Hospice and Palliative Medicine - Mixed Message

A recent post on the Geripal blog (read here) raised an interesting (and as it turns out provocative) question - would the specialty field of Hospice and Palliative Medicine be better off if the word Hospice were dropped and the specialty was known as Palliative Medicine.

Some say this is merely a matter of semantics, so why bother? I'd like to offer my thoughts, as someone who has been involved with "hospice" since the mid-80s.

The reason why this is an important issue is quite simply because it matters to the public. It matters because use of the terms together suggests to some that they are synonymous, and to others that they are distinct. I submit they are neither the same nor distinct.

In its earlier days, hospice described a concept of care. Over the past quarter-century (once hospice became covered by Medicare as a benefit), it has come to describe (define?) an organized and highly prescribed system through which end-of-life services are provided. The practitioners of these services have taken on, perhaps out of convenience, the name of hospice into their titles.It's analogous to surgeons describing themselves as Operating Room and Surgical Medicine physicians, or ER docs referring to their specialty as Hospital and Emergency Medicine. I'm sure you could think of other analogies.

Those receiving palliative care do so in many settings (home, hospital, SNF, outpatient office, assisted living, hospice inpatient unit) while utilizing various health benefits/coverages (of course the hospice benefit but also home health benefit, physician services, i.e Medicare part B )to pay for these palliative services. In other words, palliative care is provided by a host of professionals to patients during "late-life". Some, but certainly not all of these patients use the hospice benefit (provided by Medicare and most private health insurance plans) to cover the cost of palliative care.

A recent study commissioned by the Center to Advance Palliative Care found that much of the public did not understand or was not familiar with the term palliative care. But it's not only the public who is confused. The specialty's own practitioners are confused, and are unintentionally adding to the general misunderstanding. On the website of a prominent Midwest medical center, a reader comes across this comment,“Palliative care and hospice are different,” explained the medical director of the palliative care service.  “Hospice is restricted to people who have a prognosis of less than six months to live. However, palliative care does not have that restriction because it does more than just help people at the end of their life.” What does a patient, or family member do with such information? For that matter, what does a prospective referring source (a discharge planner, or family physician) do with that information?

The question we in the field should be asking is how we can best increase access to palliative care. If some of that palliative care is provided by a licensed hospice, reimbursed by the hospice benefit, fine. If some of the care is provided by a hospital, or a SNF, reimbursed by the physician services benefit, all to the good. If some of the palliative care is provided by a home health agency, reimbursed under a home health benefit, all the better. What matters is that a patient (and family) receive timely access to palliative care and its practitioners.

More on this subject in future posts. in the meantime, I invite your feedback.

Reducing Hospital Readmissions: A Role for Hospice and Palliative Medicine Practitioners?

Hospices and their palliative medicine specialists have proven, several studies have shown, to be effective at reducing use of hospitals for their patients. In fact, families cite avoiding transitions among multiple settings as one of the benefits of hospice. In a previous post, we've examined the role of palliative medicine physicians in reducing readmissions.
One of the first financial impacts to hospitals resulting from PPACA legislation is a reduction in reimbursement for excessive readmission of Medicare inpatients. Starting with discharges in October 2011, the impact of the payment penalties may be significant.

The Medicare Payment Advisory Commission (MedPAC) has estimated that nearly one out of every five Medicare patients admitted to the hospital is readmitted within 30 days and unplanned readmissions are estimated to cost Medicare approximately $17.4 billion annually. Readmissions have become a widely accepted measure of hospital effectiveness. Although only one of many performance metrics, low readmission rates do correlate with overall clinical excellence.

As part of the CMS value-based purchasing program, 30-day readmission rates are a performance measure already closely watched in the industry. Now PPACA legislation allows CMS to withhold a portion of all inpatient Medicare payments due to excessive readmissions, starting with up to 1 percent in federal fiscal year 2013, and rising to 3 percent in 2015 and beyond.

Hospitals will likely look to post-acute care networks to assist in managing the care of at-risk (for rehospitalization) patients. Should we consider deployment of palliative care specialists (physicians and nurse practitioners) by these networks to visit patients in their homes (especially but not only when a referral has not been made to home health)? If not palliative care practitioners, then who?

Exemplar Hospitals for Late-Life Care

Geisinger Medical Center, in Danville, Pa., has become a favorite of President Obama when he discusses models of health care delivery worthy of emulation (so has Mayo Clinic and several others, but that's a subject for another post). It set me to wondering: how well does their (Geisinger) model translate into late-life care? Using data of palliative outcome measures drawn from the Dartmouth Medical Atlas, the research staff at DAI Palliative Care Group compiled a Hospital Palliative Performance Profile for Geisinger. Not unexpectedly, Geisinger produced a Palliative Performance Score of 105, earning it an A Grade and Exemplar Hospital status. Geisinger scored well in deaths by location (its patients were 8% less likely to die in the hospital than the national average) but where its performance stood out was in avoiding use of the ICU during a decedent’s last six months of life (Geisinger’s rate was less than half of the national average).

The DAI staff identified at least two other Exemplar Hospitals in Pennsylvania – Lancaster General Hospital (Lancaster) and Susquehanna Health System (Williamsport).
Susquehanna’s score dazzled us – 130, one of the highest in the nation. There are seven palliative outcome measures used to develop the Performance Profiles – Susquehanna scored better than the state and national averages in six of seven measures. For one measure, hospital days per decedent during the last six months of life, Susquehanna’s experience was nearly 40% better than the national rate. Surely, there must be lessons to be learned here, practices to be emulated.

Could it be that an Accountable Palliative Care Organization (APCO) has evolved over the past decade, under the leadership of a chief palliative care officer in the Williamsport community? Is there a “bellwether” HPM practice which contributes to the Hospital’s exemplar status? Suffice it to say, for the present, that there are exemplar hospitals and communities whose performance in late-life care suggests that there remains considerable room for improvement for most hospitals, and in most communities.

A Closer Look at an Exemplar Palliative Care Community - How Did They Do That?

Previous posts have taken a look at exemplar palliative care communities (read here , here , and here ) and the factors contributing to their exemplary performance. In this post, let's examine more closely another community (LaCrosse, Wisconsin) whose late-life care practices earned it exemplar status in the DAI Palliative Community Performance Profiles. The aim of our (DAI Palliative Care Group) studies of such communities (and their health care institutions) is to identify communities that have achieved results suggesting high performance in late-life care, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. These studies are intended to enable other hospice and palliative medicine (HPM) leadership to draw lessons from the experience of exemplar performers that will be helpful in their own efforts to become high performers. These communities, and health systems within the communities, we believe, are well-positioned to develop Accountable Palliative Care Organizations (APCOs).

In LaCrosse County, Gundersen Lutheran Health System has a market share of 59 percent of the inpatient cases. Gundersen is a physician-led, not-for-profit integrated delivery system serving an area with more than 550,000 people in a tristate region that includes parts of western Wisconsin, northeastern Iowa, and southeastern Minnesota. The population it serves, which is both urban and rural, is healthier, less transient, and more educated—but older and poorer—than the national median. The hub of the system is a 325-bed teaching hospital, which serves as the western clinical campus for the University of Wisconsin Medical School and the University of Wisconsin–Madison School of Nursing. While the hospital has an open medical staff, fewer than 5 percent of credentialed physicians are non–Gundersen Lutheran employees.

One of the keys to Gundersen Lutheran’s strategy for improving quality of care and lowering its cost is the optimal use of medical resources for patients with complex conditions and minimal social support. Through a care coordination program, the health system identifies patients who are frequently hospitalized—or who make frequent visits to the emergency care or urgent-care clinics, lack strong support at home, or simply have difficulty coping with the complexity of their health care needs—and assigns them to one of 28 registered nurses and social workers who are trained to help them navigate the health care system. The care coordination program has demonstrated significant cost savings. Charges per patient after 12 months in the program have fallen on average by $7,300 (generating net savings of $5,100 after accounting for program costs of $2,200 per patient), as patients are hospitalized less and make less frequent use of the emergency department for care. The hospital uses the program for its health plan members as well as for the fee-for-service population, though doing so reduces its hospital revenue. “This is living up to [the] mission of improving the health of the community,” says Jeffrey E. Thompson, M.D., Gundersen Lutheran’s CEO.

Lutheran has also increased coordination of care at the end of life—a time at which medical expenses rise—by implementing a comprehensive system for understanding, documenting, and honoring patient values and goals for care at the end of life in all health care settings. The documentation begins with the creation of advance directives that spell out what actions should be taken in the event that a patient is incapacitated or is no longer able to make decisions. Advance directives are embedded in the system’s electronic medical records and are made available to all providers in all care settings. Discussions are held and reviewed periodically during many types of patient encounters to make sure that plans remain current.

A strong partnership with other local providers and community groups promotes advance care planning among community members before they become terminally ill.
A training program developed in partnership with a competing local health system, Franciscan Skemp Healthcare (a division of Mayo Health System), and other community groups helps promote a consistent approach to advance care planning among social workers, chaplains, and other volunteers who carry out community education.

Partnership with other hospitals and community groups is essential to ensuring that conversations with patients about treatment preferences at the end of life—and the documentation of them—are consistent across settings and sites of care. Without such assurances, providers are tempted to dismiss documentation of treatment preferences from competitors because they are uncertain of the methods used to collect the information.

A recent study involving 400 deaths of residents of La Crosse County at all health care institutions over seven months in 2007 and 2008 found that 96 percent had either a written advance directive or a Physician Order for Life-Sustaining Treatment (POLST), a standardized medical order that reflects patient choices about key medical treatments often used at the end of life. An internal study among these patients found that those with advance directives used $2,000 less in physician and hospital services in the last six months of life.

In 2005, the health system began offering palliative care services to patients with end-stage disease, which reduced the rate of readmission by nearly two-thirds and lowered hospital-billed costs per patient by approximately $3,500 in the first 15 months of the program. Hospice and palliative providers have access to inpatient and outpatient medical records via the EHR, helping to ensure that patients who have serious and eventually fatal chronic conditions obtain seamless medical care across multiple settings, including home and hospital.

Owing in part to these programs, the cost of inpatient care at Gundersen Lutheran in the last two years of life was $18,359, or 29 percent lower than the national average of $25,860. The number of hospital days in the last two years of life was 13.5, nearly 43 percent lower than the national average of 23.6, according to data from the Dartmouth Atlas of Health Care on chronically ill Medicare beneficiaries.

For physicians who demonstrate leadership potential, the organization has created a physician learning community that helps them understand the strategic and business side of health care. The group meets monthly with the organization’s leaders to discuss institutional challenges and engage in problem-solving. The community also provides an opportunity to learn and practice leadership skills. Gundersen Lutheran does not use an incentive-based compensation system. Instead, salaries are set to be competitive in the market. Physicians are evaluated for productivity and citizenship; the latter is defined by adherence to a physician compact. They are also evaluated on measures of patient satisfaction, disease management, and patient access, which are recorded in the health system’s dashboard. The measurement feedback is critical to improvement.

To address this, Gundersen Lutheran uses data on clinical and financial outcomes to set goals for physicians to aspire to. Department chairs and administrators are also evaluated on such measures, which may include disease management targets and patient satisfaction measures, as well as measures of financial efficiency.

Gundersen has received national recognition and ratings, and The Commonwealth Fund Commission on a High Performance Health System identified Gundersen as a health sytem providing high-value care.

Several points come to mind. The power of partnerships and collaboration across the community. The influence of a palliative care network that spans acute, outpatient, and home settings. The importance of setting ambitious targets, and then monitoring and measuring performance. For LaCrosse, it took 15 years to become an overnight success. For most other communities, time is not on their side. HPM leaders would do well to accelerate their efforts to build attractive and influential palliative care "enterprises."

Accountable Palliative Care Organizations - Pathway to Improving Late-Life Care?

The days of open access for hospice, regrettably, have yet, with few exceptions, to come to fruition. The hospice industry in the US has been taken over by single-purpose organizations who are adept at "enrollment management" - that is, identifying both low-cost patients who would be financially attractive(and encouraging these patients to enroll on the hospice benefit) AND high-cost patients who would be financial drains (and discouraging those patients from enrolling). And it is difficult to fault these organizations, as their managers are merely responding to the financial incentives built into the hospice benefit by Medicare and other payers.

 We are faced with the paradox that introduction of the hospice benefit has improved access to better end-of-life care, yet at the same time has come to define end-of-life care, and by extension, palliative care. It's similar to how 28 days of inpatient care came to define alcohol and drug rehab treatment merely because that's what the payers would cover.

How can we see further improvement in end-of-life care? By reorganizing how end-of life care is provided, so that "accountable palliative care organizations", of which hospices are an integral but not the entire piece, are the center of late-life care within health systems and communities.