Improving Performance in Late-Life Care - A Modest Effort Starts in Philadelphia

I’m working with a small group of Philadelphia-area  hospital executives who have joined together in a campaign to improve late-life care in the region. While recognizing that many factors influence the overall performance of communities in how patients are treated in the final stage of life, these executives appreciate the enormous sphere of influence their institutions exert on their respective communities.

Until shown the DAI Palliative Performance Reports for their respective hospitals, these executives, all of whose hospitals reportedly have a palliative care service, felt  their institutions had been effectively caring for the late-life needs of their patients. Yet the hospitals’ performance lagged behind state and national benchmarks, and well behind the performance of  hospital exemplars.  The Philadelphia region’s performance similarly lagged.

Examples abound.  According to the DAI Palliative Performance Profile (P3) for Philadelphia, a Philadelphia resident will spend 20% more days in a hospital during last six months of life than the national average, and twice as many days as would a resident of the exemplar region of Portland, Oregon. The Philadelphia resident is one-third more likely to die in a hospital than his counterpart in Portland, and twice as likely to have had an ICU stay associated with that terminal hospitalization.  On a positive note, at least one indicator shows Philadelphia to be performing better than national benchmarks – while 41.9% of those who die in the US use the hospice benefit, 44.6% of Philadelphia residents received services from a licensed hospices prior to their death. Yet considerable opportunity  remains for improvement.
How much? Consider that in 10% of communities  across the nation (the exemplar benchmark)  more than 55% of their decedents utilized the hospice benefit.

While few of the executives were surprised by Philadelphia’s poor performance in late-life care, most were surprised by the enormous gaps between the region’s performance and that of exemplar communities. Yet, should we be so surprised? After all, the Dartmouth Medical Atlas (from which the DAI P3 draws its data) has for years documented such variations. In a recent study titled Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness, the authors concluded that  geography continues to play a huge role in late-life care, noting that “care patients received in the months before they died depended largely on where they lived, and widespread variations persist.”

In future posts, we’ll take a closer look at what the DAI Palliative Performance Profiles tell us, and perhaps more importantly, how they might provide sharper focus for performance improvement campaigns, not unlike the modest effort  briefly described above. In the meantime, I invite your comments on the state of late-life care in your region, or the US, in general, and welcome your ideas on the sort of performance improvement campaigns which could make a difference. We’ll also take a closer look at exemplar communities (read here for an earlier blog post on this subject) and how do they do that?

Short-Stay Hospice Patients? Intractable?

Utilization of the Medicare hospice benefit by those dying continues to grow. In 2003, fewer than one out of every three Medicare decedents  received care from a  certified hospice. By 2007, that number had grown more than 30%, as 42% of decedents used  their hospice benefit during their final days (these figures are drawn from the Dartmouth Medical Atlas).

What hasn’t changed over that period are the number of short-stay (those who use the Medicare hospice benefit for a week or less) patients. One of out every three referrals to the hospice benefit.  So, late referrals continue to plague the hospice sector. Why? Theories abound, of course. You know them well, I’m sure.

And surely, it couldn’t be insufficient knowledge of hospice, as most hospices now deploy “community education” specialists to inform potential referring sources of their service offerings.  Prognostication tools have improved, so inability to confirm prognosis probably isn’t an explanation.

A growing number of HPM practitioners offer an intriguing theory.  It is, they say,  because the hospice benefit  does not “enable” concurrent care ,that is, curative treatment along with palliative measures. Patients, families, and physicians are hesitant to make early referrals to hospice  because the patient must choose to forego curative care.  Yet that does not lessen the need for, and the value of, palliative care. It simply means the providers of palliative care must be resourceful in marshaling the resources (reimbursement) to provide palliative care.   Palliative care, to be sure, may be provided under many health  plan benefits, including, of course,  the hospice benefit, the home health benefit, and Medicare Part B, for physician outpatient or home-based  visit coverage.

I'm curious to learn your experiences in this regard. Does this "concurrent care "disabling" theory hold true in your experience? 

Use of Hospice Benefit Grows, Late Referrals Persist

A recent discussion at a regional meeting of Hospice and Palliative Medicine practitioners grew lively when the subject turned to use of hospice, and whether use has grown. Following the meeting,  I reviewed NHPCO reports for 2010 and 2005. Turned out opposing viewpoints were each right, to some extent. Here's what I concluded.

• 30% growth in the percentage of Medicare decedents using hospice benefit. Impressive! 
• Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. Intractable?
• The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. Subscale?

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 twenty 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?

Trends in Hospice and Palliative Medicine (HPM) Physician Compensation

Compensation for expertise does not always follow the supply/demand imbalance. Hospice and Palliative Medicine (HPM) physicians are a current example.

I’ve  been monitoring compensation practices for full-time HPM physicians for the past five years. Through  2010, I relied upon the Compensation Reports compiled by DAI Palliative Care Group (disclosure: I am employed by its parent company). I now rely upon the recently published report of HPM physician compensation and benefits, drawn from the findings of a survey by the American Academy of Hospice and Palliative Medicine (AAHPM) of its members. Nearly 800 AAHPM physician members responded to the survey conducted in November 2010, providing information regarding their 2009 compensation from practicing Hospice and Palliative Medicine (HPM).

As I review the reports over the preceding five years, several observations come to mind:

• Compensation for full-time HPM  physicians continues its rise, yet at a  slower pace than one would expect from a field marked by a shallow talent pool.
• The gap in compensation based upon place of employment is narrowing. Compensation for hospital based HPM physicians is somewhat greater than that for hospice-based physicians, but the difference is decreasing.
• Differences are insignificant for physicians practicing in urban, suburban, or rural areas. There are some regional differences, yet these too are insignificant. The greatest determinant of higher compensation is practicing HPM in a certificate-of-need state, such as Florida, where there is a concentration of larger-than-average size hospices who are more likely to deploy full-time physicians.
• Salary compression, unsurprisingly, is characteristic of the specialty. Average compensation for three position layers (team physician, associate medical director, and medical director) are little more than 10 percent.The best way to improve one’s compensation is to move into leadership positions, typically within hospices.
•  Compensation lags behind that of other specialties and primary care physicians (according to the 2010 AMGA Medical Group Compensation and Financial Survey the median salary for  is $214,000 for internists, $208,000 for family practitioners,  and $267,000 for emergency medicine physicians) .

The 2010 AAHPM report is chockful of information relative to compensation, benefits, and workload. I recommend its purchase (click here).