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?

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.