that palliative care is the lengthened shadow of a practitioner’s knowledge of clinical best practices. And, you’d be on the right track, for the provision of palliative care is based upon one component of intellectual capital, the know-how, skills, and competencies of the practitioners. Whether a practice or program has sufficient number of practitioners to render this knowledge-based care, first-hand, throughout the community, is a critical decision whose studied deliberation can tip the scales in a program’s outcome.
Two other components make up a program’s intellectual capital: one, structural capital (or infrastructure) - those workflow processes (automated or manual), revenue cycle practices, databases, and routines that enable effective day-to-day operations. The other is customer capital - or goodwill to many - the program’s relationship with its referring, and non-referring medical community, payers, partners, and, of course, its patients. The effective formation of these three components leads to the desired result – development and sustainability of the practice, and its affiliated programs.
So, what’s my point about being undercapitalized, you’re likely wondering? Most programs, and by extension the practices that support them, are subsidized by hospitals, hospices, or grants and philanthropy. This support is often renewed annually, thus demanding of the program’s managers a yearly impact statement of the program’s results. Long-term sustainability depends upon revenue generation, a business process oft shortchanged, at best, or neglected, at worst. This structural capital is often borrowed from the parent organization, whose resources, no matter how well intentioned, rarely offer the sharp focus, attention, and insider know-how so necessary to effective revenue capture.
OK, there may be a shortage of intellectual capital, but overcommitted? Palliative care specialists, were they to be queried, would remark that they don’t have sufficient time to develop the program. Programs report either of two situations – that palliative care has been widely adopted as the standard for late-life care in the community, and that there aren’t sufficient qualified staff to respond to referrals, or that palliative care has not sufficiently diffused throughout the community and a stronger referral base needs to be built. In either instance, what's lacking is a critical mass. Hospices provide part ofthe answer. So do hospital-based palliative services. Only Accountable Palliative Care Organizations (APCOs), through their effective formation of intellectual capital, have the capability of providing the entire answer.

Thursday, November 26, 2009

Engage with Grace - Communicating End-of-Life Wishes

Some conversations are easier than others

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.
It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.
Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.
A bit of levity.
At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.
To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

(To learn more please go to This post was written by Alexandra Drane and the Engage With Grace team. )

Tuesday, November 24, 2009

Why Intellectual Capital Matters to Growth of Palliative Care Programs

Our experience and research within palliative care have shown that "program champions" have been successful not so much because of what they bring to the role, but what the organizational program sponsor brings to the program champion. Certainly, a multi-talented physician champion increases the chances of success, but we've found it is the tools (intellectual capital) that she/he has to work with that are the primary determinants of success. The physician starting a practice (which is essentially what the program champion will be doing) needs to have strong clinical skills and knowledge, to be sure, but will need also to create goodwill (to build solid referral patterns), establish business processes, workflow, and databases, and generate revenue to produce a sustainable program. Organizational sponsors typically don't possess this intellectual capital specific to palliative care, and so, champions often find themselves stretched to produce results with little "infrastructure". As a result, the program champion finds her/himself spending time toward "marshalling" resources, at the expense of "deploying" those resources to grow the program.

Friday, November 6, 2009

Palliative Medicine Physician Compensation

In delivering current information to help clients and candidates and make informed recruitment and career decisions, DAI Palliative Care Group compiles and updates compensation information for physicians with a full-time practice in hospice and palliative medicine (HPM). We know how important the latest trends in physician salaries and compensation are to the negotiation process. These statistically evaluated results pinpoint mean (average) and median HPM physician compensation by:

§ Region
§ Title
§ Size of organization
§ Gender

Earlier this year, DAI Palliative Care Group made available for purchase, for the first time, the 2008 report for HPM physician compensation. We are currently updating this compensation information, and will soon have available the 2009 Report. As you might expect, compensation rose nearly 10%. And as you might also expect, compensation for full-time HPM physicians continues to lag behind other primary care sub-specialties - that of family practitioners by 9% , and internists and hospitalists by nearly 15%.
While overall numbers do not yet suggest a groundswell movement, more employers/practices are shifting away from straight salary to a combination of income guarantee and productivity incentives.

Drop me an email at , mention that you saw a reference to the Report on this blog, and I'll arrange to have the 2009 Report sent to you electronically (in PDF format) at a professional courtesy rate. It could be worth thousands to you.

Thursday, November 5, 2009

Palliative Medicine Physician Practice Profile-interview with HPM Physician Amy Mohler,MD

Grand Junction, CO, was recently lauded in the news media and at a town-hall meeting with President Obama as "a health community that works" -- "-for controlling health care costs while maintaining high quality. Data from the Dartmouth Atlas and from the DAI Palliative Care Group show it to be an exemplary palliative care community as well, based on metrics such as lower rates of in-hospital deaths, fewer hospital readmissions, less reliance on ICU care and higher hospice enrollments. (For more information on DAI's palliative care community metrics, see

"We can't take all of the credit," quips Dr. Amy Mohler, a board-certified hospice and palliative physician and the Chief Medical Officer of Hospice and Palliative Care of Western Colorado (HPCWC). The local medical culture emphasizes the role of primary care physicians. Grand Junction's non-profit hospitals and health plan came together 16 years ago to establish HPCWC as hospice provider for the entire community. "Those entities have been in Grand Junction for decades, and our medical culture has grown from the ground up. But for the past 16 years, HPCWC has been an integral part of that system," Dr. Mohler says. "I see great collaborative relationships here, and our local physicians are very open to our palliative expertise and to getting calls from us whenever we see opportunities to improve our patients' symptoms and quality of life." The hospice's census has grown to 250 in a metropolitan area of less than 140,000 people. HPCWC also offers in-hospital and community-based palliative care consultations, community bereavement services, grief programs for children and teens, and a cadre of 1,200 volunteers. It also operates three satellite hospice teams an hour or more from Grand Junction. "Grand Junction is like the poster child for primary care, and this is fertile ground to be passionate about your work," says HPCWC CEO Christy Whitney. "Even before our hospice existed, there was a very active non-profit HMO, Rocky Mountain Health Plans, that closely monitored hospital days. But I believe we have helped considerably to lower hospital days at the end of life, which means lower end-of-life costs. Having excellent hospice physicians who are available for teaching other physicians has also helped us make inroads."

Scheduling, Compensation and Call

Dr. Mohler and two physician colleagues work full-time for HPCWC, dividing up medical responsibilities for 12 hospice interdisciplinary teams based in home settings, nursing homes and assisted living facilities. Four days a week, Dr. Mohler sees patients at the hospice's freestanding 13-bed inpatient unit, which opened last October. The other doctors put in four-day work weeks heavily tilted toward direct patient visits, which are scheduled and geographically bunched by an administrative assistant. They generally make four or five home care or six to eight facility-based visits per day, and the local geography does not impose long driving times. "We try to get all of our new hospice patients seen early in their admission, especially since we see 30 percent of them for seven days or less," Dr. Mohler says. Each physician spends about an hour a week on interdisciplinary team meetings, with each team coming together every other week for a tightly structured reporting format to get through 20 to 25 patients within 30 minutes. "We used to be quite fantastic about allowing the IDT to run for hours, which wasn't helpful to anybody," Dr. Mohler says. Regular contacts between IDT meetings include "mini-team" updates and frequent phone calls. This year HPCWC implemented a productivity model for compensating its staff physicians, based on their billable visits, with a base salary to cover essential administrative activities. "I think everyone is happier with it, in terms of their workload. If they want to make more money, they know they can work harder and make more visits. If they like their balance of quality of life versus workload, that's okay too. The expectations are clearer and there's a feeling of shared responsibility," Dr. Mohler says. Between them, the three doctors also divide up evening on-call coverage, "physician-of-the-day" responsibilities, including first response for palliative care consultations, and three-day weekend call, including daily patient visits at the inpatient care center. The three-day weekend shift is designed to give the doctor on call more time to acclimatize to the needs of those patients. That may seem like a lot of call responsibilities, especially with the spectacular scenery of Western Colorado so close at hand. But it really isn't as bad as it sounds, Dr. Mohler says. "We find the schedule is still reasonable, because of the emphasis on primary care physicians in this community, their investment in what happens to their patients, and our commitment to supporting that relationship. That translates, when we are on call, into serving more as specialists consulting on their patients, so that our responsibilities aren't such a huge deal," she explains. "Our staff knows that when something is going on with a patient, their first line of help is the primary care physician. They still may call me to spend a few minutes running through the scenario and what might be most helpful for the patient, before they call the physician. I tell the nurses they need to know what they want to ask for from the doctor in a given clinical situation before they place that call." Still, the hospice is finding that three physicians are not enough to cover everything that needs to be done, especially since a nurse practitioner who made most of the in-hospital palliative care consultation visits moved away earlier this year. "When you are the doc of the day, you're in the hot seat. You may get the consultation call that comes in at ten minutes before five. But we're not doing a huge volume of inpatient palliative care consultations right now. We also have a community-based nurse and social worker palliative care team that uses more of a case management model, with a current census of 58," she says.HPCWC hospice teams in the three satellite offices draw upon local community physicians in part-time or volunteer roles to staff their hospice teams. The three full-time hospice doctors in Grand Junction are HPM-certified, but the four part-time satellite physicians, who have full-time clinic practices in internal medicine or family practice, are not. The satellite team physicians don't make many home visits. "If there are complex patients who need to be seen, we try to make special arrangements for seeing them out of this office," Dr. Mohler says. The agency also has a medical suite available at its inpatient unit to see patients who may be in central Grand Junction for other medical services. Dr. Mohler would like to have more time for visiting the satellite sites and working hands-on with their physicians and teams, rather than doing that by phone and email. Current plans are to recruit a fourth full-time physician for HPCWC while perhaps involving other Grand Junction physicians in on-call coverage and encouraging the satellite office physicians to enhance their palliative care skills through occasional shifts at the inpatient unit.

A Representative of Hospice

Although Dr. Mohler's job is largely clinical, covering the inpatient unit Monday through Thursday, Friday is spent in the hospice office on administrative functions. These include supervising the other physicians, participating in quality improvement activities and on the hospice's senior leadership team, teaching in a local family practice residency program, staff teaching, educating the local physician community and the public about hospice care, and "quite a lot of social networking as a representative of hospice."
"We have made a big investment in physician services. At our best we cover only 50 percent of medical costs from billing revenues," Whitney says. "But we decided to make that commitment, and having Amy, with her geriatric background, has been fabulous for our patients. My feeling is that hospice and palliative medicine is a specialty. Having our physicians available by phone supports our nurses, who sometimes have a hard time reaching the attending physician when they're out in the field. It brought a higher standard of care to our patients, and it gives us the opportunity to truly practice evidence-based medicine."
Dr. Mohler has been with HPCWC for seven years and its Chief Medical Officer, a position created to oversee the medical care provided by the other hospice physicians, for the past 18 months. An Arizona native, she trained as an internist and did a geriatrics fellowship at Good Samaritan Hospital in Phoenix. "I always knew that I would do geriatrics and, specifically, long-term care. But I became interested in end-of-life care during my residency," she says. "I spent so much time in the hospital and ICU and attended so many deaths there that I just felt there had to be a better way."

Thursday, October 29, 2009

Future of Palliative Medicine Practices

Will reform help or hinder the practice of Hospice and Palliative Medicine(HPM)?

Help, if HPM physicians reconfigure themselves into "sought-after practices". The reconfiguration must be willful and carefully planned, and in advance of implementation of national health reform. In other words, bets must be placed now that the health care delivery system will be restructured, and payment for health services will be revamped.

In upcoming blog posts, we'll take a close look at likely scenarios, and how the organizational alignment we've identified as Advanced Palliative Care Organizations will evolve into Accountable Palliative Care Organizations (APCOs). And, we'll examine the likely role of HPM physicians in APCOs, or what we refer to as the emerging role of the Chief Palliative Care Officer. This blog will be one forum for this discussion, so your comments and experiences are invited.

Also, we plan a regular publication (HPM Practitioner) that will offer you insights into "bellwether" practices. An upcoming issue will feature the HPM practice in Grand Junction, Colorado, about which I have posted previously.

From our study and research into best practices of palliative care, we've developed theories of what differentiates exemplar palliative care communities from others. How HPM physicians are utilized is one distinguishing feature. How they are organized is another. And under health reform, how they are paid will likely be another. Think bundling, and the value of a "network of HPM physicians" tightly organized to increase negotiating (with both payors and providers) clout.

As always, your comments are invited.

Building a Hospice and Palliative Medicine (HPM) Medical Staff

A former colleague with many years of hospital executive experience recently accepted a position as the chief executive of a mid-sized, not-for-profit hospice (115 ADC). Upon review of employee staffing, she noticed that the hospice had half-dozen "arrangements" with physicians (with varying commitments but all under 15 hours per week) to provide largely unspecified clinical and administrative services. She asked if medical staff planning customary in hospitals had applicability and relevance for hospices. Of course, I replied, the "planning process" has great relevance, although there are several differences in scope and scale.

To prepare a Hospice Medical Staff Development Plan, we follow a systematic five-step process:
Step1 – analyze HPM professional fee billings and Activity/Effort reports and job descriptions for physician roles,
Step2 – conduct interviews with key stakeholders (including all physicians practicing HPM in any capacity and commitment),
Step3- compile Hospital and Community Palliative Performance Profiles using Dartmouth Medical Atlas,
Step4 – review Hospice strategic plan and contracts/agreements between the Hospice and physicians,
Step5 – using Responsibility Charting process, define professional expectations, metrics, and accountability.

Through this five-step process, we gain insights that address the most common questions posed by hospice executives (administrators and physicians) about medical staff development: To what extent may nonphysician providers be used to meet additional clinical demands?When will additional physician staff be needed, and what are the anticipated time requirements to recruit these individuals?When should recruitment occur given practice ramp-up time and total recruitment budgets?Are there sufficient resources and the political will to build a hospice-sponsored HPM physician group?In what communities and health provider sites do we place physicians to meet our organization’s strategic objectives?

Are there other questions regarding building of a medical staff on your minds? I invite your comments on what challenges each of you face in building a hospice medical staff?

Wednesday, October 7, 2009

Grand Junction - an Exemplar Palliative Care Community

President Obama held a town hall recently in Grand Junction, Colorado. To healthcare reformers, Grand Junction, CO., is one of the areas of innovation -- a place that provides high-quality healthcare at a fraction of the costs in most other communities. And, according to some experts, Grand Junction chalks up some impressive statistics. Only 12% of Medicare patients required readmission 30 days after a hospital visit, as opposed to the nationwide rate of 20%. Children on Medicaid in the HMO are four times as likely as other Colorado Medicaid children to receive all immunization treatment -- and adults on Medicaid were up to 10 times as likely to get comprehensive diabetes care. How does Grand Junction stack up for its palliative care practices? The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of lowest percentages of deaths occurring in a hospital (20.7%). And hospice enrollment nearly 30% greater than the national average. Is it mere coincidence? We think not, as a profile of one of the senior palliative care physicians in Grand Junction will show in future posts.

Palliative Medicine Physician Practice Profile-interview with HPM Physician John Mulder, MD

Balancing Clinical and Administrative Roles: Interview with HPM Physician John Mulder, MD
(read here for one of Dr. Mulder's thoughtful essays on palliative care)

"I find that my passion to make sure no one suffers needlessly outweighs my desire to go home from work at 5 pm," John Mulder, MD, says to explain how his commitment to hospice and palliative medicine (HPM) shapes his balancing act of clinical and administrative responsibilities for Faith Hospice and the Spectrum Health hospital system, both based in Grand Rapids, MI. Dr. Mulder formed a professional corporation in order to contract with his two primary clients, Spectrum and the hospice's parent company, Holland Home. For Spectrum he provides palliative care consultations in two acute care hospitals (with two to three new consults ordered per day) and fills a variety of administrative roles aimed at promoting and advancing palliative care within the system. These include strategic planning, one-on-one meetings with physicians, and attendance at tumor board and cancer interdisciplinary meetings. For the hospice, he serves as vice president of medical services and sits on its leadership team. Recently, he relinquished to a colleague, Dr. Martha Ording, the responsibility of hospice medical director as spelled out in Medicare's conditions of participation.
His current role emphasizes quality initiatives such as protocol development, a new HPM fellowship program, and medical management of the hospice's freestanding, 20-bed inpatient facility. "That's the daily clinical environment for my hospice physician practice." Dr. Mulder also carries a beeper 24 hours a day ("I've always done that; I feel very possessive of my patients"), although with the option of arranging for back-up as needed. Time management remains an ongoing challenge, and it can be difficult to precisely parse out which is hospice versus palliative care or administrative versus clinical (and billable) time. "But I don't stand on protocol. I feel comfortable with how my time is spent, as do the folks to whom I'm accountable," he says. "At the end of the day, I want to make sure that they have gotten their money's worth. And there is the intangible value of my availability as a hospice and palliative physician - that existential presence, that leadership role brings value in and of itself. It's all about establishing relationships and building trust in my role and in what HPM offers."
Dr. Mulder recently took a phone call from a colleague who is well known as a pioneer in the field of HPM, and is considering a job change from an academic to a hospice setting. "She asked about the business aspects-employed versus contracted, how to negotiate salary and benefits, things like that. These are basic issues for those who are immersed in the business, but they can be confusing if you've never had to deal with them." In Dr. Mulder's previous job as chief medical officer of Alive Hospice in Nashville, TN, the position was structured in a way that allowed him to learn on the job the business and practice management aspects, gaining a clearer sense of what the medical director contributes to hospice and palliative care. "(CEO) Jan Jones understood and fostered the medical component of hospice, and emphasized my education as medical director and medical leader," he relates. One of the keys was attending national hospice educational meetings. "It's not only having a seat at the table for the physician's role, but sharing what I know. Which affects how care is given, and the policies that are developed - just being able to exercise what you know as a doctor to be a partner on the team."
How to Find Satisfaction-and Make a Living - Dr. Mulder was instrumental in convening an informal group of about two dozen HPM physicians practicing in Western Michigan. They now meet every other month to talk about both practice and clinical issues, and they are in discussion with a local managed care company about establishing a contracted physician network that could provide expanded hospice services and covered palliative care benefits, including in the outpatient setting. Several of these physicians work full-time in hospice or palliative care, others are part-time, and a few are board certified in HPM but not currently working in the field. "Two or three others have a deep interest in palliative medicine and want to do it some day," he explains. At the group's first meeting in January, "I could see doctors huddled in groups of three or four. They couldn't stop talking. There was such a hunger for this exchange," Dr. Mulder reports. "We want to communicate through this dialogue how you can make a living, how you can find satisfaction, meaning and personal growth in HPM - but also that the work requires a personal commitment to scientific, cutting-edge medicine and a willingness to be truly present with patients and families." He agrees that it is curious that so many physicians who are motivated to become board-certified in HPM have not gone the next step to full-time positions practicing this specialty. "A lot of part-time hospice docs, because of their hospice compensation and the hospice's lack of commitment to the medical role, don't believe that this can be a career option. It's hard to extrapolate from their experience to how it could turn into a full-time job. And if they don't believe it can be, they will remain shy in their contract negotiations with the hospice - even though a portion of every per diem the hospice collects is meant to cover the medical director's role." Unfortunately, hospice physicians are too often underused, overused, misused or abused. "Their responsibilities are defined by people who may have very little understanding what physicians do - or could do. The physician's role and responsibilities in hospice care need to be viewed in different ways. Not that the doctor is more special than other members of the hospice team, but what he or she brings to the table is different," Dr. Mulder says. "If a hospice wants someone simply to come to meetings and sign documents, that's how it will structure the position. But if you truly want what a physician can contribute to increasing the skill levels of all staff and the quality of the care that is provided, that's a whole different ball game. It requires a different level of commitment by the agency."
Just as palliative care consultations in the hospital more than pay for themselves through decreased length of stay and reduced use of expensive, unbeneficial treatments, the active presence of a substantially full-time physician raises the hospice's exposure in the medical community and can lead to increased referrals and lengths of stay and better decisions about drug therapies and other palliative treatments for hospice patients. "We're fortunate to have a very strong, high-quality hospice program here in Grand Rapids, respected by physicians and the community at large," Dr. Mulder says. In fact, data from the DAI Palliative Care Group, derived from the Dartmouth Atlas of Health, gives the Grand Rapids region an A grade for its end-of-life care. The region has fewer deaths occurring in hospitals or associated with ICU admissions than state or national averages and a higher percentage of decedents (46 percent) enrolled in hospice than national (31 percent) or state (38 percent) averages. Dr. Mulder was trained in family medicine and practiced obstetrics. He was first asked to serve on the Board of Directors of a local hospice in 1985, and became intrigued by its work. "When they asked me to be the medical director, I began learning what a difference hospice made at the bedside."Today, he finds HPM a great field to work in. "I am well compensated, and have never been more satisfied. Who knew?"

Palliative Care Grand Rounds - October edition

Visit here for the October edition of Palliative Care Grand Rounds - a monthly blog carnival highlighting some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. This month's host of Palliative Care Grand Rounds, GeriPal gives its own "spin", incorporating posts that feature the intersection between geriatrics and palliative care. GeriPal (Geriatrics and Palliative care) is a forum for discourse, recent news and research, and freethinking commentary and invites the perspectives of generalists, specialists, gerontologists, palliative care clinicians, and anyone else interested in care of the elderly or palliative care.

Sunday, September 27, 2009

Accountable Palliative Care Organizations - Mayo style?

As hard as health insurance reform is, compared to health care DELIVERY reform, that’s the easy part, Mayo Clinic CEO Denis Cortese said at a recent presentation to the National Press Club. Mayo has been frequently cited as a model for health care delivery reform by President Obama and others, but the question of Mayo’s value as a model for overall reform has also generated considerable discussion from both sides.

Cortese cited the significant regional variation in medical practice documented by researchers at Dartmouth (and discussed periodically in this blog, see here and here ) , and he listed several factors common to institutions and regions that produce what he called "high-value care": patient-centric cultures; high levels of physician engagement in leadership and change; much higher levels of teamwork, collaboration, and coordinated care; more "connectivity" and sharing of electronic medical records and information; and much greater use of "the science of health care delivery," meaning systematically looking at how patients flow through an organization in order to reduce waste and standardize processes to reduce errors.

These factors, it occurred to me, are similar to the attributes possessed by Accountable Palliative Care Organizations (see here, here, and here). Producing "high-value care" , whether for an acute episode, in an ambulatory setting, or for late-life care, is a formidable challenge. And it is why, if palliative medicine physicians can incorporate into their practices those skills requisite to success in these emerging delivery models, their practices will be highly sought after.

Thursday, September 3, 2009

Thursday, August 20, 2009

Redeploying Physician Services at End-of-Life

A recent post (read here) suggesting that the "redeployment" of physician services for end-of-life care is one way to address the health care cost issue at once threatens the income potential of many physicians.

In a statement before the April 2009 US Senate Finance Committee Roundtable on Delivery System Reform, Allan Korn, M.D. ,Senior Vice President and Chief Medical Officer of Blue Cross and Blue Shield Association, called for the creation of "clinical pathways to help physicians provide compassionate and cost-effective end-of-life care." Among patients who died of cancer, Dr. Korn noted, a major contributor to cost and quality-of-life issues is the widespread use of chemotherapy in the last three months of life. Studies show that 15 to 20 percent of patients with incurable, end-stage cancer receive chemotherapy within 14 days of their death, a time when chemotherapy has no benefit. He went on to recommend funding a pilot starting in 2009 to identify the extent of overuse errors in treatment of cancer patients, for example by measuring non-palliative chemotherapy use in the last two weeks of life, and to establish best use of palliative care.

The American Hospital Association identified longer-term cost-containment strategies that will be pursued, as evidence, tools and nationally-endorsed measures emerge. One such strategy advanced by the AHA is to "Promote Efficient Resource Utilization" – more specifically, to promote palliative and hospice care through the use of advanced directives and best practices.

Indeed, palliative care should be better distributed throughout our communities. But palliative care is not an add-on. Rather, its value lies in its offering an alternative, or a substitute for another type of physician care/service already being provided to patients with advanced ilnesses. Lots of revenue/income is at stake. Is it any wonder why critics of health reform are associating palliative care with rationing?

Thursday, August 6, 2009

August Edition of Palliative Care Grand Rounds

Palliative care has been much talked about in the context of health care reform. The August edition of Palliative Care Grand Rounds (here) , hosted by Risa Denenberg, offers readers an excellent round-up of the commentaries from the blogosphere.

Monday, June 29, 2009

Palliative Care Grand Rounds Vol 1, Issue 6

Welcome to the sixth edition of Palliative Care Grand Rounds, a monthly (appearing the first Wednesday of each month) summary of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.


Health reform has been at or near the top of the news this past month, so it's hardly surprising that health reform and palliative care has found its way into the blogosphere. Usually within the context of rationing and futile care.

The blog Practical Bioethics addresses this issue in a well-reasoned way on a regular basis. In one of last month's posts, Dr. John Landos comments on one particularly useful way to think of the debates about rationing. Nearly 30 years ago, early in my career as a health care executive, one of the must-read publications for us was an insightful piece on rationing by the noted health economist Uwe Reinhardt. The title is as clever as it is fitting: Table Manners at the Health Care Feast.

What should a doctor recommend for a 90 year old man with pancreatic cancer and liver metastases? Palliative care? An Ohio surgeon thought so. Read the experience of Buckeye Surgeon in his blog . KevinMD picks up on this notion of futile care in his post.

Maggie Mahar offers an edifying piece around who should be responsible for defining futile care. In this post, she presents the case that " we also need to “pay more” for certain vital services such as primary care, chronic disease management, and palliative care. "

Are financial incentives for providers properly aligned with good palliative care? A New England Journal of Medicine article offers up a report on this matter, and Drew Rosielle, MD captures its highlights in his post. In a similar vein, Pallimed picks up on the hospice cap issue, as well as a recent press release from the National Alliance for Hospice Access. Access to the hospice benefit is a vital issue for patients, clinicians, executives, and policymakers, and has stirred up conflicting position statements and controversial points of view. To this blogger, the key question has been submerged. How should health care providers best organize to better assure open access for those with advanced illness, is what we ought to figure out.

Rationing versus futile care. Reading the blogosphere, and particularly comments to postings, leaves one with the impression that advanced illness management is either one or the other.

Prompted by President Obama's interview reply on the subject of the American approach to the end of life, David Tribble, MD, blogs about the "absurdity" of spending scarce resources on therapies known to be ineffective, but which Dr. Tribble adds, "we employ simply because we cannot stand not to."


Alex Smith, MD, posts in the blog Geripal of the challenges of incorporating geriatric and palliative care into the Emergency Department. Dr. Smith asks "How can we integrate the vast experience and strengths of palliative and geriatric medicine in a setting such as the emergency department to meet the needs of older adults with serious illness, and contain costs?" No easy answers, to be sure, but a question every ED director and hospital executive should be asking. We know the HPM MDs and geriatricians have been asking questions like this for the past 15 years.

In his Medical Futility blog, Thaddeus Mason Pope comments on the disappointing, but unsurprising, survey results that Advance Directives are followed SOME of the time. Should we be doing more to make POLST documents a national standard?


For patients and families seeking answers about palliative care, there are a handful of worthy blogs. In one, Dr. Pedro Calves relates an encounter with a patient who found the "pal" in palliative care. In another, written from the perspective of a patient under the care of hospice, the blogger/hospice patient comments on her health plan's reversal of an earlier denial and her change of hospice providers. When the author first started this blog, it was mainly to keep the people in her life up to date on how she was doing; now, it seems that she has picked up readers outside her immediate circle of family and friends. Angela Morrow brought this blog to my attention in last month's Palliative Care Grand Rounds.

Dr. Drew Roselle posts that most patients with advanced illnesses prefer to have hospice discussions, yet a recently published study found that only half of patients in this study had such discussions, and in a separate yet related post that understanding of CPR outcomes and code status is poor among hospitalized patients.


Mort Kondracke is the Executive Editor of Roll Call, the newspaper of Capitol Hill. While technically not a blog (it's actually a column), Mr. Kondracke pays tribute to his mother's example of living - and also a "public policy" tribute to the manner of her death, in HOSPICE care. As health reform moves through Congress, a voice like that of Mr. Kondracke can be very powerful.

Veteran journalist Larry Beresford, who has written extensively about palliative care, discusses the emotional barriers to hospice access for people with terminal illnesses in a thought-provoking piece . Referring to several recent research studies, Mr. Beresford notes that
"this kind of research can help us understand some of the nuances of such encounters at the end of life, but I wonder if they take us closer to solving hospice's Flying Dutchman status in our society."


Jessica Knapp writes in her blog The Good Death that she gives a two thumbs-up to the film, Departures, which, without much fanfare, won this year's Academy Award for Best Foreign Film. Then again, how many foreign films (award-winning and not) are greeted with great fanfare?
Glad that Ms. Knapp brought it to our readers' attention.

For a peek into the week of a hospice nurse, see Dethmama Chronicles. And Pallimed directs us to a week in the life of a palliative consult service, via Twitter.

Christian Sinclair, MD, co-editor of Pallimed and one of the prime movers behind Palliative Care Grand Rounds, announced a social media marketing venture and a sabattical from Pallimed. But not before he posted a useful summary of legislative and regulatory issues concerning palliative care.

On the arts/technology side, Amy Clarkson, MD reports on the complimentary blog of Pallimed about The Digital Afterlife, the legacy lockers and digital memorials brought to us by digital technology.


Thanks to all who sent me suggestions for this month's Grand Rounds! And if you're interested, here's where you can find issues 1 , 2, 3, 4, and 5.

PCGR now has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Next PCGR will be out August 5 and will be hosted by Risa Denenberg forward suggestions or links to .

Friday, June 26, 2009

Palliative Care Blog Wrap-Up

I'll be hosting next month's Palliative Care Grand Rounds. Sign up here for a feed... and you'll have next month's, and the ones following, delivered to your desktop.

Monday, June 22, 2009

Advanced Palliative Care Communities (APCCs) - What Distinguishes Them?

What is it about Advanced Palliative Care Communities (APCCs) read here that distinguishes them from other communities (or regions) when it comes to providing care to those with end-stage disease? One is the presence of an organized provider network collaborating on the delivery of palliative care in many settings of care throughout the community. Another is the documentation of, and adherence to, patient preferences. Think POLST or similar tools. Surely, these attributes do not come about on their own. We’ve looked more closely at the deployment of palliative medicine specialists in these communities (APCCs) and have found greater numbers (than in other similar communities) of physicians practicing palliative medicine and greater use of those physicians in clinical consultative roles in multiple settings throughout the community. What does not matter, we've found, is the organizational sponsor (or employer) of these palliative medicine physicians.

Wednesday, June 3, 2009

Palliative Care Grand Rounds 1.5

The latest edition of Palliative Care Grand Rounds is up today on Angela Morrow's blog. Excellent summary of last month's most interesting posts about palliative care and related topics. For issues 1-4, visit the Grand Rounds Blog.

I will be hosting July's Grand Rounds (July 1) - send your suggestions to

Tuesday, June 2, 2009

Physician Services at the End-of-Life - Are We Now Ready for REDEPLOYMENT?

Los Angeles, California; Manhattan, New York; and New Brunswick, New Jersey, had very high physician labor inputs for both Academic Medical Centers' (AMCs) end-of-life cohorts and the region’s Medicare population. Minneapolis and Rochester, Minnesota (home of the Mayo Clinic), had low regional and AMC physician labor effort. This correlation suggests that the variation observed across regions cannot be explained by differences in health status, adequacy of care, or patients’ preferences but is linked to idiosyncratic patterns of labor input found in both AMCs and their associated regions. So concludes a 2006 study "End-Of-Life Care At Academic Medical Centers: Implications For Future Workforce Requirements", David C. Goodman, Thérèse A. Stukel, Chiang-hua Chang and John E. Wennberg.
[Health Affairs 25, no. 2(2006): 521–531; 10.1377/hlthaff.25.2.521]

The authors also observe that in several of the low-input regions, much of the care is provided by large, multispecialty group practices (for example, the Mayo Clinic) or integrated delivery systems (for example, Intermountain Health Care). What is it about such practices and delivery systems that lower the barriers to palliative care, in fact, may encourage more appropriate use of palliative care for those with advanced AND chronic illness? Just a hunch, but I'd surmise that a key element is a shared or common compensation system among palliative medicine physicians, primary care physicians, and specialists. What might support the design of new compensation systems to promote the sort of physician collaboration essential to this redeployment? The likely prospect of payment bundling , a payment reform which has been advocated as a means of reducing readmissions.
Surely there must be other factors besides compensation incentives at play. I'm curious to learn what other possibilities come to your mind?

End-of-Life Care and Physicians: Shortage or Surplus?

If fewer physicians are needed to care for the growing numbers of seniors, as this article concludes, then how will physician services be redeployed? In favor of palliative medicine physicians, to be sure. Yet, other specialists can not so readily be expected to relinquish their current roles in end-of-life care. Or, is there plenty of room for many "specialists", each applying their own competencies in close coordination with their medical and nursing colleagues. I'm curious to learn your views on the surplus/shortage issue (especially as it relates to end-of-life care) and suggestions on how to best hasten the redeployment of physician services so that it is factored into health reform.

Choosing Where to Live Based Upon End-of-Life Preferences

A health executive new to hospice asked the other day, in advance of assuming an executive role of a palliative care organization in a resort community, what role should physicians play in the end-of-life care in the community? I replied a small one (relative to the role that specialists were presently serving). But a larger one for palliative medicine physicians. He asked why that wasn't the case at present. Because patients don't choose their regions they live in based on the amount of care they wish to receive in their last six months of life, I replied.
I wonder, will there be a day when those choices are made?

Thursday, May 14, 2009

Performance Management and Palliative Medicine

I hear from palliative medicine physicians whose experiences suggest that their successes often go unrecognized, or at best taken for granted, while their failures are highlighted, particularly during times of program evaluation or subsidy renewal. What prompts these misguided views and feelings? Is it numbers-driven executives who see these palliative medicine practices producing revenue that in best cases meets no more than half of the practitioners' salaries? Or is it underperforming physicians whose practices fail to meet productivity standards? Or is it quite simply a misunderstanding of the value of palliative medicine programs in general, and of palliative medicine physicians specifically?
Our study suggests that another factor is at play here. Call it a misalignment of expectations, a misalignment that manifests itself in role confusion. What is role confusion, and why should palliative medicine be more vulnerable than others to this rather abstract influence? The short answer is that most palliative medicine programs were launched on the proverbial shoestring, and when met with growing demand for their services, turned their attention to their most recent referring sources. These new referring sources, of course, were not the ones behind the launch of the program. Additional MD or NP resources to serve this growing demand are months way from being hired, if at all. And so we find role drift, which inevitably leads to role confusion. This is the time, we find, for the introduction of performance management programs.

Showcasing Advanced Palliative Care Communities

To detractors of health reform, universal health care is code for rationing, or "less care". And for those detractors, palliative care is associated with less care. Reform opponents use the argument of rationing because they know that there is little political will to provide "less care".
Yet this argument falls short on two counts. Less care ,or rationing, takes place in the current system, for those who are uninsured, or underinsured. And less care does not have to mean substandard care, as data from the Dartmouth Medical Atlas has shown. Interestingly, those opposing health reform are the same who oppose comparative effectiveness studies, and their deployment to guide clinical practice.
The promises to contain costs advanced recently by the coalition of hospitals, physicians, and pharmaceutical manaufacturers, among others, are surely commendable. But one has to wonder what can these providers and organizations do that hasn't already been tried? Their promises were surely short on details.
When it's time to fill in the specifics, it will be time to take a close look at Advanced Palliative Care Communities (APCCs) see here and here , and how palliative medicine physicians in those communities practice their specialty to produce better outcomes at lower costs.

Monday, May 11, 2009

Responsibility Charts for Palliative Medicine Practices

Palliative medicine programs, and by extension the practices associated with them, are characterized by conflicting demands for their resources. Role confusion often is the result.

The symptoms of role confusion we often find within palliative medicine services are:
-Concern over who makes decisions
-Out of balance workloads
-Lack of action because of ineffective communications
-Questions over who does what (clinical and administrative)
-Multiple “stops” needed to find an answer to a question or gain approval.

Responsibility charting is a management tool we've used effectively to reduce or avert role confusion. This tool can be used either in program development or in established programs. We've found it to be especially useful where an Advanced Palliative Care Organization (APCO) is being assembled through the collaboration of several health organizations and many stakeholders.

Monday, May 4, 2009

Reducing Hospital Readmissions: A Role for Palliative Medicine Physicians

Rehospitalizations among Medicare beneficiaries are prevalent and costly. So concluded a recent study published in the April 2, 2009 issue of NEJM - excellent synopsis here from the Commonwealth Fund. The study found that 20% of Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. Is there a role for palliative medicine physicians? Th experience of Advanced Palliative Care Communities(APCCs), with lower than average rates of hospital readmission and percentage of deaths in a hospital, suggests indeed there is. As does the modest study (abstract cited) below:

Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care
Richard Brumley, MD * , Susan Enguidanos, PhD, MPH † , Paula Jamison, BA † , Rae Seitz, MD ‡ , Nora Morgenstern, MD § , Sherry Saito, MD ‡ , Jan McIlwane, MSW § , Kristine Hillary, RNP * , and Jorge Gonzalez, BA †
* Kaiser Permanente Southern California Medical Group, Downey, California; † Partners in Care Foundation, San Fernando, California; ‡ Kaiser Permanente Hawaii Medical Group, Honolulu, Hawaii; § Kaiser Permanente Colorado Medical Group, Aurora, Colorado.

OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.
DESIGN: A randomized, controlled trial.
SETTING: Two health maintenance organizations in two states.
PARTICIPANTS: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months.
INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services.
MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care.
RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P<.05) and were more likely to die at home than those receiving usual care (P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P<.001), resulting in significantly lower costs of care for intervention patients (P=.03).

In APCCs, we've found that Palliative Medicine physicians assume a major role in the care (in any setting) of older patients with a hospitalization. What makes these APCCs different? They structure care for those advanced illnesses around the principles of palliative care, rather than hospice eligibility.

Tuesday, April 14, 2009

Palliative Care Grand Rounds

The third edition, like the first two, of Palliative Care Grand Rounds merits a look. This month's host is Jessica Knapp at her blog, The Good Death.

Monday, March 23, 2009

APCOs and Palliative Care Performance

In a recent article Slowing the Growth of Health Care Costs — Lessons from Regional Variation authors Elliott S. Fisher, M.D., M.P.H., Julie P. Bynum, M.D., M.P.H., and Jonathan S. Skinner, Ph.D. describe research findings in which physicians in higher-spending regions were much more likely than those in lower-spending regions to recommend hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit this patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Put another way, differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending on health care.

Not surprised, you say. Perhaps one shouldn't be. After all, data from the Dartmouth Medical Atlas has long shown there are huge differences in health care spending from one region to another that are best explained by intensity of practice patterns rather than intensity of illness. This same article goes on to say that a consensus is emerging that integrated delivery systems that provide strong support to clinicians and team-based care management for patients offer great promise for improving quality and lowering costs.

Similarly, our studies of palliative care in high-performing communities (and health systems) have shown that Advanced Palliative Care Organizations (APCOs) possess attributes similar to those of integrated delivery systems, while being led by chief palliative care officers. Who are these chief palliative care officers? Mostly, physicians (sometimes nurses) with training, experience, and expertise in palliative medicine.

What difference can APCOs make? For starters, they can deliver care to patients with life-limiting illnesses that is consistent with the preferences of these patients and their families. Residents of Sarasota, Fla. (a high-performing palliative care community) are nearly 30% less likely than the average American to die in a hospital, and will spend during their last six months of life nearly 25% fewer days in a hospital than the national average.

So why aren't there more APCOs? The answer is complex and will be better addressed in future posts, but let's just say for the moment that one of the reasons is that there is more competition than collaboration among this country's hospices and hosptials. Yet another possible explanation is that there is an acute shortage of qualified HPM physicians who are interested and willing to practice palliative medicine on a full-time basis.

Monday, March 16, 2009

Do Hospices Need Medical Staff Planning?

Hospices are evolving into advanced palliative care organizations (APCOs)in which care spans organizational and professional boundaries and physician services are integrated into a collaborative model that reconfigures a traditional nurse-centric organization,. Such a convergence will, unsurprisingly, strain an organization’s resources and its roles. For organizational strategic considerations, meeting community needs, and regulatory compliance, medical staff planning improves the likelihood of hospice success.

However, shortages of experienced, fellowship-trained, and Board certified Hospice and Palliative medicine (HPM) physicians and the growing need for such physicians in specific practice areas (long-term care, hospital consultative, home visit) will lead to increased frustrations among hospice executives, clinical staff, and physicians and hinder the achievement of hospices’ strategic goals.

Given the “not if, but when” trends surrounding the role of HPM physicians in a community’s end-of-life care practices, hospices that initiate a medical staff planning process in the short term will provide themselves with the time required to muster and develop the necessary financial and other resources to align their medical staff plan with their strategic objectives. Such a medical staff resource planning service will also help identify potential opportunities to enhance market position through physician recruitment.

Wednesday, February 11, 2009

Palliative Care and the Stimulus Bill

Those interested in how palliative care makes out in health reform (and stimulus bill) discussions should keep an eye on a small (relatively, at $1.1 billion) item in the House version related to effectiveness comparison research.

The $1.1 billion in research funding would be doled out primarily to the National Institutes of Health. President Obama supported research into comparative effectiveness during his campaign. He could launch a new federal Comparative Effectiveness Institute along the lines of the British National Institute for Health and Clinical Excellence (NICE). Surely, palliative care would be viewed favorably in this context, would it not?

Meanwhile, the drug and medical-device industries are mobilizing to gut this provision in the stimulus bill, portraying it as the first step to government rationing. Interesting, because discussions around "best" end-of-life care inevitably get around to "rationing", as if palliative care were merely a stripped-down version of full-fledged medical care.

Reminds me of the "effectiveness research" done in the mid-90s, when the government's Agency for Health Research Quality suggested that there were too many unnecessary back surgeries. Of course, certain industry groups attacked the conclusion, and Congress at the time slashed the agency's budget and stripped its authority to make Medicare-payment recommendations.

Monday, January 26, 2009

Successful Palliative Medicine Practice Business Models -Are There Any?

I regret that my posts have been irregular of late. I don’t wish to be circumspect, so please know that my recent silence around health reform is not born of indifference, but a result of my participation in a group studying issues around health reform and whose participants have been asked not to reveal its deliberations until its work has been submitted. So while I haven’t been forthcoming about my thoughts around health reform and its impact on palliative medicine, I’m confident that what hypotheses I might offer hereon will be better informed. And while predicting the outcomes of highly charged and politicized issues such as those surrounding the nation’s health care system is surely not my intent, if I can help frame the key issues for those of us seeking to advance the profession and field of palliative medicine, then perhaps we can better prepare for the sweeping changes that will engulf us.

Back to the question I’ve contemplated a great deal over the past couple of months – will health reform accelerate or stall the progress of palliative medicine? It seems to me that the answer depends upon whether one believes that there exists today a business model that pretty much guarantees a livelihood to a physician practicing palliative medicine full-time. In other words, the practice can sustain itself through patient revenues without having to rely upon subsidies from a hospital or other sponsoring organization (if a hospital , for example, wishes to support a practice because it recognizes the value of a palliative medicine practitioner, by all means such support should be accepted). But there is a big difference between HAVING to GO back to a sponsor to request additional subsidies to relieve the growing pains of a palliative medicine practice, and operating a practice whose value (financially and clinically) is so widely acknowledged that the practice is actually “sought after” by other providers. And while palliative medicine physicians are surely in demand, just as surely palliative medicine practices are not. Therein lies the great disconnect.

As we have learned, it is very difficult to disengage the success (or lack of ) of a palliative medicine practice from its related program. More later on why practices are not in great demand. For now, just ask yourself, how many physicians have you recently heard mention that they planned to start an independent practice in palliative medicine?