APCOs and Palliative Care Performance

In a recent article Slowing the Growth of Health Care Costs — Lessons from Regional Variation http://content.nejm.org/cgi/content/full/360/9/849 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.

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.