Challenges of Expanding Palliative Care

Why are we not likely to see the influence of palliative care advanced during the health reform period? Two reasons leap to mind.
One, hospitals and hospices are the most prominent, and frequent, sponsors of palliative care programs, and we know what’s happening to their reimbursement (it's getting squeezed, with no end in sight). So, as these provider organizations are forced to tighten their belts, is it reasonable to expect (especially in light of the heightened priority on patient safety ) hospitals to increase their financial support of palliative care services? Furthermore, it’s unlikely that the financial performance of hospices will dramatically improve anytime soon. So, we shouldn’t expect a legion of hospices across the nation committing greater resources to palliative care services. It’s not that hospital and hospice executives are tone-deaf to palliative care. It’s just that these executives are faced with budgetary trade-offs and palliative care is not (yet) a high priority.
Two, primary care continues to be undervalued within the American medical system. Will these prevailing views change? Of course. Anytime soon? Unlikely. American primary care is in shambles, and it is now clear that it will not be viable in the future unless significant changes occur in our national attitude about its value and in the way we pay for it. While in other developed nations, 70-80 percent of all physicians are generalists and 20-30 percent are specialists, in America the ratio is reversed, the result of a payment system that has evolved to reward expensive care and penalize proactive management, even though the data are unequivocal that more palliative care (according to the Dartmouth Medical Atlas) within a community results in lower costs and better late-life care.
The result of our studies into the compensation of palliative medicine physicians is revealing. Specialists typically take home at least double the income of the palliative medicine practitioner. Medicare’s payment system, which is the basis for most commercial payment as well, favors specialists in two ways. It pays them a higher rate for their time (implying that what they do is more difficult and more valuable), and it allows them to earn money through procedures that are unavailable in primary or palliative care.The career-choice implications of these financial dynamics are not lost on medical students, who have been diverted in droves away from what many apparently see as an unrewarding primary care office existence. Between 2000 and 2005, the percentage of medical school graduates choosing Family Medicine dropped from a low 14% to an abysmal 8%. Among Internal Medicine residents, an astonishing 75% now end up as hospitalists or sub-specialists rather than office-based general internists. By the way, average salaries for hospitalists are nearly 30% higher than those for palliative medicine physicians.
What I find discouraging is that the reform discussions and proposals have not addressed the issue of reimbursement for primary care . Tell me, please, that I’m missing something here. More on this conundrum of primary/palliative care to follow in future posts.

The Unofficial Role of a Community Chief Palliative Care Officer

In a recent post (see here) I commented on the exemplary performance of Susquehanna Health System (in Williamsport, Pa.) in its end-of-life care practices, according to the DAI Palliative Care Group Hospital Performance Profile. In researching communities and health systems whose palliative practices have earned them an A grade, we're finding several common attributes. One of these attributes is the presence (usually unofficial or sometimes formalized) of a chief palliative care officer. Below are excerpts of an interview with Alexander Nesbitt, MD, chief of palliative care and hospice for the Susquehanna Health System, which appeared in a recent issue of HPM Practitioner.

Dr. Alexander Nesbitt was an established family practice physician and very part-time hospice medical director in Williamsport, PA, when he heard a 2003 presentation by Dr. Diane Meier, director of the Center to Advance Palliative Care (CAPC). "I had never heard of palliative care, but I became convinced that it was a really good idea, and that somebody in Williamsport should do it." He attended the Program in Palliative Care Education & Practice at Harvard Medical School (www.hms.harvard.edu/Pallcare/PCEP.htm) and began working toward board certification in HPM, earning that credential in 2004. He pursued an expanded role in Susquehanna Hospice and started advocating for a palliative care consultation service at 180-bed Williamsport Hospital & Medical Center. Both belong to the local Susquehanna Health System."The idea of starting a new program, which included hiring a full-time nurse practitioner to staff it, was an uphill push. I had to convince the hospital's administration that we should spend the money, even though the system was undergoing financial difficulties. Fortunately, CAPC has highly practical tools to use, well adapted to just that purpose." Dr. Nesbitt is an employee of the health system, which employs about half of the physicians in its region. "I had been working with administrators every step of the way, persuading them of the importance of this work - for patients and families, as well as for the system - and sharing outcomes data." When it came time to transfer full-time to hospice and palliative care, the various responsible parties were ready to sign off on the change. Dr. Nesbitt's salary is based in part on billing income from palliative care and inpatient hospice consultations, annualized, as well as an hourly rate for dedicated administrative responsibilities, which amount to nearly half of his roughly 50-hour week. "Although initially I wasn't so sure, I felt I could set it up piece by piece, and make a job of it," with the combination of hospice and palliative care a good package for the system, he says. "There's increasing information out there that this work is beneficial for the patient and family, for the reputation of the hospital, for customer satisfaction, for the bottom line, and for readmission rates."
In the beginning, Dr. Nesbitt took the lead on hospital palliative care consults, but as the program established its credibility, the nurse practitioner now makes over half of the visits. Another palliative care physician joined the team in 2007 and sees patients in affiliated, rural Muncy Valley Hospital, 10 miles away, and in the region's nine long-term care facilities. In addition to the hospital-based nurse practitioner, there is a second nurse practitioner based in the nursing homes, and an advanced practice nurse who sees patients in nursing homes and coordinates professional education events."Within the (HPM) team, each of us has a primary base, but we also work to float extra team time to wherever it is needed," he explains. The five members meet monthly to discuss practice issues. Growing demand for services is a problem, and the team tried to manage growth in sustainable ways while it extended services into the long-term care setting. Recently, it was decided to limit weekend palliative care consults to emergency cases only. "Sometimes we're really busy on the weekends, so we're working to make that part of this work more manageable," Dr. Nesbitt says. Dr. Nesbitt starts a typical workday by rounding on patients in the inpatient hospice unit, and then, depending on demand for palliative care that day, goes to the hospital. He makes occasional home visits to hospice patients and sees some patients in his office in the medical building. So far there is no formalized outpatient clinic setting or schedule for palliative care, although that may change in the next year, perhaps in conjunction with the system's Cancer Center. Dr. Nesbitt takes night and weekend call every third week, and he also meets regularly with various administrators within the health system's organizational chart. He spearheaded a POLST (physician orders for life-sustaining treatment) initiative in the region, working with the hospitals and nursing homes. The State of Pennsylvania does not give legal recognition to POLST, but a study group is working toward initiating a statewide form. He also chairs the hospital's ethics committee.

Surely, there are many factors contributing to the success of health systems and communities in their provision of late-life care to their patients and residents. I don't mean to ovrsimplify, but it's becoming apparent to us that the role of full-time HPM physicians is one of those influences.
I'm interested to learn of similar examples. Or, am I exaggerating the influence of HPM physician practices?

Palliative Care Grand Rounds - January edition

Visit here for the first Palliative Care Grand Rounds of 2010, hosted this month by Christian Sinclair, MD, a co-editor of the widely read and highly regarded blog Pallimed. Palliative Care Grand Rounds, now in its second year, is a monthly review of the best of hospice and palliative care content from blogs.

Emerging Role of Palliative Medicine Physicians is Straining Hospice Relationships

I've been intrigued recently by the spate of articles and seminars concerning themselves with the relationships between physicians and hospitals. Of course, hospital-medical staff relationships have been contentious for years, and consultants advising hospital executives on the most effective ways to align physician objectives with hospital goals is hardly a recent development. So, what do I find intriguing? That similar concerns are surfacing with greater frequency among hospices and palliative medicine physicians, as hospices build their medical staffs and expand the role of physicians within the hospice's clinical and administrative activities.

What we're seeing can best be described as role drift, where there is a disconnect between what the physician sees as his/her role, and what the executives and/or other clinical staff see as the physician's role. Such role drift is magnified in those palliative care organizations where resources are strained. I don't mean to oversimplify, but one will generally find fractious relationships in organizations where the HPM physician does not have:
-Clear roles, responsibilities, expectations and accountabilities
-Well-established performance measures and standards
-Performance management system that tracks performance and offers feedback.

I'm curious to hear your experiences, and what methods you've used to build a high-performing hospice medical staff.