Thursday, December 23, 2010

New Considerations for Developing a High-Performing Hospice Medical Staff

Beginning January 1, 2011, face-to-face recertification visits with hospice patients will no longer be simply good practice. The Centers for Medicare and Medicaid Services ("CMS") has implemented certain provisions of the Patient Protection and Affordable Care Act of 2010 and regulates that such visits become mandatory.

Face-to-face encounters may not occur earlier than 30 calendar days prior to the start of the benefit period for which it applies. Certifications may not occur earlier than 15 calendar days prior to the start of the benefit period for which it applies. A required face-to-face encounter must occur prior to its associated certification.

This requirement will better enable hospices to comply with hospice eligibility criteria, and to identify and discharge patients who do not meet those criteria. How to best comply with this regulation will be a determination made upon specific circumstances of each hospice's medical staff, including:
  •      variability in clinical commitment of current staff, including nurse practitioners
  •      nonclinical commitments that may include administration, teaching, and research
  •      productivity data to analyze MD capacity to absorb additional volumes

Several points to keep in mind as you develop a plan to comply with the requirement:

  • The face-to-face encounter by the hospice physician or the NP for the purpose of gathering clinical findings to determine continued eligibility for hospice care is NOT billable. The face-to-face requirement is part of the recertification process, and therefore is an administrative activity included in the hospice per diem payment rate.

  • The certification or recertification of terminal illness is not a clinical document, but instead is a document supporting eligibility for the benefit and is considered an administrative activity of the hospice physician.

  • Providing reasonable and necessary non-administrative patient care services during the face-to-face encounter is billable: If a physician provides reasonable and necessary non-administrative patient care, such as symptom management, to the patient during the visit (for example, the physician decides that a medication change is warranted), that portion of the visit would be billable.

  • Billing for medically necessary care provided during the course of a face-to-face encounter should flow through the hospice and be billed as physician services under Part A, as the hospice physician or NP who sees the patient is employed by or, where permitted, working under arrangement with the hospice (for example, a contracted physician).

  • If there is a billable portion of the visit, hospices must maintain medical documentation that is clear and precise to substantiate the reason for the medically necessary services separate from the face-to-face encounter related to recertification. Documentation of the face-to-face encounter and any other medically necessary patient care services provided during the visit can be included in one note. Visit documentation should, of course, clearly support any billable services that were provided.

  • Medically necessary care provided during the course of a face-to-face encounter by an NP can be billed only if the NP has been designated as the patient's attending physician.

  • There is no requirement that the visit must take place in the patient's home---- it could take place in practitioner's office.

  • Electronic signatures are permitted on hospice certifications and recertifications. Narrative and the face-to-face attestation are parts of the certification or recertification and may also be signed electronically.

  • Use of telemedicine to perform the visit is not permitted.

  • Attendings cannot do the face-to-face visit without becoming a "hospice physician".

Much to consider, to be sure. 

Wednesday, December 1, 2010

Staggering Gaps in Late-Life Care Makes News

A recent post on this blog (read here) commented on the Dartmouth Atlas Project findings of variation in late-life care for advanced cancer patients. While the findings of variation are  not surprising to those who have been following the Project's studies over the past two decades, what did  leave me open-mouthed was the  enormity of these variations. In some communities, more than 70% of patients with advanced cancer did NOT receive hospice care, staggering even when one considers that nationally 45% did not receive hospice care. If hospice care is not provided to nearly half of patients with advanced cancer, what must those figures be for patients with other advanced illnesses for which prognostication is more difficult. Conversely, in some communities, more than 70% of  patients with advanced cancer DID receive hospice care.

I'm encouraged, nonetheless, by the widespread attention given to this study, in both national and regional publications. It's almost as if these study findings have sounded an alert, one that says WE CAN DO BETTER. Much better.

The Los Angeles Times commented  that "the study found that patients in Minneapolis were four times less likely than those in Los Angeles to receive aggressive life-sustaining treatment during their last weeks on earth."  The article went on to bluntly say "In other words, unless people strongly assert their preferences, their end-of-life care will largely be determined by the prevailing customs of their communities."

An article in the Chicago Tribune commented, "the gap was even greater for frail, seriously ill cancer patients who received CPR, mechanical ventilation and feeding tubes interventions deemed of little value as the end of life approaches. Some 16 percent of these patients got these therapies in Chicago, compared with 9 percent across the U.S."  More from the Tribune, "that analysis reveals some stark differences among Illinois hospitals. Notably, for Evanston Hospital, Glenbrook Hospital and Highland Park Hospital all part of NorthShore University HealthSystem only 19 percent of Medicare patients with advanced cancer died in the hospital, compared with 38 percent at Northwestern Memorial Hospital."

The Milwaukee Journal-Sentinel headline read bluntly that late-life care "needs improving".  It offered the following example of variations within the state: "At Columbia St. Mary's two hospitals in Milwaukee, which have since been consolidated, 11.2% of patients with advanced cancer died in the hospital. At St. Mary's Hospital in Madison, it was 16%. In contrast, an average of 37.3% of patients with advanced cancer at Wheaton Franciscan Healthcare-St. Joseph Campus died in the hospital, although this may be because the hospital has an area designed for patients near the end of life who want to be in a residential setting." Perhaps.

Not all of the local news reports focused on laggards. The St. Petersburg Times found that study results in that community were generally better than national averages. And the Globe Gazette (Iowa) highlighted  the exemplary performance of Mason City, Iowa in most indicators.

Future posts will take closer looks at communities and hospitals with exemplary performance in an effort to answer the question:  How Did they Do That? In the meantime, I invite your thoughts.

Accountable (Palliative) Care Organizations - A Call for Comments

Blogs Pallimed and GeriPal have posted very recently about an opportunity to influence the development of  an organizational model that some consider to be a prototype of the next decade's health care delivery system. Accountable Care Organizations (or ACOs).    The shift accountable care organizations will bring from pay-for-volume to pay-for-value and their focus on total population management, closely aligned incentives and a degree of coordination among providers not typically seen in most markets cuts to the heart of  the health care institutions within most communities . In the cards, some suggest, are:  fewer hospital admissions, shorter lengths of stay, fewer emergency department visits, and fewer procedures and tests. Hospice and palliative care advocates, take note, this is our opportunity.
There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at under the document number: CMS-2010-0259-0001.

The dealine for comments is December 3rd, so there is little time to act.  Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?

•Require evaluation of patient and family goals of care, using for example POLST and advance care planning

•Determine patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals

•Require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO.

•Assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.

Question 2: The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

•The most important aspect of "patient-centeredness" is the degree to which informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

Question 3: In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?

•Quality measures should include advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed and addressed among appropriate patient subgroups

Dr. Meier makes clear that the goal of our comments should focus on making the point that an ACO must require access to quality palliative care for its sickest high need and high cost patients in order to assure that care is directed by and concordant with patient and family goals, and not by strong ACO incentives for cost containment.

There is little time to act. Just click here and submit a comment. To make your lives a little easier, the following is a draft outline that you can use in your comment:

1.Introduce yourself as palliative medicine clinician or health professional.

2.Define palliative care as medical care focused on best possible quality of life, delivered from point of diagnosis of serious or advanced illness whether the goal of care is cure, life prolongation, or achieving a peaceful dignified death. In practice, consists of expert assessment and treatment of symptom distress including pain, anxiety, and depression; conduct of in-depth discussions with patients and families to establish achievable care goals and a care plan that meets those goals; and commitment to continuity of care and relationships across the many care settings that seriously ill patients must traverse over the course of an illness. Palliative care includes end of life care (hospice) but is not limited to it- it is especially important among Medicare and Medicaid beneficiaries with advanced disease and/or multiple chronic conditions with functional impairment- a group who are not predictably dying and who may live for many years with a significant burden of disability and medical needs.

3.The core strategy of palliative care is to help informed patients and families determine their achievable goals for care and then helping to make sure that medical care received helps patients achieve those goals.

4.The goal of ACOs is to incent quality and not quantity and to coordinate the full range of providers. Because of ACO-associated changes in financial incentives that will reward efficiency and "doing less", the risk of undertreatment- reduced access to needed care- and consequent poor quality of care is greatest for high need high cost patients. To counter that risk, ACOs should be required to provide access to specialists trained in care of this complex high need patient population across diagnostic categories, and specifically trained in the skilled communication necessary to elicit achievable care goals throughout the course of illness. Providers with this training work in palliative care programs (mostly hospital-based) and in hospices.

More on Accountable Care Organizations, and the role of hospice and palliative medicine, in future posts.

Friday, November 26, 2010

Engage with Grace - Communicating End-of-Life Wishes

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace [] – a movement aimed at making sure all of us understand, communicate, and have honored our end-of-life wishes.

The rally is timed to coincide with a weekend when most of us are with the very people with whom we should be having these unbelievably important conversations – our closest friends and family.

At the heart of Engage With Grace are five questions designed to get the conversation about end-of-life started. We’ve included them at the end of this post. They’re not easy questions, but they are important – and believe it or not, most people find they actually enjoy discussing their answers with loved ones. The key is having the conversation before it’s too late.

This past year has done so much to support our mission to get more and more people talking about their end-of-life wishes. We’ve heard stories with happy endings … and stories with endings that could’ve (and should’ve) been better. We’ve stared down political opposition. We’ve supported each other’s efforts. And we’ve helped make this a topic of national importance.

So in the spirit of the upcoming Thanksgiving weekend, we’d like to highlight some things for which we’re grateful.

Thank you to Atul Gawande for writing such a fiercely intelligent and compelling piece on “letting go” []– it is a work of art, and a must read.

Thank you to whomever perpetuated the myth of “death panels” for putting a fine point on all the things we don’t stand for, and in the process, shining a light on the right we all have to live our lives with intent – right through to the end.

Thank you to TEDMED [] for letting us share our story and our vision.

And of course, thank you to everyone who has taken this topic so seriously, and to all who have done so much to spread the word, including sharing The One Slide.

We share our thanks with you, and we ask that you share this slide with your family, friends, and followers. Know the answers for yourself, know the answers for your loved ones, and appoint an advocate who can make sure those wishes get honored – it’s something we think you’ll be thankful for when it matters most.

Here’s to a holiday filled with joy – and as we engage in conversation with the ones we love, we engage with grace.

(To learn more please go to

This post was written by Alexandra Drane and the Engage With Grace team. )

Monday, November 22, 2010

Enormous Variation in Late-Life Care Documented Once Again

The latest report from the Dartmouth Atlas Project concludes that the quality of end-of-life cancer care and use of hospice and palliative care services in a cancer patient's last month of life are enormously variable, depending on the community and the specific hospital or health system where the patient sought care. The mainstream media have picked up on this story (read here and here) as have  publications serving  the health care industry  (read here). Dale Lupu has an insightful post on Pallimed (read here) on the study's conclusions. Some newspapers have taken a closer look at study results within  their communities (read here for a report on Chicago).

A recent post on this blog (read here) commented on variation in late-life care (as identified in an earlier Dartmouth Atlas report), and how we should be looking at top decile performers as beacons whose practices should be emulated,  and another post (read here) wondered if a time will arrive when people evaluating communities in which to retire will  use a community's performance in providing late-life care as a factor in their final choice.
David Goodman, MD,   the director of the Center for Health Policy Research at the Dartmouth Institute for Health Policy and Clinical Practice and lead author of this study, put it best when he said , "Doctors and health systems need to take a look at themselves... to examine where they need to make their investments, and to make sure that they're fairly investing in what I think is one of the most undertreated (services) that we have in Medicare today, and that is undertreatment with palliative care and hospices services for those with advanced disease."

Among the striking examples of  variation, consider these:

•On average, 6% of cancer patients received chemotherapy during the last two weeks of life nationally, but in Olympia, WA it was 12.6% and in San Antonio, TX, 10.8, but only 3% in Worcester, MA and Baton Rouge, LA.

•Nationally, about 24% of Medicare patients with cancer were admitted to intensive care at least once during their last month of life. But variation across the country was seven-fold. In  Los Angeles and Miami it was 40.3%.  But in Mason City, Iowa, it was only 6%.

•Nationally, about 55% of cancer patients used hospice services in the last month of life. But again, variation was nearly fourfold across the country depending on hospital referral region. .

•About 9% of patients with end stage cancer nationally received life sustaining treatments, such as endotracheal intubation, feeding tube placement and cardiopulmonary resuscitation. But rates varied by more than six across the nation, from 18.2 in Manhattan and 17.5% in Los Angeles to 3.9% in Minneapolis.

Nancy Foster, vice president for quality and patient safety with the American Hospital Association, said studies like the Dartmouth Atlas Project's "help shine a light on the importance of end-of-life care." She went on to say,"Unfortunately, hospice care is not readily available in all parts of the United States." A curious comment, when one considers that use of hospice is below national average in some cities, regions, and states which have a relatively higher number of hospices per capita.

How much of this care is futile? Hard to say, of course. Living well has a different meaning for each patient, and it is the responsibility of clinicians and health care systems to help patients articulate their goals for living and for their medical care.

But we do know that there is a huge gap between patient preferences and the care they receive. In a post titled " Marginal Treatments at a High Emotional Cost from Families" on the site, Dr. Marya Zilberberg wrote about her father's battle with advanced cancer and was left wondering  "what are we prolonging in many of the cases that we treat at the end of life life or death?"
As Dale Lupu wrote in her post, perhaps this study will  be the impetus for performance improvement projects in some of these regions with poor results. I'm optimistic it will be.  Progress will be slow, however, if these performance improvement projects are isolated to individual hospitals and hospices - what are needed, as our (DAI Palliative Care Group) studies of exemplar palliative care communities have shown, are community-wide initiatives, or networks, whose "members" span settings of care and adopt "tools" like POLST to "spread the science" of HPM.

What a wonderful opportunity for HPM practitioners to assume leadership positions in the development of such networks. Much more on this subject to appear in future posts.

Thursday, November 4, 2010

Palliative Care Grand Rounds - November MMX

Read here for the November edition of Palliative Care Grand Rounds, a monthly round-up of the best from the blogosphere about late-life care. 

Sunday, October 31, 2010

Evaluating Performance of Hospice and Palliative Medicine (HPM) Physicians

I'm often asked (usually by hospice executives) how the performance of palliative medicine physicians can best be evaluated. What they're really asking is: how can they tell  if the hospice's investment in its medical staff is paying off? While there is no single, or simple, answer, there are several proven ways.

 I find that most palliative care programs (including hospices) have only recently added to their medical staff (up to this point the majority of physicians practicing palliative medicine (HPM) have been in conventional, part-time hospice medical director positions), and so a strong need for an ongoing performance evaluation program has not been perceived.

But as palliative care organizations move toward a model  relying  on an expanded  role for physicians, performance management takes on greater importance.

To underscore this point, the Joint Commission recently introduced a standard named Ongoing Professional Practice Evaluation (OPPE). The intent of the standard is to encourage health care organizations to  look at data on performance for all practitioners with privileges on an ongoing basis rather than at the customary two year reappointment process, to allow the practitioners to take steps to improve performance on a more timely basis. While this standard applies specifically to hospitals, hospices and palliative care programs should take note.

In coming posts, I'll offer some ideas for physician performance management which we've seen work well, and may suggest a starting point for those grappling with the issue of evaluating and managing a palliative care  organization's investment in physician resources. And, I'd like to swap ideas with readers.

Saturday, October 23, 2010

Hospice Industry Data from NHPCO - A Look Back Five Years

As Dr. Christian Sinclair pointed out in a recent post on the  blog Pallimed, the 2010 edition of the NHPCO report  Facts and Figures:  Hospice Care in America was short of surprises when compared to data from last year's report.

So I looked back to a 2005 report to better understand how the hospice industry has changed (or not) over the past five years. Among my surprises were these:

-Impressive growth in the percentage of decedents receiving hospice care. Sure, I expected growth, but not at the rate we've seen.

-Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. Is this an intractable issue, in which case hospices should consider improving their capacity to provide exemplary care for short-stay patients, or does there remain optimism that  knowledge of more timely (earlier) referrals will spread quickly, thus reducing the percentage of short-stay patients.

-The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. Given the speculative talk about consolidation, I  expected that over the past five years there would have been considerably fewer hospices admitting less that 150 patients per year.

Got me to thinking. If I was considering hospice care for a family member, aware that there is a one-in-three chance that the episode of hospice care will be no longer than a week, I'd want to select a hospice that admits ten times the number of patients than the average-sized hospice. I figure that the additional volume would mean greater proficiency in short-stay care.

Does volume matter? No studies to prove either way.
What do your professional instincts tell you?

Thursday, October 14, 2010

Disruptive Innovation in Health Care - Has It Arrived At Last?

The authors of the 2000 Harvard Business Review article Will Disruptive Innovations Cure Health Care? suggested that organizational delivery models were in need of  modernization, or as they put it, "the health care industry is trying to preserve outmoded institutions". New organizations to "do the disrupting" need to be created, the authors went on. 

 What few could have predicted was the timing of the modernization. Organizational structures to deliver health care have largely remained static over the past decade, outside the ascendancy of  stand-alone ambulatory surgery centers. If Accountable Care Organizations (ACOs) do little else, they will be considered as successful because the spectre of their implementation has brought parties together who likely would have otherwise remained apart.

In future posts, we'll take a closer look at the role of one of those parties - palliative
medicine -  in a post-acute network.

Wednesday, October 13, 2010

Closing the Performance Gap in Palliative Care by Reducing Clinical Variation

The Dartmouth Medical Atlas gives us a compelling portrait of the variations in practice in late-life care. It also offers insights into the palliative performance improvement opportunities in communities.

How wide are the variations? Let’s take a look at Charlottesville, Virginia, an area of about 100,000 residents, with an academic medical center and a community hospital, a large not-for –profit hospice, and plenty of smaller hospices. According to the DAI Palliative Performance Profile (drawn from the Dartmouth Medical Atlas), Charlottesville earned a B grade for its late-life care practices. Respectable, for sure, but short of exemplary. What’s the difference between respectable performance and that of the top 10% performers? Consider the following: in Charlottesville, 32% of Medicare decedents died in a hospital. That’s better than the state average, yet 25% higher than residents of a community in the top 10%. In other words, a Charlottesville resident is 25% more likely than a resident of a high-performing community to die in a hospital than at home. That same Charlottesville resident is 40% more likely to have spent 7 days or more in a hospital during the last six months of life than someone in a top-performing community. Considerable room for improvement, I think you'd agree, and yet Charlottesville's performance is better than most communities across the nation.

Tightly integrated delivery systems have proven to be the most effective in reducing clinical variation. Because of their structure, these delivery systems are adept at disseminating evidence-based practices. It is time that hospice and palliative care leaders accelerate collaborative efforts to create networks with greater potential to reduce clinical variation in late-life care. What better opportunity for HPM specialists to take the lead?


Wednesday, October 6, 2010

Is Palliative Care A Disruptive Innovation in Health Care?

It's been a short (or is it long?) ten years since the September-October 2000 issue of Harvard Business Review published the article "Will Disruptive Innovations Cure Health Care?  In that piece, the authors (Clayton Christensen, Richard Bohmer, and John Kenagy) argued that powerful institutions fight simpler alternatives to expensive care because those alternatives threaten their livelihoods. If history is any guide, the authors posited, the health care system can be transformed only by creating new institutions that can capably deliver lower-cost, higher-quality, and more convenient care, rather than attempting a tortuous transformation of existing institutions (read that as acute-care hospitals) that were designed for other purposes. They went on to comment that our major health care institutions have together overshot the level of care actually needed or used by the vast majority of patients. Has much changed  during the intervening decade? And, it set me to wondering, is  palliative care  considered a disruptive innovation?

James Cleary, MD (palliative care chief at the University of Wisconsin Hospital and Clinics), referred to hospital-based palliative care as a disruptive innovation in a 2008 keynote address to an audience of hospice and palliative care professionals. And as one considers that disruptive innovations "sneak in from below",  start by meeting the needs of "less-demanding customers", and enable "less-expensive professionals to do progressively more sophisticated things in less expensive settings", the case sharpens  for palliative care as a disruptive innovation.

So why doesn't palliative care always feel like a disruptive innovation? Surely one reason
is that new organizations to do the disrupting have not sprung forth  the palliative care sector. That is likely to change soon, as  the formation of Accountable Care Organizations (ACOs),  encouraged by the health reform bill,  reconfigure the delivery models of health care over the next decade. And within the ACOs will emerge Advanced Palliative Care Organizations (APCOs), proven to be  successful models for improving delivery of chronic and late-life care because their characteristics encourage processes of care that are:

Timely - delivered to the right patient at the right time (early identification of patients)

Patient-centered - based on the goals and preferences of the patient and family, articulated in goals of care conversations

Beneficial and effective - demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)

Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

I invite our readers to weigh in.  Is palliative care a disruptive innovation? And if so, what steps will best advance its influence within the larger health care system?

Sunday, September 19, 2010

What Might A "Sought-After" Hospice and Palliative Medicine (HPM) Practice Look Like?

At a recent forum addressing the subject of HPM physician performance, one of the panelists asked the above question. During our study of bellwether practices, we've asked ourselves a similar question - how does a HPM practice create value? While our research has been far from exhaustive, our findings offer some insight into this question. A post last year on this blog offered an early take on this question.

Let's revisit this question, this time from a post-reform legislation view.

Unarguably, HPM practices are not, and will not be, sought after because of their revenue-generating capacities, either from direct patient care services (home visits, hospital consults, inpatient hospice management) or ordering tests, performing procedures, or utilizing a hospital's facilities. To be sure, hospital palliative consults have proven to be effective cost avoidance services for hospitals. This effectiveness, however, is subject to the law of diminishing returns, in that the "savings" are front-loaded in the first few years following introduction of the palliative care service. Once the "new" standard of care is firmly in place, savings become more difficult to squeeze out of the palliative care service. Some counter that eliminating the palliative care service would return costs to the hospital. While that may be the case to some extent, I don't know of many health care CEOs and CFOs who would "recount" savings that had already been accounted for.

The Dartmouth Medical Atlas has shown that there is enormous variation in late-life care, AMONG and WITHIN communities. In fact, it is not unusual to find wide variation in practice from one IDT to another within a hospice provider. Reducing clinical variation, simply put, is not a quality improvement priority for most hospices and palliative care organizations. In future posts, we'll take a closer look at the clinical variation question.

Tightly integrated delivery systems have proven to be effective in reducing clinical variation. These delivery systems may soon serve as models for the development of Accountable Care Organizations (ACOs). A recent article highlighted Dartmouth-Medical Clinic, a 900-physician group practice in New Hampshire, which has earned $13 million so far in the Medicare Physician Group Practice Demonstration, the model for accountable care organizations. The Clinic focused on reaching out to patients with chronic illness, improving coordination of care for patients transitioning between care settings, and more aggressively monitoring patient between physician visits.

For these activities, surely HPM physicians, palliative care nurse practitioners, and hospices play a vital role. A network of physicians and palliative care clinicians will be extremely valuable to these ACOs. Why? Because these networks will already be in place to provide timely, patient/family centered, and evidence-based care to those with advanced illnesses. Such care will likely cost less, as fewer days are spent in ICUs and hospitals, and more at home, under hospice and palliative care.

You may be thinking, ACOs aren't called for in the health reform legislation until January 2012.
Keep in mind, building an effective delivery network is a years-long process, so yesterday was the best time to start. There are at least three steps, each of them formidable, to building a tightly integrated network to deliver advanced-illness care. These are:

- applying clinical protocols proven to reduce clinical variation,
- electronic capture and transfer of clinical information across settings,
-"internal transfer" of reimbursement.

Future posts will look closely at each of these steps, as well as the value that a high-performing hospice medcial staff brings to the formation of a HPM network, and how HPM practices may best position themselves to become the "go-to provider" for late-life care.

Thursday, September 2, 2010

September Edition of Palliative Care Grand Rounds

Read here for this month's edition of Palliative Care Grand Rounds, hosted by Christian Sinclair. You'll find a wide-ranging mash-up of the best from the blogosphere around palliative care, including discussions and commentary about Atul Gawande’s article in the New Yorker titled ‘Letting Go.‘ and research published in the NEJM demonstrating early palliative care improves quality of life.

Sunday, August 22, 2010

Spreading the Message and Science of Palliative Care

A recent study published in the New England Journal of Medicine identified the merits of early palliative care intervention, for patients with a lung cancer diagnosis. Among the benefits from such interventions were improved quality of life and longer survival. This study has received wide coverage in the mainstream press -New York Times (read here) , Wall Street Journal Health Blog (read here) , Boston Globe ( read here) , USA Today (read here) , and Associated Press (read here) and medical blogs, such as this blog post by the Deputy Medical Officer of the American Cancer Society).

While an important study, to be sure, it is hardly the first to tout the benefits of palliative care.
A study published in an August 19, 2009 issue of JAMA (read here) found that patients with advanced cancer who received a palliative care intervention focused on addressing physical and psychosocial issues and care coordination provided AT THE SAME TIME as cancer treatment had improved quality of life and mood. Interestingly enough, these patients did not experience a significant change in the number of days in the hospital or the severity of their symptoms compared to patients who received usual care.
In an earlier article, published in the June 2007 issue of Critical Care Medicine, (read here)
researchers at the University of Rochester Medical Center found that early palliative care interventions reduced the length of stay for seriously ill patients in the medical intensive care unit (MICU) by more than seven days without having an impact on mortality rates.

And, in early 2008, a Kaiser Permanente study (read here) was the first multi-center randomized trial to show that hospital-based palliative care results in improved quality of care, including higher patient satisfaction, improved communication, and fewer ICU admissions.

So is this most recent study a “game-changer”? Could be. Just like previous similar studies have been/could have been.

Evidence that palliative care intervention (regardless of timing) improves quality-of-life has been available for some time. Whether as a result of such evidence, or other factors, unquestionably there has been growth in the availability AND use of palliative care services. Most would also agree that the “spread of science” around palliative care has been slow, that is to say, programs whose results could replicate the benefits of these studies have been slow to produce similar results. Why?

It certainly hasn’t been for lack of effort. So then, one might ask, what are the obstacles? Simply put, two of the most formidable barriers are organizational and financial. Let’s take a closer look at this most recent study.

It was performed at a single, tertiary care site with a specialized group of thoracic oncology
providers and palliative care clinicians, thereby limiting generalization of the results to other
care settings or patients with other types of cancer. And I suspect that reimbursement for these palliative care services was not an issue.

Such care requires organizational models tightly integrated in order to produce similar results. As has been discussed in previous posts on this blog, such organizational models exist only in a few areas across the country. In most communities, palliative care has been viewed as an alternative to curative care, not as concurrent care. Moreover, current delivery models within today’s health care system (more on this in future posts) do not encourage nor facilitate the close coordination and collaboration among providers (individual and organizational) necessary to replicate this study’s findings. Nor do they encourage the adoption of evidence-based best practices. And, of course, the current reimbursement system, which rewards more procedures and aggressive care, surely does not encourage coordination. In future posts, we’ll explore the make-up of those communities (and its health care providers) that encourage tightly coordinated and bundled care.

A final thought on the study. Of course, more studies are needed to identify the value of palliative care. The efforts to promote study results should focus on VALUE (most significantly, quality), rather than longer survival (“Cancer Patients Live Longer With Palliative Care” screamed the headline from the consumer website As Drew Rosielle, MD reminds us, “surveying the 'average' advanced cancer patient will reveal that most of them rate QOL (Quality of Life) as more important than survival" and we “should not spend too much time basking in the survival benefit”. And as Lyle Fettig, MD posts in Pallimed blog, “the PRIMARY (emphasis added) outcomes of the study stand on their own as important--it's yet more evidence that palliative care interventions improve quality of life and reduce psychological morbidity.”

David Weissman, MD puts it bluntly and best :

"While three cheers are certainly in order, I would be very cautious about saying that palliative care improves survival. Although randomized, the study was small and from a single institution. I love the results, but think we all need to be careful about over-interpreting single study results. When the next study shows no change in survival, which I fully expect, the fall for the field could be hard."

Tim Kirk , assistant professor of philosophy at the City University of New York where he specializes in philosophy of nursing and healthcare ethics with an emphasis on hospice and palliative care, writes “ All of these organizations have been focusing on the fact that patients in the study who received palliative care lived a bit (2.7 months) longer than patients who did not. While I understand that the hospice and palliative care communities have long suffered from the stigmatized perception that they welcome (or, even, hasten) death, and that this study seems to provide a rebuttal to such a perception, I believe the way the study is being embraced and promoted is misleading. He continues, "The emphasis on time to death perpetuates exactly the belief that hospice and palliative care have been working to change for decades: that what is important is how long you live rather than how well you live. If we begin promoting hospice and palliative care under the premise that such care extends life, we tacitly accept that extension of life is the primary goal of healthcare. And, we tacitly send that message to our colleagues, patients, and the public at large.”

More aggressive care is not necessarily associated with longer survival. That’s an important message in the efforts to lower cultural barriers to palliative care access. But as important, perhaps even more so, in achieving the “spread of science” in palliative care, will be how effectively we reconfigure organizational and reimbursement models that will improve access to, and delivery of, palliative care.

Certainly, there is a need to replicate this study in other settings. And since this intervention is probably very dependent on the skill of the palliative medicine providers, we need to better understand how various models of palliative care delivery improve outcomes.

Finally, I do not consider as insignificant the matter of prolonging life. Nonetheless, it is an issue with more relevance to other populations for whom palliative care intervention can be important. Alex Smith, MD describes it this way in the blog GeriPal,
“I would hazard a guess that those who would have the greatest survival benefit are geriatric patients with multiple co-morbid illnesses and no dominant terminal condition. Nothing like tailoring of medication, attention to physical, psychological, social, and spiritual concerns for frail elders. I think that's why so many patients with "general debility" and "failure to thrive" are discharged from hospice alive, only to fall apart again after discharge.”

As always, I invite your feedback.

Wednesday, July 7, 2010

Palliative Care Grand Rounds - July MMX

Read here for this month's PCGR, hosted at the GeriPal blog. You'll find an interesting, enlightening, and well-rounded mash-up of the best from the blogosphere.

Wednesday, June 30, 2010

Gentiva-Odyssey - Who Will Be the Beneficiaries?

I've suggested in the past that the hospice industry is sub-scale (too many small providers) so I've been asked recently if the news about the Gentiva acquisition of Odyssey marks the beginning of a consolidation that will benefit the delivery of hospice services in the US.

The recent business transaction between Gentiva and Odyssey is a blockbuster deal (or as some analysts put it, a game-changer) not only because of the dollars involved (a billion of them) but also because it involves the combination of a for-profit home health provider with a for-profit hospice.

Several points struck me:

-Gentiva will be under great pressure to make this deal work because it expects to raise $1.1 billion in NEW DEBT financing to fund the purchase price and refinance existing debt. Such financial pressure encourages management decision-making where patient enrollment trumps patient service.
-Identifying synergies (not to be confused with economies of scale) between home health and hospice has been elusive. It's probably why there haven't been such large-scale combinations to date, and why even small-scale home health/hospice collaborations (either for-profit or not-for-profit) have been few and far between. That said, Gentiva's management has had a solid track record and may be up to the task of capitalizing on these elusive synergies.
-Health care (especially home and hospice care) is local, and after the transaction is completed, the key question will be: can a home health-hospice behemoth better advance (than other organizational delivery models) the provision of palliative care to those with chronic or advanced illness? To the extent that the new Gentiva/Odyssey entity may be able to develop accountable palliative care organizations (APCOs) within the communities it serves, then it may be worth the effort.

I'm curious to learn your thoughts.

Monday, June 28, 2010

Accountable Palliative Care Organizations (APCOs)

From time to time, clients inquire if there is a single factor which keeps communities, in general, and hospital/health systems, specifically, from realizing the full potential of palliative care. Our analyses of the Dartmouth Medical Atlas suggests to us that HOW communities are ORGANIZED to deliver and distribute palliative care may be the single most important determinant of success.

Drawing a composite picture of a hospital’s (and community's) palliative care performance from palliative outcome indicators can reveal lots about performance in meeting the needs of those with advanced illness. Our study of better-performing communities identifies several attributes shared by these exemplar palliative care communities (much has been written recently about one of these Exemplars - LaCrosse, Wisconsin). These shared attributes are:
• Multiple Points of Patient Access
• Multiple Sources of Reimbursement and Mechanisms to Enable Internal Pricing and Transfers
• Chief Palliative Care Officer
• Protocols/Tools Span Settings of Care
• Relentless Collection of Data and Focus on Accumulating and Disseminating Knowledge of Best Practices.

We refer to virtual structures possessing these attributes as Accountable Palliative Care Organizations (APCOs). In coming posts, I'll offer more detail on why these attributes matter, and why APCOs are so difficult to develop. In the meantime, I'm curious to learn your thoughts, and how your assessment of current late-life care practices in your communities confirms or refutes this organizational model.

Monday, June 14, 2010

Bellwether Hospice and Palliative Medicine (HPM) Practices

If the Hospice and Palliative Medicine(HPM) specialty is in its nascence, as widely considered, then what will the practice of palliative medicine look like five years from now? The bellwether theory offers several ideas. What, or who, are bellwethers? Simply, one who, or that, serves as a leading indicator of future trends. A bellwether stock is widely believed to be an indicator of the overall market's condition. In sociology, the term is applied to a person or group of people who tend to create, influence or set trends.

What practices might be considered as bellwethers for the HPM specialty? One might start with the practices associated with Advanced Palliative Care Communities. These are communities which score highly in the DAI Community Palliative Performance Profile. The DAI Profile uses data from the Dartmouth Medical Atlas to compile a snapshot of a community based upon its performance in an array of patient palliative care preferences. Grand Junction, Colorado and LaCrosse, Wisconsin are two Exemplar communities. A recent post on this blog had an interview with the HPM practice chief in Grand Junction.

Another bellwether is the HPM group practice which has attained “critical mass” of palliative medicine intellectual capital. What is it about these practices that makes bellwethers of them? We find that their "mass of intellectual capital" enables the "spread of science" and positions them well to take on roles as chief palliative officers of the Accountable Palliative Care Organizations (APCOs) within their service area. APCOs are virtual networks of providers whose collaboration around palliative services likely leads to higher levels of patient/family satisfaction and more efficient use of acute hospital beds. The chief palliative care officers are the integrators of these networks.

Others contend that bellwether practices are generally found in bellwether states (Florida leaps immediately to mind). Why? Because late-life care organizations (hospices, typically) in these bellwether states make greater use of HPM physicians. As illustration, Medicare data from Healthcare Market Resources reveals that Florida hospices generate revenue from physician services nearly three times that of the national average. Finally, the practices, small or large, which stand out by virtue of their chiefs. Some argue that such practices, dependent upon a single individual, have an unstable foundation and thus would not "qualify" as a bellwether because their best practices are not institutionalized.

Others counter that Accountable Palliative Care Organizations, and Communities, are often the lengthened shadow of their leaders. We’re uncertain to which view we lean. Yet, one is hard-pressed to deny the influence of these pioneers. So, until we learn that the exercise is fruitless, we’ll continue to look at these "pioneering" practices as bellwethers.

I invite your professional experiences and insights, as we explore in upcoming posts the future practice of Hospice and Palliative Medicine, as seen through the eyes of the bellwether theory.

Wednesday, June 9, 2010

Future Growth Prospects for HPM Physicians - Where Will They Be?

When I describe to health care colleagues outside the hospice and palliative care field the nature of my work (developing medical staffs of palliative medicine physicians) the usual response is something along the lines of : That must be a high-growth field". At first, it was easy to agree. I'm unsure now.


One, industry data suggests that hospice utilization may be approaching its zenith. In the ten states with highest hospice penetration (% of deaths served by hospice), utilization has dropped in recent years in seven of the ten.

Two, while the number of people availing themselves of the hospice benefit has grown annually by 2.3% from 2001-2008, the number of hospices has grown nearly 5% annually, or a rate more than twice that of the growth of patients using the hospice benefit (2010 MedPac Report). If one believes that small equals proficiency, then surely this is the golden era of hospice care. 50 % of hospices ADMIT fewer than two patients per week.

Three, hospital-based palliative care programs, another significant employer of HPM physicians,
may be experiencing growth in terms of new programs, but hospital-based programs are finding "same-store" growth slowing.

There's no disputing that hospices of today's median size are not as likely as hospices with an average daily census of 100 or more to deploy the services and expertise of a full-time HPM physician. Industry observers have been asserting for the past decade (and perhaps longer) that hospices will be consolidating. Meanwhile, there are few signs that such consolidation is indeed occurring. In fact, the biggest transaction in 2010 has been the acquisition of a national for-profit hospice chain by a HOME HEALTH giant. Who's to say if such a transaction will lead to hospices combining their operations with like-minded organizations, thus spurring the oft-cited predictions of consolidation.

Are home health-hospice combinations a positive development? Certainly could be, depending upon where one sits. And how will HPM physicians fare under such combinations? I'm curious to learn your thoughts.

Tuesday, June 8, 2010

Leadership Competencies in Exemplar Late-life Communities

What competencies are common among the leaders in exemplar palliative care communities, I'm asked from time to time. At the risk of oversimplifying, I'll suggest three

These community leaders, whether professional managers, physicians, or nurses, are particularly skilled at envisioning, energizing, and stimulating a change process that coalesces communities, patients, and professionals around new models of late-life care. These leaders have an uncanny ability to align their own priorities with those of the organization and the needs and values of the community. Call this a transformation competency.

These leaders display the ability to use metrics and evidence-based techniques to hold stakeholders to high standards of performance, using force of personality rather than the power of one's position. These leaders also understand the formal and informal decision-making structures around late-life care. In other words, they are adept at execution, translating vision and strategy into optimal organizational AND community performance.

And, these leaders are competent at building and sustaining relationships that evolve into networks, and take a personal interest in coaching and mentoring others. Put another way, these leaders possess exceptional people skills.

What competencies have I overlooked? I'd like to hear from this blog's readers.

Monday, June 7, 2010

Palliative Care Grand Rounds- June 2010

Have a look here for this month's round-up of the highlights from the palliative care blogosphere, hosted by Julie Rosen at the blog Bedside Manners.

Sunday, May 23, 2010

Exemplar Late-Life Communities Five Years Later - The Role of the HPM Physician

In previous posts, we've featured interviews with physicians currently practicing Hospice and Palliative Medicine (HPM) in exemplar late-life communities, as identified by DAI Palliative Care Group in its study of end-of-life care data from the Dartmouth Medical Atlas. We're also followers of the Institute for Healthcare Improvement (IHI), and have followed closely IHI's identification of regions where high-value (low cost, high-quality) medical care is provided. One of our present studies is taking a closer look at the role of the HPM physician today in those communities identified both as exemplar late-life regions AND high-value medical care regions.

For more background on this issue, have a look at earlier posts for the regions of Grand Rapids,
Asheville, and Grand Junction. And for a look at exemplar late-life care hospitals, read here. More will follow in future posts. And, of course, your comments are invited.

Wednesday, May 19, 2010

What's the Right Amount of Practice Subsidy?

Why does a particular Hospice and Palliative Medicine (HPM) practice require more support than another? This is one of the most common questions I am asked. While there is no data to indicate what a "typical" subsidy may be, it is helpful to understand why the amounts vary so widely from one practice to another.

First, there isn't a uniform definition of subsidy. Some refer to subsidy as the difference between a practitioner's guaranteed salary (some will include benefits as well in this figure) and the amount of professional fee revenue generated. Others will carve out non-clinical time (such as administrative activities) from the subsidy calculation, and will treat that portion of practitioner compensation as an administrative expense. It's not unusual to see this difference in definition amount to $50,000 annually per practitioner.

Some other common reasons for the wide variance in subsidies:

Documentation, Coding, Billing, and Collecting

This is an area in which many, if not most, practices have room for improvement. One simple way to estimate how your practice is doing in these processes is to think about how you're performing on the following tasks:

Do all HPM practitioners understand the documentation requirements for each CPT code, and is their performance in selecting CPT codes audited regularly (we suggest at least yearly)?
Does the practice have a reliable method of charge capture that minimizes problems like lost charges?
Is there an established "chain of custody" of this information, from the HPM practitioner to the biller?
Is there a periodic review or audit of the biller's performance?
Does the practice monitor metrics, such as days in accounts receivable, collection rate. An audit could be as simple as reviewing ten billed encounters within the past three months for each practitioner, and identifying the status of each bill (e.g., paid, written off, or perhaps the bill has vanished or never made it into the billing system).

Payor Mix
The payor mix for most HPM practices is primarily Medicare, but in those areas with heavier penetration of Medicare Advantage plans, the contracted (negotiated) payment from the Medicare Advantage plan may be significantly different from the standard Medicare reimbursement.

Practitioner Productivity
Some hospices and hospitals have systems of care that interfere with HPM practitioner productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or practitioners being expected to do clerical work. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency.

The "right" amount of subsidy is a judgment call, and so will vary from practice to practice. A solid understanding of the factors behind the wide variances in subsidies, and an evaluation of those factors specific to your practice, will be valuable in determining your "right" amount.

Friday, May 7, 2010

Palliative Care Grand Rounds - May 2010

Have a look here for the May issue of Palliative Care Grand Rounds, hosted this month by Thaddeus Pope at his blog Medical Futility.

Thursday, April 29, 2010

How Do They Do That? - Providing High-Value Late-Life Care

More than 10 years ago, the Robert Wood Johnson Foundation funded a study that analyzed Americans' values, opinions and attitudes concerning end-of-life care. Based on in-depth focus group discussions involving 385 Americans in thirty-two cities as well as two sets of follow-up interviews, The Quest to Die with Dignity identified how Americans then thought about death and dying, how they want to be treated, and how they viewed planning documents such as living wills.

Some suggest that those participating in the study share similar, clearly articulated concerns, hopes and beliefs about the process of dying in America today. Dying well, for most of these Americans, means dying pain-free, relieved from all suffering. For many, it means dying at home, surrounded by loved ones, and untethered to machines.

Are there communities that do a better job of complying with patient preferences? Communities that could be considered "bellwethers" or "exemplars", communities where high-value late-life care is provided? Using data drawn from the Dartmouth Medical Atlas, such communities can be identified.

Recently, the Institute for Health Care Improvement(IHI), an organization led by Don Berwick, MD, who will soon be leading CMS, identified ten communities where high-value care is being provided. We've taken a look at those communities, to analyze whether there's a connection between their success stories in providing high-value health care and their performance around late-life care. and we've found that some regions do provide high-value health care and patient-centered late-life care.

A previous post on this blog took a closer look at Asheville, North Carolina, one of 10 communities identifed by IHI in their How Did They Do That? study. Among the lessons from the IHI study:

Some patterns: a culture of collaboration to put patients first; considering finances as a constraint, not a goal; the importance of physician leadership; the real or virtual integration of delivery systems across the continuum of care; the importance of strong primary care; the value of electronic health records and the information-sharing it makes possible; and an emphasis on measuring and reporting data on quality and utilization.

We'll take a closer look at some of these communities, in an effort to better understand why some regions' late-life practices produce outcomes that match patient preferences better than other regions.

Tuesday, April 20, 2010

Compensation Conundrum

I'm asked from time to time what are the prevailing compensation rates for HPM physicians. The follow-up to that question is often, "what are the most common compensation models?"

The most common compensation model for HPM Practitioners is a guaranteed (straight) salary. Guaranteed base salary is straightforward, thus simple to implement. Its greatest value is in its simplicity. But one of the results of straight salary is that often role confusion emerges, because expectations are not clearly articulated, and often misaligned.

We are beginning to see variable (incentive) pay used more frequently than in the past. Base salary with incentive (or what we refer to as a hybrid model) is becoming more common -- where base salary is set, we've found, is critically important to how meaningful are the incentives. Conventional wisdom suggests that at least 20% of compensation should be at risk for the incentives to alter behavior.

Choosing metrics to be used for incentive pay, however, is a daunting process, and it is why straight salary remains the most common plan today. Yet, choosing metrics is a highly valuable process, and the mere exercise of that process yields substantial benefits. In a compensation plan with incentives, the key stakeholders will sit down and eventually come to an agreement on which metrics are most important, and then quantify those metrics. It is a process we refer to as "valuing physician activity".

Incentive pay is typically based upon a work effort metric (such as RVUs, collected revenue, patient visits/encounters). There are metrics in addition to work effort, although at present their use in HPM compensation plan design is uncommon. I'm familiar with a couple of hospices that require a quality gate be passed through before incentives kick in. I'm familiar with plans in which exceeding certain scores in family satisfaction surveys will trigger a bonus payment. And there are a small but growing number of compensation plans that reward what we refer to as group citizenship -- or activities such as committee participation, or mentorship.

The metrics that are used, in the end, are not as important as the process of valuing physician activity.

Different Paths, But Same Destination

I've learned that there are many paths to a full-time practice in Hospice and Palliative Medicine(HPM).

Two physicians (Drs. Cote and Martin) with thriving hospice and palliative medicine practices are profiled in the most recent issue of HPM Practitioner. Both started in private practice, one in internal medicine and the other in family medicine. One put down roots in his native Rhode Island after completing his residency, started working part-time for the local hospice and gradually increased his role until the hospice position became full-time 21 years later. The other has practiced in diverse hospice settings and moved his family cross-country several times in pursuit of opportunities for career development. But both are doing the work they love in hospice and palliative medicine full-time, seeing patients while building innovative end-of-life care programs.

Monday, April 12, 2010

Evolving Role of the HPM Physician - What Will the Third Generation Look Like?

Most would agree that the role of the Hospice and Palliative Medicine (HPM) MD is evolving – or moving into a second generation. The first generation has been characterized by contractual relationships, usually hourly pay, for a part-time medical director role. That role describes, by the way, the predominant arrangement today. It is giving way to the full-time MD, and to compensation arrangements that are typically 100% guarantee, accompanied by subsidies.

But we are starting to see pushback by program sponsors to continued subsidization – and I would respectfully submit that a physician specialty cannot be sustained when it is dependent upon subsidies. Look no further than geriatrics, if you need an example. There are 5% fewer certified geriatricians (7,345) today than 10 years ago, or, put another way, roughly half the number currently needed, according to estimates by those who have studied this workforce issue. Why is that? Surely not because there is less of a need for geriatric specialists. Geriatric services are no longer subsidized by hospitals at the rate, and amount, that they were just a decade ago, and a result compensation has not risen to levels that make the field attractive.

What will be the next (third) generation role of HPM physicians? And, how will those physicians be paid? I would watch closely to what Medicare Advantage plans are doing when it comes to reimbursement. Think bundled payments, or global capitation. What other likely scenarios do you see?

Sunday, April 11, 2010

Accountable Palliative Care Organizations (APCOs)

Recently I was asked by a client to describe the role of Accountable Palliative Care Organizations (APCOs) in creating exemplar practices around "late-life" care within a community (see here for a previous post describing exemplar communities). The client is situated near a shopping mall that had been struggling until it recently brought in a major department store - a topic which had been a subject of an earlier conversation that day. An APCO, I replied, is like an "anchor tenant" of the palliative care community, setting norms to encourage the free-flow of ideas and collaboration, producing enduringly successful communities.

Within these APCOs, physicians , hospices, hospitals, and long-term care facilities adopt measures to blunt harmful financial incentives, thus taking collective responsibility for improving care for those with advanced illnesses (what I'm terming late-life care). Much has been written and commented of late about the role of financial incentives in the health care system, and what provisions in the health care reform bill could bring about better outcomes while containing costs.

I'm curious to learn your thoughts and experiences, as we explore this subject in greater depth in future posts.

Tuesday, April 6, 2010

Palliative Care Grand Rounds - April MMX

A grand welcome to the April edition of Palliative Care Grand Rounds (PCGR), a monthly (first Wednesday) summary, or mash-up, of thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere. For a look back at year-to-date PCGRs, see here, here, and here. Now, onward.

With the landmark health reform bill commanding news throughout the past month, I’ll focus on blog posts relating to palliative care that any of us might have overlooked. First, a summary of how health reform may impact hospice via Larry Beresford’s post .

A higher than usual volume of current blog postings concern futile care. To wit, the Happy Hospitalist writes in his Unfiltered Hospital Medicine Blog about a recent case that highlights for him, just as for many who posted comments, the ethical issues surrounding futile care. So is this particular case an extreme example? Or is it more common than you or I realize? Decide for yourself.

Meanwhile, a neurologist with the blogger moniker of Dr. Grumpy writes about another example of futile care that’s sure to give pause to each reader.

Then there’s Joanne Kenen, a veteran journalist who logged more than a decade covering health policy on Capitol Hill. As Senior Writer in the Health Policy Program at the New America Foundation, Ms. Kenen’s blog focuses on the intersection between health policy and health politics. Read here for her reaction to an essay “Shock Me, Tube Me, Line Me” penned by an
Emergency Medicine specialist in the esteemed journal Health Affairs. Its author, Boris Veysman, an ER doc at a New Jersey academic medical center, describes caring for a terminally ill woman suffering from metastatic cancer. Her wish—to have a low-tech death, free of tubes and machines—both countered and confirmed his to have “everything” done to prolong life when his time comes. A provocative read.

Larry Beresford, host of last month’s PCGR, posted recently about the discussion circulating more widely these days on declining enrollment at hospices. A decline in hospice referrals, Larry posits, may correlate to what the economists refer to as a necessary market correction.

The critical nexus of death and religion often fascinates Ann Neumann. In her blog Otherspoon, she weighs in with a thoughtful piece on the role that three institutions (church, state, and health care industry) play in the national structure of late-life care.
Concurrently, her post grapples with the racial disparities prevalent in hospice enrollment.

I’m indebted to Christian Sinclair for facilitating my role as Grand Rounds host in his post . It nicely crystallizes several blog posts that have deservedly garnered much attention and discussion.

Dr. Michael Kirsch asks in his blog “Are Feeding Tubes Futile Care or Morally Obligatory?” See where you stand.

A family medicine physician who writes a blog, Musings of a Dinosaur, posted last month that “Palliative Care is an Unnecessary Specialty”. Well, as you’d expect, this view generated considerable discussion throughout the blogosphere. Some came from Buckeye Surgeon, who comments occasionally about palliative care, posting these comments.

On Geripal, Alex Smith writes about how his “What is palliative care?” response has evolved. Today, he starts by saying, "Palliative care is about matching treatment to patient goals." Hard to argue with that.

Are you curious how physicians choose to practice in hospice and palliative medicine? In the first edition of Pallimed’s new feature, Origins, Pam Harris, who recently passed her Physical Medicine and Rehabilitation boards and is HPM-certified, details what drew her to the HPM specialty.

Suzana Makowski joined Pallimed last month as a blogger, posting about emergency room use by patients with cancer approaching end of life. Dr. Makowski adds her suggestions to those of the study’s author on how ER visits could be reduced. One notion: establishing “palliative care medical homes” that provide palliative care seamlessly across healthcare settings.

Risa’s Pieces has been a blog whose posts have been regularly featured in PCGR. In this post,
Risa writes about her new roles in and out of end-of-life care.

Over at the blog Death Club for Cuties, look for a new feature titled Memorial Monday.
Blogger Jerry Soucy visits a site called Find a Grave, searches through its database to find the people who died on the particular date of a given Monday, and then selects an entry that has some relevance to palliative care, or that otherwise resonates with him personally.

Next month’s host is Thaddeus Pope, at his blog Lots of March posts on the subject of yes, medical futility. Among these posts you'll find many video links, one of them of a short film nominated for Best Animated Short Film at the 2010 Academy Awards. I think you'll find it worth eight minutes of your time. And while on the subject of the connection between the arts and death and dying, have a look at Pallimed's Arts and Humanities blog and postings by Drs. Christian, Clarkson, and Wollesen.

Of course, your comments are, as usual, invited.

Tuesday, March 30, 2010

Minimum Volume Thresholds - Do They Apply to Late-Life Care?

The Volume-Outcome Relationship

Over the past 30 years, there has been considerable research on the relationship between surgical volume and outcomes for a variety of complex procedures. The proposed cause of the relationship is intuitively simple: practice makes perfect. Surgeons who perform high volumes of, for example, coronary artery bypass surgeries (CABG) per year are expected to have improved outcomes over surgeons who perform low volumes.

The finding that higher procedure volumes by facility and by surgeon are associated with improved outcomes has led to the development of minimum procedure requirements. These initiatives promote patient care by surgeons and facilities who meet certain volume thresholds. Guidelines published by the American Heart Association/American College of Cardiology specify the minimum number of procedures performed annually by cardiac surgeons.

Perhaps the most influential initiative has been the selective purchasing strategy of the Leapfrog Group (, a large coalition of public and private purchasers of about $60 billion of health insurance annually. Members include many Fortune 500 companies such as Chrysler, Cisco Systems, Inc., IBM and Verizon. The Leapfrog Group’s mission is to trigger giant leaps forward in the safety, quality, and affordability of health care by "supporting informed healthcare decisions by those who use and pay for health care and promoting high-value health care through incentives and rewards."

As part of its “Evidence-Based Hospital Referral” guidelines, the Leapfrog Group recommends that its members contract for selected surgeries, including CABG, only with hospitals that meet minimum volume thresholds.

In line with Leapfrog’s initiatives are state regulatory policies towards the regionalization of healthcare. These projects aim to concentrate certain medical services in facilities throughout the state. The most widely adopted approach towards regionalization is state-based certificate-of need-programs. Think Florida and hospice. The goal is to distribute certain specialized procedures and services rationally and efficiently across the state.

Initially devised to restrain increasing healthcare costs, these programs have led towards concentration of specific procedures to high volume facilities. New York State is considered by many students of this issue to be a model for the successful regionalization of healthcare. One study by Hannan et al. titled “Improving outcomes of coronary artery bypass surgery in New York” showed that increasing the number of CABG procedures performed at high volume hospitals decreased the risk-adjusted mortality rates by 41 percent. Another study demonstrated the positive effect of certificate-of-need programs on percutaneous coronary intervention outcomes across a number of states. The authors showed that in states with certificate-of-need programs, Medicare patients with acute myocardial infarction were less likely to undergo revascularization procedures than patients in states without certificate-of-need programs.

So, do minimum volume thresholds have a role in improving late-life care, or put another way, is the spread of a health service innovation, like palliative care , accelerated or slowed as a result of organizational concentration? The NHPCO FY2008 National Summary of Hospice Care shows that 40% of hospices care for fewer than 25 patients per day, and that 80% of hospices care for fewer than 100 patients per day. Perhaps more to the point, almost half of this nation's hospices ADMIT less than 150 patients per YEAR (or fewer than three every week). The obvious question is, are Florida's hospices delivering better late-life care because of their volume of patients. Hard to say, because there are few agreed-upon measures of the quality of late-life care. Yet, what is widely acknowledged is that Florida's hospices make more expansive use of Hospice and Palliative Medicine (HPM) physicians. That must count for something in spreading the influence of hospice and palliative care, don't you think?

Monday, March 22, 2010

An APCO Developing in Asheville?

In a recent post (read here), I commented about the exemplary results of Asheville, North Carolina in the DAI Community Palliative Performance Profile. To learn more, we interviewed Janet Bull, MD, VP of Medical Services for a not-for-profit hospice (Four Seasons) serving the Asheville area.

Some excerpts:

"We are very heavy in physician staffing, and think that is a good real positive," with the physicians mainly out making billable visits to hospice patients and serving as attendings or consultants on about 80 percent of patients enrolled in hospice care, she explains. "They actually paid for themselves last year."

Essential to the palliative care program's success was being clear on what kinds of patients it would see -- or not see. Dr. Bull continues, "We learned early on that we can't be all things to all people. We didn't want to be a chronic pain service or post-acute, post-surgical consultants. We wanted to stay focused on serious, advanced illness, generally for patients with three years or less to live. At Four Seasons, we are all about delivering quality care and looking at measurable outcomes. We take our patient and family satisfaction surveys very seriously.The program emphasizes continuity of care across care settings. From the get-go, we saw patients where they were, and we followed them from one setting to the next."

Integrating the hospice and palliative care departments was also a priority. "Many organizations bump up against the problem of palliative care being viewed as a step-child to hospice. Here we value the great things palliative care brings, and how it complements hospice," Dr. Bull says."We consider ourselves one big team, whether palliative care or hospice, with a lot of interface between the two. Patients can flow both ways between these programs. We used an explicit strategy of building the connections between the two. Some employees serve both programs, and we share resources and administrative tasks, integrating them whenever we can," she reports. "Often at staff meetings we'll have presentations by palliative care leadership or providers, explaining their work to hospice staff. We focus on education, both internally and externally, explaining the differences between hospice and palliative care, and how they complement each other. We inform patients that hospice offers many more services than palliative care."

Seems to me that what we're seeing in Asheville is the early development of an Accountable Palliative Care Organization, led by a chief palliative care officer for the community. Surely, there are other factors contributing to Asheville's performance, but just as surely one cannot underestimate the value of a strong and well-developed medical staff of HPM specialists.

Improvisational Nature of Palliative Care , and APCOs

I'm often asked why the Accountable Palliative Care Organization (APCO) model is vital to the success of palliative care programs. There are many reasons, of course, but here's one at or near the top of my list. Currently, there is no third-party reimbursement specific to the provision of palliative care, although palliative services are often billed in other reimbursement categories, most frequently, the hospice or home health benefit, and physician or nurse practitioner consultation services (in the hospital, long-term care, or home settings). In addition, there is no regulatory structure or standard-setting body for palliative care (although JCAHO has recently introduced proposed regulations and the National Quality Forum compiled in 2006 a compendium of 38 preferred Practices in Hospital Palliative Care). ( ).

The absence of targeted reimbursement and regulation is reflected nationally in the improvisational nature of palliative programs. The Accountable Palliative Care Organization (APCO) offers a structural model that improves the odds for success for a program’s sponsor. Improvisation does not have to mean trial and error, or fitful starts in a program's development.

An APCO provides the structure that brings together professionals to transfer knowledge across settings and disciplines, and the technical capacities through which staff across disciplines and settings are trained in palliative care- specific techniques and tools.APCOs have been successful models for improving delivery of chronic and end-of-life care because their characteristics encourage processes of care that are:
Timely – delivered to the right patient at the right time (early identification of patients)
Patient-centered – based on the goals and preferences of the patient and family, articulated in goals of care conversations
Beneficial and effective – demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)
Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

After all, aren't these processes of care all program sponsors strive for. Yet, so many of us struggle in developing successful programs. I'd like to learn your thoughts.

Tuesday, March 2, 2010

Palliative Care Grand Rounds - March MMX

Read here for this month's Palliative Care Grand Rounds, a round-up of the best from the blogosphere. This month's host is Larry Beresford, who has written extensively over the years on hospice and palliative care matters.

Sunday, February 28, 2010

Palliative Care - 1996 and 2010

More than 13 years ago, Philadephia Inquirer reporter Michael Vitez wrote a series about end-of-life care which won a Pulitzer Prize - see here for the first installment of that five-part series.

Some excerpts from that piece:

"Medicine has gotten so good at keeping people alive that Americans increasingly must decide how and when they will die. They must choose if death will come in a hospital room with beeping machines and blinking monitors or if it will come at home, with hospice workers blunting the fear and pain that so often accompany the final hours."
"The intensive-care unit offers a hope for recovery, but the price can be a miserable death. Deciding when to surrender can be a torture all its own."
"Advocates for change believe doctors are too optimistic, too sparing in what they tell patients. They say that families would be more willing to accept death earlier if doctors were more honest, more realistic. Reformers want to make sure that patients get the care they need, but not unnecessary or unwanted treatment. The key to humane and cost-effective intensive care is to treat those who will benefit, but not squander precious resources and impose futile treatments on those who will not. But often it is impossible to know who will live and who won't."

In today's Philadelphia Inquirer appears an article by Michael Vitez (read here), as part one of an occasional series on the dilemmas facing today's hospitals. The subject is how hospitals are addressing end-of-care issues, and in his article Mr. Vitez follows the work of the palliative care team, led by palliative medicine physician Dr. Diane Dietzen, at Abington Memorial Hospital, a large, suburban Philadelphia hospital. An insightful article, one that lays out in very personal stories the challenges faced by families and providers alike. In Mr. Vitez' words: "My goal is to spend a year at Abington, writing stories that show how one hospital deals with the biggest issues in health care today and also the changes that are coming fast and furious - regardless of what Congress and the President do - to hospitals and health care.
This first story looks at how the palliative care movement is medicine's response to the dismal way people have died. I try to show, up close, how the team works, the agony that families feel, the immense costs involved. "

Has much changed around end-of-life care in those 13 years? Surely, a patient in an ICU with a poor prognosis is more likely today than 1996 to be consulted by a palliative medicine physician such as Dr. Dietzen. But how much more likely, and if a consult is requested, is the timing appropriate? Just as surely, large variations in late-life care continue to persist among hospitals and communities, still raising questions about the appropriate role for acute hospital care in the management of patients with advanced illnesses.

As one of the doctors in the 1997 article stated ," America wants to offer the most advanced technology and treatments to everyone, yet keep health-care costs down."
How to balance those desires, the doctor added, "is a discussion nobody wants to have." Thirteen years later, when one considers the discussions taking place in the name of health reform, one must wonder how far have we advanced.