Palliative Care Success

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

2011-11-28T09:51:00.000-05:00

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?

2011-11-25T20:08:00.000-05:00

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

2011-11-25T16:47:00.002-05:00

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

2011-11-25T15:22:00.001-05:00

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).

Hospice and Palliative Medicine - Mixed Message

2011-10-30T21:44:00.000-04:00

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?

2011-10-26T08:12:00.000-04:00

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

2011-10-14T09:45:00.000-04:00

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?

2011-10-07T11:13:00.000-04:00

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?

2011-10-04T13:59:00.000-04:00

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.

Tracking HPM Physician Performance - Physician Value Index

2011-09-27T21:25:00.000-04:00

At a recent regional symposium for hospice executives and chief medical officers, following a presentation on the building blocks of a high-performing medical staff, I was asked how I would assess if the performance of a hospice medical staff is "high-performing". Of course, there is no single answer, but we (DAI Palliative Care Group) have developed a tool that has successfully been used to benchmark performance.

Many factors weigh in upon the performance of HPM physicians within a hospice setting. Some factors can be quantified, many cannot not. So, based upon years-long study of hospice physician practices, our research group developed a metric we refer to as the HPM Physician Value Index , or HPM-PVI. As with other indices, such as an economic index used to track changes in the economy, the HPM-PVI is a single number calculated from an array of figures. In other words, it is a statistical composite that measures changes from one period to another, and can be used to help answer a question often posed by hospice executives - "how can I determine if I'm getting a reasonable return for the investment (physician compensation) in the medical staff"?

The HPM-PVI has served as a useful metric because it assigns a value to one of a hospice physician's principal activities - oversight of an interdisciplinary team. I invite your feedback and participation in our ongoing efforts to spread the use of this HPM physician value index.

Hospice and Palliative Care - Diffusing the Health Innovation

2011-09-27T20:43:00.000-04:00

A graduate student in a Health Policy program asked me during a Q&A session at a national colloquium why I characterize end-of-life care in this country as three parts potential for two parts accomplishment. I've been asked similar questions before, but what gave me pause this time was the context of the query (the workshop was addressing the issue of access to hospice). The previous speaker had just presented a strong case statement on why access to hospice has been threatened by the "cap". And why the main reason for the decelerating growth of hospice was poor reimbursement.
I replied that the delivery system for late-life care is fragmented, and there is insufficient collaboration among providers within most communities. Thus, conditions are uninviting for the "spread of the science" (palliative medicine and nursing). The Center to Advance Palliative Care (CAPC) has effectively spread the science throughout the hospital sector, as it relates to hospital-based palliative care services. No small accomplishment, to be sure. But the other major palliative care providers (hospices) have been slow to scale, in part because hospices have taken competitive stances to protect their market share rather than the collaborative approach which studies have shown to be more conducive to the dissemination of best practices. A recent post described the current structure of the hospice industry. Communities known as providing high-value late-life care are characterized by several attributes - one of the most defining is a coalition (some might say network) of palliative care stakeholders (organizations and individuals) which come together to deliver care across settings and boundaries. The beginning of an Accountable Palliative Care Organization (APCO), some speculate.

The structure of the social system can facilitate or impede the diffusion of health care innovation, concluded Thoms Bodenheimmer, MD, in a September 2007 report for the California Health Care Foundation on how innovations in health care become the norm. Do the current social systems in our communities best position HPM leaders to 'spread the science"? As always, your comments are invited.

Building Blocks of a High-Performing Hospice Medical Staff

2011-09-08T12:05:00.001-04:00

I'm asked from time to time what makes for a better- performing hospice medical staff. I'm unsure that there is a straightforward answer. The strategy of hospices building medical staffs is a recent and uncommon practice. Uncommon because the median daily census (in 2007) of U.S. hospices was just over 50, and more than three-quarters of hospices admitted fewer than 500 patients annually. Hardly sufficient scale to employ a single full-time physician, let alone a medical staff of five or more. By one rule of thumb oft cited for physician staffing levels (1 FTE per 100 ADC), only 18% of the U.S. hospices would consider employing a full-time HPM physician.
Those who have closely followed other health care sectors, such as home health and infusion therapy, are quick to point out that consolidation swept rapidly through these sectors once reimbursement was tightened or reformed, and sub-scale agencies found that size did indeed matter. Will hospices follow a similar pattern? I wouldn't want to wager a hospice's existence against it. So the hospices of the future will likely be larger. And with size comes the need for a medical staff structure that enables access and quality.

The structure may vary from hospice to hospice, but most will arrive at the right structure by careful and thoughtful building of the medical staff. Here follows, from our study, the eight building blocks.

· Create full-time “blended” practice opportunities that attract and retain HPM physicians
· Develop bench strength to account for volume fluctuations, departures, back-up coverage
· Amass “intellectual capital” for an infrastructure that supports an effective and efficient medical staff
· Deploy hybrid compensation models to align physician and hospice incentives, and reassess at least annually
· Maintain relentless focus on capturing information on physician activity to provide timely and constructive feedback and aid performance management
· Clearly articulate expectations among medical staff practitioners, medical leadership, and hospice management
· Create virtual organizational structure to extend influence of medical staff into greater community to reduce fragmentation of late-life care
· Foster an unswerving commitment to performance improvement to minimize inappropriate practice variation, reduce regulatory risk, and win the confidence of referring sources.

We'll examine, over the coming months, each of these building blocks with a little more precision. As always, your comments are invited.

Salary Compression Stalls Growth of Hospice and Palliative Medicine Specialty

2011-07-20T09:27:00.000-04:00

Hospices and hospital-sponsored palliative care programs are experiencing increased demand for physician services in clinical and quasi-administrative capacities (read here for an analysis by the Center to Advance Palliative Care on the growth of palliative care programs). As these organizations build their medical staffs by employing additional HPM physicians, they're finding that creating and filling "leadership" opportunities are proving to be a formidable challenge. Why?

The features of a compensation program which enable staff growth become liabilities when the principal objective of medical staff development turns to leadership building. Some compensation experts label it salary compression. Others refer to it as salary stagnation. Either way, it is the result of forces converging in the palliative medicine sector.

When there is a shortage of credentialed professionals, the imbalance between qualified people available to fill positions and the demand for physicians forces hospices, hospitals, and other program sponsors to offer higher salaries to attract the limited number of qualified applicants. And when insufficient revenue sources limit funding for medical staff development, those limited funds are typically used to attract new staff members. While such a priority enables staff growth, compression at the "senior" medical director levels typically results. Salary differentials between the ranks have an increased potential for erosion. And so leadership opportunities look unattractive, and prospects (both inside and outside the organization) shun opportunities that in all other respects represent a professional advancement opportunity.

Some hospices have implemented structural modifications to their HPM physician compensation program, with varying degrees of success. But success, nonetheless. It all begins with a reevaluation of the "value" placed upon HPM physician activities and responsibilities.

Improving Late-Life Care - Do We Know Exemplary Performance?

2011-07-19T20:58:00.000-04:00

We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.

For example, in a recent report Trends and Variation in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness (read here), we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable for late-life care across settings within a specific community or region? Any of these, or all of them?

And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care? As always, your ideas and opinions are invited.

What Do Hospice and Palliative Medicine (HPM) Physicians Look For in a New Opportunity

2011-05-26T11:24:00.001-04:00

I'm often asked what has made us (DAI Palliative Care Group) successful in recruiting palliative medicine physicians. There are, of course, a number of reasons. Experience is one. Our experience "informs" our recruitng efforts. We've made a study out of understanding what physicians look for. We've come to appreciate "What's Important in a Practice Opportunity to Palliative Medicine Physicians".

We 've learned from our experiences in HPM physician recruiting that most prospects evaluate practice opportunities through four filters. Let's refer to these filters as:

Rewards (monetary)
Community/environment (supportive culture of teamwork and recognition of contribution by HPM physicians)
Workload schedule (manageable workload and sustainable schedule)
Autonomy/control (ability to impact key factors that affect job performance).

Of course, each physician will place his or her own value upon each of these criteria in career decision-making. The key to recruiting physicians (particularly in a market where demand far exceeds supply) is to create a practice opportunity that recognizes and addresses all four filters in a balanced way.

Future posts will offer more detail into each of these filters and recommendations on how to create the "balanced" HPM practice opportunity.

Recruiting in Markets Where Demand Exceeds Supply

2011-05-25T13:56:00.000-04:00

From time to time, clients inquire how they might best recruit a talented palliative care specialist. I've found success by utilizing recruitment approaches that have produced results in other markets where demand for talent exceeds its supply. In such markets, the scales are tipped in favor of the professional, in this case, the palliative medicine specialist.

How to best restore a balance? By understanding how specialists in short supply make career decisions, and then using methods that can best reach those "passive" candidates. The most commonly used method - job board postings - are most effective in reaching "actively-looking" candidates, usually in markets where supply exceeds demand. Such postings will typically not work in reaching "passive" candidates, since these individuals know well that, because of their relative scarcity, securing a new position is relatively easy.

Candidates in short supply need to be "approached and asked" and then "sparked and nurtured". This process is very demanding of time on the part of the hiring company /manager, and so frequently the "inside" recruitment team will be strengthened on an adhoc basis by bringing on a recruitment specialist with insider knowledge of the particular market.

When to Add a Hospice and Palliative Medicine (HPM) Physician to your Practice

2011-05-22T22:49:00.000-04:00

Most hospice and palliative medicine (HPM) programs and practices are experiencing growing demand for their physician services. These growing pains, obviously, can put a strain on current staff and the practice's infrastructure. A physician practice that is stretched beyond capacity because of an unfilled position cannot carry the patient and on-call load of a larger group for an extended period of time. The overtaxed and overwhelmed physicians are prime candidates to leave the practice, seeking opportunities where they can find better control over their workload. In other words, unfilled positions beget unfilled positions. That is why turnover is often referred to as the "silent killer" of a practice.

One of the most challenging tasks for a HPM medical director or practice manager is determining how many physicians are needed to staff the program. Since most HPM practices do not generate revenue greater than their compensation, knowing when to add a full-time physician is not an easy decision to make. But it is important to consider the costs and lost revenue associated with an unfilled position as well as the salary it takes to fill it. Take a hospital inpatient palliative care consult service, for example. A 2008 study by the National Palliative Care Research Center found that savings from palliative care consults for hospital inpatients ranged from $1,500 to $5,000 per admission. A palliative medicine physician who performs 40 such consults per month will produce savings of at least $60,000 per month for the hospital. Or take a hospice program with a palliative care consultation service and a physician making home visits to palliative care patients. One-third of those patients can be expected to transition to the hospice benefit, generating, on average, $1,500 in hospice revenue per patient. An HPM physician visiting 30 patients per month on the palliative service will produce $15,000 in patient service revenue for the associated hospice.

While these guidelines are handy in building a case, alone they do not make a clear case for when a physician should be added. Nor will the conceptual approach, projecting the work for a time period (e.g., 5,000 home visits/year) and dividing that projection by the amount of work performed by one FTE HPM physician (e.g., 920 home visits/year). Careful consideration of several other factors will also enhance the decision-making process: use of non-physician providers, such as nurse practitioners; variation in workload (need to staff higher than the average to address spikes in service demand); expectations around nonclinical commitments that may include administration, teaching and research; and the need for off-hours coverage, vacations and the like. The right timing in adding a physician to a HPM practice will likely accelerate success. Mistiming will stymie program (and practice) growth. In future posts we will look more closely into effective ways to attract the right candidates to your practice.

Palliative Care Grand Rounds - May 2011

2011-05-11T00:12:00.001-04:00

Hiatus over. Welcome to the May edition of Palliative Care Grand Rounds (PCGR), a monthly (now appearing the second Wednesday of each month) summary, or mash-up, of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.
Several topics dominated the news, and thus the blogs, covering palliative care. Prescription opioid abuse is one, and Drew “Feeling Grumpy” Rosielle addressed this subject in his post on the blog Pallimed.

Also, on the 16th of last month bloggers united around the 2011 Blog Rally for National Healthcare Decisions Day (NHDD). Nathan Kottkamp founded NHDD back in 2008 as a nationwide advance care planning awareness initiative. Larry Beresford, accomplished hospice journalist, took up the torch in posting a personal story about completing his own advance directive. In the blog Hospice Doctor, a palliative medicine specialist muses about the decision-making process (for clinicians and family) behind the care of an 88-year woman whose death in a hospital followed 11 days there with considerable (some futile?) treatment.

Which leads me to the third subject in the April palliative care news stream. The Dartmouth Atlas of Health Care has released a new report, "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness," documenting trends in the care of chronically ill patients in the last six months of life. This report was covered extensively in the mainstream media, less so in the blogosphere. You can check the PBS NewsHour coverage of this story in this post on its blog.
Then see the comments this blogger posted regarding the huge and persistent variations across hospitals, communities, regions, and states. If you agree that these variations in late-life care practice appear intractable, share with us your thoughts—what do you think can be done?

GeriPal bloggers Drs. Eric Widera and Alex Smith were themselves featured in a New York Times blog post. Together with colleague Dr. Sei Lee, they are developing a Web site that offers individual prognoses based on 18-20 different geriatric prognostic indices. When you visit the blog post, be sure to spend a few minutes reviewing the comments. Here’s a topic that apparently resonated with many readers.

And speaking of the blog GeriPal, congratulations on being chosen as the Best Clinical Weblog of 2010. In one of its April posts, it looks more closely at the results of a study on nurse practitioner models of palliative care. And Geripal blogger Alex Smith jumped over to another blog, Kevin MD, to comment on
the hospice and palliative care community’s unrelenting yet fruitless search for a simple and consistent message. Speaking about a message that benefits from consistency, and also at the blog KevinMD (its tag line is “social media’s leading physician voice”), a geriatric psychiatry fellow posts that palliative care and medical interventions are not mutually exclusive.

Many thanks to Christian Sinclair for originating Palliative Care Grand Rounds several years ago, and for sustaining it since. But to state the obvious, PCGR’s continued publication depends upon fellow bloggers…like you. Do let Christian know of your interest in adding your incisive post.

National Healthcare Decisions Day - April 16

2011-04-15T09:23:00.000-04:00

This post is part of the 2011 Blog Rally for National Healthcare Decisions Day. If you have a blog please post it and leave it up on the front page through April 16th. -Ed.

Rallying to Encourage and Empower Us All to Make Our Healthcare Decisions Now for the Unknown Later…

College education. Career path. Relationships. Starting a family. Buying or selling a house. Vacations. Retirement. From the age that we’re old enough to understand, most of us are taught and accept that these are the markers in life that we plan for. However, there’s one key marker that’s all-too-often missing from this list: healthcare decision-making. Like planning for these other life events, planning for the time (or times) that we are unable to express our healthcare wishes is of the utmost importance. It is something that should be well thought out, documented and revisited at different points in life to reflect any change in our desires or family situation or the person we wish to advocate for us. Unfortunately, it is a planning point that that majority of us have missed. As a consequence patients’ families suffer the added burden of having to guess when a health crisis happens. That’s why Nathan Kottkamp founded National Healthcare Decisions Day (NHDD) back in 2008 and why this nationwide advance care planning awareness initiative is as important as ever. So this year, I’ve joined my fellow bloggers throughout the country to spread the word about the importance of advance care planning with this special NHDD edition blog.

NHDD, which happens every April 16, is a collaborative effort of national, state and community organizations as well as dedicated individual advocates committed to ensuring that adult Americans – like you and me —have the information and opportunity to communicate and document their healthcare decisions.

Here are some things you can do for yourself and your loved ones to prepare for NHDD 2011:

Lead by example. Schedule time with your loved ones to “Have the Talk” and complete your own advance directive. There are many tools, including free forms, you can use to walk you through the process and make your wishes known; access them through the NHDD Public Resources page.

Encourage your loved ones and friends to learn more about advance directives and to complete their advance directives. You can forward this link: http://www.nhdd.org/p/resources.html to them. Or, encourage them to find a nearby participant and attend a local NHDD event.

Share your advance directive with your healthcare providers and make sure it is on file in the event it is needed.

Already had the conversation with your loved ones, but want to do more? Here a few suggestions to rally support for NHDD and encourage even more action:

Like the NHDD Facebook fan page and share it with your Facebook friends

On Twitter? Follow @NHDD and share the information with your followers.
Send an email to your friends, staff, colleagues, lodge/social club members, and/or house of worship, telling them that you are participating in NHDD and encouraging them to do the same. Share the information above with them and/or use this template email:

April 16 is National Healthcare Decisions Day, and I hope that you will join me in taking this time to discuss and document your healthcare wishes. We all need to be prepared in the event of a health crisis, and having the talk is easier than most people think, but many of us need a little inspiration or a reminder to do it. I hope that this message and National Healthcare Decisions Day are all you need. Please mark your calendar for April 16 to have the talk with your loved ones. There are all sorts of free resources, including free advance directive forms for each of the 50 states, on the NHDD website: www.nhdd.org. Additionally, please help me spread the word with Twitter, Facebook, and LinkedIn. Advance care planning is something we ALL should do and encourage others to do, regardless of age or current health. Discussing your wishes can be one of the most important gifts you ever give your loved ones.

Act now and grow this rally further: use and share the resources available through the NHDD website and encourage and empower us all to make our healthcare decisions now for the unknown later.

Variations in Late-Life Care Persist - What Can Be Done? And By Whom?

2011-04-13T23:19:00.000-04:00

A recent blog post commented on the enormous clinical variation in late-life care. Another blog post remarked on the difficulty of "spreading the science of palliative care" because of the fragmented system delivering palliative care. And this week The Dartmouth Atlas Project issued a study - "Trends and Variation in End-of-Life Care for Medicare Beneficiaries with Severe Chronic Illness" - which further documented the enormous clinical variations across the nation as late-life (final six months) care is provided. The differences among communities is staggering, and these variations persist. For example, in 2007, chronically-ill patients in Manhattan spent, on average, 20.6 days in the hospital during their last six months of life, almost four times more than patients in Ogden, UT, where the average was 5.2 days. Chronically ill patients in Fort Lauderdale were half as likely to die in a hospital than similar patients in and around New York City. Is there a question as to which region's late-life care practices better comply with patient and family preferences?
The report documents trends from 2003 to 2007 in the use of medical resources to treat Medicare patients at the end of life at hospital referral regions and at 94 academic medical centers. The study found that Medicare patients diagnosed with severe chronic illness were less likely to die in a hospital and more likely to receive hospice care. They also had many more visits from physicians, particularly medical specialists, and spent more days in ICUs. The overall picture, one could say, is mixed; although patients experienced fewer hospital days and more hospice care, at the same time therre was an increase in the intensity of care for patients who were hospitalized.

"In addition to its effects on patients' quality of life, unnecessarily aggressive care carries a high
financial cost. About one-fourth of all Medicare spending goes to pay for the care of patients in their last year of life, and much of the growth in Medicare spending is the result of the high cost of treating chronic disease," said David C. Goodman, MD, lead author of the report, in a media release. Elliott S. Fisher, MD, report author and co-principal investigator of the Dartmouth Atlas Project, perhaps put it best, "While current trends demonstrate that change is occurring in many regions and at many institutions, it is not always in the direction that patients may prefer." Dr. Fisher went on to say more work needs to be done "to ensure that future variation in care reflects the well-informed preferences of patients."

Chronically ill patients were significantly more likely to be treated by 10 or more doctors in the last six months of life in 2007 than they were in 2003. Visiting such a number of physicians certainly must place a premium on effective care transitions. Is our current system well structured to enable effective and coordinated patient transitions?

Future posts on this blog will take a closer look at the findings of this Dartmouth study, and examine those regions, and academic medical centers, that may offer promising approaches. In other words, we'll identify exemplars.

We need to be better at disseminating the science and art of palliative care to reduce these clinical variations. But how to do that, and who should be leading the effort? Should we take a closer look at a national campaign to improve late-life care, like the 30/30/30 Campaign described in a previous post on this blog. Your thoughts are invited.

30/30/30 Campaign to Improve Late-Life Care

2011-03-17T13:52:00.000-04:00

A Palliative Care Summit was recently convened in Philadelphia by the School of Population Health at Thomas Jefferson University. It was described as the “First National” and the “Leading Forum on Palliative and End-of-Life Care”.

An impressive array of speakers over the two days. Diane Meier,MD, Sean Morrison, MD, Don Schumacher, David Wennberg, MD, Christine Richie, MD, Terri Maxwell, PhD,APRN, James Cleary, MD.,Todd Hultman,PhD,APRN to name but a few. A roster of thought leaders in the field. Compelling cases were made during the presentations on why hospice and palliative care (is/are?) the solution to many of the health care industry’s woes. Meanwhile, just next door, other industry thought leaders were offering compelling cases on why “medical homes” or ‘expanded chronic care models” or “mobile technology” were desirable solutions for transformation of the health care system.

In other words, competing, or one might say, conflicting visions. These competing/conflicting visions exist across specialties, and within them. Dr. Morrison addressed this issue when he stated that the public and professionals are confused by references to hospice and palliative care , as if these were two distinct fields or sectors.

While my training is as a health executive, I’ve spent much of my professional career advancing the work of palliative care/hospice professionals and organizations. So I pay closer attention to the hospice/palliative care field, and how it may best fit into the larger health care system. And as Dr. Morrison stated directly, and others commented more indirectly, while progress has been made over the past 15 years, the institutional culture of dying in the US has not dramatically changed. I refer to palliative care as one parts accomplishment for every three parts of potential. Yes, we have a long way to go, indeed.

At the end of the Summit, I was left with a nagging question: If hospice and palliative care are such an obvious solution, then why hasn’t the “art” and “science” of hospice and palliative care spread more quickly and widely than it has? No simple answers to be sure. Yes, many of the speakers offered calls (some powerful) to action. Yet calls for action have been sounded for the past 15 years, with some, but most would argue, insufficient progress. Why? The promise of palliative care to improve late-life care has been stymied by a highly fragmented field of hospice and palliative care where stakeholders are perpetually “staking” out their ground.

Some suggestions for the Second National Palliative Care Summit. Let’s have discussions around:

How nursing AND medicine can best collaborate to improve access to palliative care in all settings across the community.

What NEW organizational models might best bring together key stakeholders in late-life care within a community?

What can be learned from communities whose late-life care practices make them exemplars?

Finally, we need a unifying campaign to improve late-life care in the US. Here’s a suggestion. The 30/30/30 Campaign. A national campaign carried out locally/regionally.

Something like the following:

No more than 30% of deaths occur in hospitals.
At least 30% of deaths in hospital are consulted by palliative care specialists.
No more than 30% of patients who die will be enrolled in hospice for 10 days or less.

Your comments, ideas, feedback are, as usual, invited.

Improving Performance in Late-Life Care

2011-03-10T20:51:00.000-05:00

I’ve now been involved in hospice and palliative care for 25 years, on the management rather than clinical side. During that time, I’ve seen how the principles of palliative care can improve care for those with advanced or serious illnesses. While hospice has been the organized vehicle through which much of this care has been applied, and there’s no disputing that improvements in late-life care have been made over the past couple of decades, hospice does have its linmitations. And so, I’ve spent much of my time studying organizational and business models that can successfully "distribute" palliative care principles across a larger population.

Part of that study has involved benchmarking on an organizational level, that is, using benchmarking principles to improve the performance of individual hospices. As a hospice executive, this exercise certainly has value.

There’s another measure of performance improvement. The firm with which I’m associated assists palliative care organizations in crafting medical staff development plans. These are staffing plans that are aligned with the organization’s objectives and the community’s needs. We’ve determined that one of the best ways to identify a community’s needs for palliative care is to use available data about the community’s practices around palliative care. The best source , we’ve found, of such information, is the Dartmouth Medical Atlas. The Dartmouth Medical Atlas began in 1993 out of Dartmouth University as a study of utilization of health care resources, generally inpatient resources, in geographic markets across the US. The study uses Medicare claims data. The Dartmouth research group has been updating and expanding its studies. Recently, a study was conducted of Medicare beneficiaries who died (decedents) between 2001 and 2005. This study analyzed use of resources (inpatient, outpatient, home, and long-term care facility), in the final two years of life. The results begin to answer the question of how we care for those with advanced illness.

The researchers concluded, among other things, that there is enormous variation (across regions, and across hospitals within those regions) in how people are cared for near the end of life. When one considers that 75% of Medicare resources are spent to care for those in the last two years of life, I would be understating to say there is great interest among Medicare officials and other payers on how care is provided. In fact, one of the calls to action the researchers recommended is that pay-for-performance programs should reward those practices that improve system-wide efficiency in providing care for those with chronic illness.

The goal of performance improvement as it applies to healthcare systems is to reduce variability in the way care is provided. And a key factor in closing the gap between best practice and common practice is the ability of health care providers and their organizations to rapidly spread innovations and new ideas. I'm interested to learn how palliative care specialists are "spreading the science".

Accountable Palliative Care Organizations (APCOs)

2011-03-10T20:34:00.000-05:00

Some of you have asked about the characteristics of APCOs. First, they are virtual enterprises, that is to say, unincorporated structures, that are 'sponsored" by a community-based health care organization, most often either a hospital (health system) or hospice.

Simply, the key elements of an APCO are:

-A Chief Palliative Care Officer (full-time physician credentialed in hospice and palliative medicine) accountable for palliative care services across all settings,

-Integrating tools that encourage dissemination of knowledge and promote collaboration across settings and disciplines (for example, APCOs have found Physician Orders for Life-Sustaining Treatment (POLST) www.polst.org to be just such an integrating tool),

-Multiple sources of revenue (hospice, home health, physician services) that offer opportunities for cross-subsidization of individual patient care and economies of scale on the expense side.

How one constructs an APCO depends on many factors, mostly related to the amount of "palliative intellectual capital" already in place at the sponsoring organization.

How Often Should Patients with Advanced Illness Be Visited By a Physician?

2011-01-13T19:11:00.001-05:00

We believe the role of the physician within hospices has been undervalued, and we would like to see the physician's participation increase in the care of long-stay patients. That’s one of the messages to take away from the CMS regulation mandating physician (or nurse practitioner) face-to-face encounters to certify a patient’s continued hospice eligibility. The Medicare program reimburses a hospice nearly $30,000 over a six-month period to provide for the total healthcare needs of a patient with advanced illness– a single physician visit to that patient’s residence over that period isn’t too much to require, is it?

To me, it seems likely that such patients would benefit from a care planning visit by a physician. After all, the distinguishing feature of hospice care from most other care covered by Medicare is its collaborative nature, and the primacy of the interdisciplinary team. Such care, of course, lies at the core of palliative medicine.

Rather than treating this regulation as a compliance issue, hospice executives, and physicians, would do well to incorporate physician recertification visits into their clinical practice patterns. One can be confident that patients, and their families, will appreciate the value of these visits.

Recently, a family member passed away after a broken hip confined her to a skilled nursing facility. A hospice program served her during her final three months. During that time, she was not seen by a hospice and palliative medicine physician. And while her (and the family's) hospice experience was positive, the interdisciplinary team concept seemed incomplete without a single bedside appearance from the physician.

HPM Physician Performance Management

2011-01-08T13:55:00.001-05:00

At a recent regional assembly of hospice executives and Hospice and Palliative Medicine (HPM) physicans who had gathered to strategize about the advantages (and disadvantages) of building a provider network for late-life care, I was asked what tools are available to measure performance of HPM physicians (and nurse practitioners). I suggested turning to the Joint Commission's standards on OPPE (which I have written about previously, read here) for a closer look into how hospitals are expected to evaluate their medical staff practitioners. How might these standards be applied for HPM physicians in the hospcie setting? Here's one approach to applying physician performance core competencies to HPM practitioners we've found successful:

Patient Care. Providing patient care that is compassionate, appropriate and effective for managing
late-life care.

Medical/Clinical Knowledge. Degree of knowledge of established and evolving practices and principles of HPM, as well as the application of that knowledge to patient care and the education of others.

Practice-based Learning and Improvement. Use of scientific evidence and methods to investigate, evaluate and improve late-life care practices.

Interpersonal and Communication Skills. Establish and maintain professional relationships with patients, families and other members of health care teams.

Professionalism. Commitment to continuous professional development, ethical practice, an understanding and sensitivity to diversity, and a responsible attitude toward patients, the profession and society.

Systems-based Practice. Understanding of the contexts and systems in which palliative care is provided and the ability to apply this knowledge to improve late-life care.

Of course, specific metrics need to be developed to evaluate performance in each of these domains. The metrics will vary from organization to organization and are less important than the process of sitting down to develop the metrics. Yet, doing so will take executives and physicians a long way toward satisying one of the building blocks of a high-performing HPM medical staff -  to  foster an unswerving commitment to performance improvement to minimize unwarranted practice variation, reduce regulatory risk, and win the confidence of referring sources.

New Considerations for Developing a High-Performing Hospice Medical Staff

2010-12-23T17:26:00.000-05:00

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.

Staggering Gaps in Late-Life Care Makes News

2010-12-01T22:24:00.000-05:00

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

2010-12-01T20:49:00.000-05:00

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 regulations.gov 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.

Engage with Grace - Communicating End-of-Life Wishes

2010-11-26T12:28:00.000-05:00

For three years running now, many of us bloggers have participated in what we’ve called a “blog rally” to promote Engage With Grace [http://www.engagewithgrace.org/] – 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” [http://www.newyorker.com/reporting/2010/08/02/100802fa_fact_gawande]– 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 [http://www.thehealthcareblog.com/the_health_care_blog/2010/10/engage-with-grace.html] 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 http://www.engagewithgrace.org/

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

Enormous Variation in Late-Life Care Documented Once Again

2010-11-22T22:42:00.001-05:00

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 KevinMD.com 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.

The Evolving Role of Hospice and Palliative Medicine Leadership

2010-11-17T12:00:00.000-05:00

As hospices and palliative care services evolve into advanced palliative care organizations with greater scope and influence over late-life care within their communities, a "new" physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the "chief community palliative care officer".
These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:

-build and sustain relationships that evolve into community-wide palliative care networks

-disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance

-inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics

-envision and stimulate a change process that coalesces the community around new models of late-life care

Daunting challenges, to be sure. As hospice executives and HPM physicians come to grips with impending rules around face-to-face recertification requirements, and other day-to-day operational issues, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We've seen the importance of the role of HPM leadership in exemplar communities across America (some of which have featured in this blog).

Palliative Care Grand Rounds - November MMX

2010-11-04T10:27:00.000-04:00

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.

Evaluating Performance of Hospice and Palliative Medicine (HPM) Physicians

2010-10-31T15:56:00.000-04:00

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.

Hospice Industry Data from NHPCO - A Look Back Five Years

2010-10-23T19:30:00.001-04:00

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?

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

2010-10-14T20:37:00.000-04:00

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.

Closing the Performance Gap in Palliative Care by Reducing Clinical Variation

2010-10-13T23:10:00.002-04:00

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?

　

Is Palliative Care A Disruptive Innovation in Health Care?

2010-10-06T21:00:00.001-04:00

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?

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

2010-09-19T12:57:00.005-04:00

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.

September Edition of Palliative Care Grand Rounds

2010-09-02T09:54:00.003-04:00

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.

Spreading the Message and Science of Palliative Care

2010-08-22T20:04:00.004-04:00

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 Medicinenet.com). 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.

Choosing Where To Live Based On Late-LIfe Preferences

2010-08-01T10:05:00.003-04:00

In an earlier post (read here) , I wondered if ratings of retirement towns and cities would eventually include information about their culture and practices around late-life care. Our study of "retirement cities" and their palliative care practices, using data drawn from the Dartmouth Medical Atlas, reveals that a huge distance separate better performers from lesser performers.

One community recognized widely among desirable retirement towns is Asheville, North Carolina. Turns out that Asheville is among the better-performers in late-life care.Residents of the Asheville region are 20% less likely to die in a hospital than the state average, and 30% less likely during their final six months of life to spend time in an ICU. Asheville's overall results have earned an A grade in the DAI Community Palliative Performance Grading, placing it among exemplar communities.

Sarasota, Florida is another "retirement" community scoring high in the DAI Community Palliative Performance grading. We conclude, upon further analysis, that these exceptional results don't happen by accident. Rather, they are produced by design, including the presence of palliative medicine physician-champions and a large hospice with close relationships with the community's health care providers.

Palliative Care Grand Rounds - July MMX

2010-07-07T10:58:00.003-04:00

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.

Gentiva-Odyssey - Who Will Be the Beneficiaries?

2010-06-30T17:11:00.003-04:00

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.

Accountable Palliative Care Organizations (APCOs)

2010-06-28T11:57:00.001-04:00

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.

Bellwether Hospice and Palliative Medicine (HPM) Practices

2010-06-14T08:28:00.004-04:00

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.

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

2010-06-09T21:59:00.007-04:00

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.

Why?

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.

Leadership Competencies in Exemplar Late-life Communities

2010-06-08T22:53:00.004-04:00

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.

Palliative Care Grand Rounds- June 2010

2010-06-07T08:34:00.002-04:00

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.

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

2010-05-23T17:51:00.006-04:00

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.

What's the Right Amount of Practice Subsidy?

2010-05-19T22:54:00.002-04:00

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.

Palliative Care Grand Rounds - May 2010

2010-05-07T17:05:00.004-04:00

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

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

2010-04-29T22:32:00.009-04:00

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.

Compensation Conundrum

2010-04-20T19:55:00.000-04:00

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

2010-04-20T17:33:00.003-04:00

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.

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

2010-04-12T21:23:00.005-04:00

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?

Accountable Palliative Care Organizations (APCOs)

2010-04-11T19:44:00.004-04:00

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.

Palliative Care Grand Rounds - April MMX

2010-04-06T21:02:00.017-04:00

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 http://medicalfutility.blogspot.com/. 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.

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

2010-03-30T22:02:00.007-04:00

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 (www.leapfroggroup.org), 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?

An APCO Developing in Asheville?

2010-03-22T14:23:00.004-04:00

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

2010-03-22T14:11:00.003-04:00

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). (http://www.qualityforum.org/publications/reports/palliative.asp ).

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.

Palliative Care Grand Rounds - March MMX

2010-03-02T22:43:00.002-05:00

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.

Palliative Care - 1996 and 2010

2010-02-28T22:25:00.006-05:00

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.

Rational Discussion, or Discussion about Rationing?

2010-02-22T23:46:00.004-05:00

In a recent post on the Health Beat blog, Naomi Freundlich comments that although life-expectancy is increasing, so is the incidence of multiple medical problems and chronic disease in the elderly. Which, once again, raises the question of how Medicare costs could possibly be tamed?

The author goes on to say that "we also face a more personal, moral challenge as life expectancy continues its relentless march forward: We must begin to separate new treatments that will help older people age better—avoiding long-term disability, dementia and frailty—from those that merely extend life at any cost. We can only do this by having honest conversations about end-of-life issues; in medical schools, among families and between doctors and patients. "

The Urban Institute, a nonpartisan research center, found in a 2009 report that the government could save $90.8 billion over 10 years by better managing end-of-life care. And, the Institute further concluded that much end-of-life spending isn’t sought by patients and goes against their families’ expressed preferences.

$90 BILLION dollars. Makes me wonder who would be receiving that money if it were spent. Surely, much of it would go to hospitals. And some of it to physicians. Makes me wonder also if this subject can be discussed rationally, rather than it being a discussion about rationing.

Can Hospice and Palliative Care Escape the R Word?

2010-02-22T23:03:00.005-05:00

The question Why are Referrals to Hospice Slowing? seems to be making the rounds these days.
Misconceptions about hospice and palliative care have abounded well before the latest efforts to refrom the health care system. How else to explain the persistent and continuing reticence to refer to, and accept hospice services, in most US communities. What's different today is that the skeptics of hospice and palliative medicine are more vitriolic than their predecessors, and their talking points (arguments) are more vivid - "death panels, socialized medicine".
I served as the chief executive of a hospice affiliated with a highly-regarded academic health center in the 90s, and the reasons then were abundant for the low referral rate to hospice: patients were referred to academic health centers because they wanted to avail themselves of the most sophisticated medical care for cure; the attending physicians were providing palliative care; the patients' religious/cultural beliefs made them unready for hospice, etc. We've all heard them before, and we still hear these reasons now.
It's just that now, in the context of health reform, palliative care, for some, is considered 'rationing."
And it gains credence because there is so much money in late-life care.

Why Organizational Delivery Models Matter to Effective Palliative Care

2010-02-21T20:10:00.010-05:00

There are multiple examples of health systems -- President Obama and health policy makers have cited Mayo, Geisinger, Cleveland Clinic, and others as models for health-care reform -- that consistently and reliably achieve similar results: providing good care at low cost, with high patient satisfaction. Bassett Healthcare, serving the Cooperstown, New York region, is among those others. What these systems have in common, we're advised, is that they are integrated systems that employ their physicians, emphasizing patient-centered care, better outcomes, and prudent stewardship of health-care resources, with accountability for results.

We've looked closer into these hospitals and communities to understand better if this model also produces desirable results around late-life care. We've learned previously that Geisinger has seen exemplay results in its late-life care practices. So we took at look through the Dartmouth Medical Atlas at the formerly named Mary Imogene Bassett Hospital, now known simply as Bassett Medical Center. The Hospital's results in the seven DAI Palliative Outcome Measures earned it an exemplary grade. Patients loyal to Bassett were 20% less likely to die in the hospital, spent almost 40% fewer days than state average in a hospital during the last six months of life , and were more likely to have been under hospice/palliative care. Yet perhaps the most telling is that in their final months, 30% fewer patients were seen more than ten physicians during late- life care. You read this correctly, TEN is the benchmark.

Thus, we find that in another community a tightly integrated health system produces desirable outcomes in late-life care. What remains unclear is what attributes of a tightly integrated health system are most responsible for these results. With that knowledge, these attributes might be replicated elsewhere (as in an Accountable Palliative Care Organization).

I'm curious to learn your experiences and thoughts.

A Medical Staff Development Plan Can be a Success Accelerator for a Hospice

2010-02-20T17:34:00.002-05:00

Resourceful (and strategic) use of physicians in hospices and palliative care programs has proven to accelerate the success of creating Accountable Palliative Care Organizations (APCOs) in some of our nation's communities (we'll explore several of these success stories in future posts). And while building an APCO is a test of endurance, will, and collaboration, the process of developing an APCO is stalled more frequently by the slow, fitful, and fragmented process of acquiring the palliative medicine "intellectual capital" requisite to an APCO. A Medical Staff Development Plan (MSDP) will serve as a management guide for the alignment of the physician staffing plan with the Hospice strategic plan.

The MSDP will allow a hospice to: (1) identify the opportunities and risks of the current medical staff complement relative to the development of a community APCO ;( 2) define a reasonable range of investment required to meet recruitment needs; and (3) demonstrate the strategic and proactive thinking of hospice/palliative service senior leadership to the community, its hospitals, and other key stakeholders.

The MSDP comprises five sections:
Section 1- Community Assessment of palliative care practices - identifies improvement opportunities and provides competitive intelligence about peer and neighboring programs,
Section 2– Three-Year Staffing Plan - translates community needs into physician staffing requirements and associated financial commitments,
Section 3- Responsibility Chart and Professional Performance Profile–these tools enable leadership to systematically identify decisions and activities that must be accomplished and to pinpoint the functions (positions) that will take on roles relevant to those results,
Section 4 - Compensation Plan –recommends physician compensation models to produce desired physician behavior and translates administrative, supervisory and teaching (AS&T) activities for physicians into fair and reasonable compensation ranges,
Section 5- Recruitment Plan - the articulation of "community hospice and palliative care" practice opportunities that attract talent and fill competency gaps.

Securing executive/Board support for building a HPM staff is easier when it's the result of a well-thought out, comprehensive and strategic plan that pegs recruitment to milestones.

Palliative Care Grand Rounds, February MMX

2010-02-04T01:02:00.003-05:00

February's Palliative Care Grand Rounds is up (see here for an interesting collection of blog posts from the previous month, gathered by Jared Porter, blogger for Alive Hospice).

Challenges of Expanding Palliative Care

2010-01-26T15:58:00.003-05:00

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

2010-01-09T15:39:00.005-05:00

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

2010-01-08T08:15:00.006-05:00

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

2010-01-03T14:30:00.002-05:00

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.

Palliative Medicine - Undercapitalized and Overcommitted

2009-11-28T15:38:00.002-05:00

The practice of palliative care, by physicians and advanced practice nurses, has gradually moved into the mainstream of American health care. While there is little debate over the need to improve late-life care, especially within acute and long-term care institutions, there continues considerable discussion over how to best improve it. Unlike most other medical specialties, palliative care is not reliant upon the effective formation of physical capital (diagnostic and therapeutic equipment using advanced technology) for its practice –to the contrary, it is totally reliant upon the effective formation of intellectual capital. Its effective formation is integral to the success of palliative medicine practices.
You’re thinking that palliative care is the lengthened shadow of a practitioner’s knowledge of clinical best practices. And, you’d be on the right track, for the provision of palliative care is based upon one component of intellectual capital, the know-how, skills, and competencies of the practitioners. Whether a practice or program has sufficient number of practitioners to render this knowledge-based care, first-hand, throughout the community, is a critical decision whose studied deliberation can tip the scales in a program’s outcome.
Two other components make up a program’s intellectual capital: one, structural capital (or infrastructure) - those workflow processes (automated or manual), revenue cycle practices, databases, and routines that enable effective day-to-day operations. The other is customer capital - or goodwill to many - the program’s relationship with its referring, and non-referring medical community, payers, partners, and, of course, its patients. The effective formation of these three components leads to the desired result – development and sustainability of the practice, and its affiliated programs.
So, what’s my point about being undercapitalized, you’re likely wondering? Most programs, and by extension the practices that support them, are subsidized by hospitals, hospices, or grants and philanthropy. This support is often renewed annually, thus demanding of the program’s managers a yearly impact statement of the program’s results. Long-term sustainability depends upon revenue generation, a business process oft shortchanged, at best, or neglected, at worst. This structural capital is often borrowed from the parent organization, whose resources, no matter how well intentioned, rarely offer the sharp focus, attention, and insider know-how so necessary to effective revenue capture.
OK, there may be a shortage of intellectual capital, but overcommitted? Palliative care specialists, were they to be queried, would remark that they don’t have sufficient time to develop the program. Programs report either of two situations – that palliative care has been widely adopted as the standard for late-life care in the community, and that there aren’t sufficient qualified staff to respond to referrals, or that palliative care has not sufficiently diffused throughout the community and a stronger referral base needs to be built. In either instance, what's lacking is a critical mass. Hospices provide part ofthe answer. So do hospital-based palliative services. Only Accountable Palliative Care Organizations (APCOs), through their effective formation of intellectual capital, have the capability of providing the entire answer.

Engage with Grace - Communicating End-of-Life Wishes

2009-11-26T15:51:00.005-05:00

Some conversations are easier than others

Last Thanksgiving weekend, many of us bloggers participated in the first documented “blog rally” to promote Engage With Grace – a movement aimed at having all of us understand and communicate our end-of-life wishes.
It was a great success, with over 100 bloggers in the healthcare space and beyond participating and spreading the word. Plus, it was timed to coincide with a weekend when most of us are with the very people with whom we should be having these tough conversations – our closest friends and family.
Our original mission – to get more and more people talking about their end of life wishes – hasn’t changed. But it’s been quite a year – so we thought this holiday, we’d try something different.
A bit of levity.
At the heart of Engage With Grace are five questions designed to get the conversation started. We’ve included them at the end of this post. They’re not easy questions, but they are important.
To help ease us into these tough questions, and in the spirit of the season, we thought we’d start with five parallel questions that ARE pretty easy to answer:

Silly? Maybe. But it underscores how having a template like this – just five questions in plain, simple language – can deflate some of the complexity, formality and even misnomers that have sometimes surrounded the end-of-life discussion.

So with that, we’ve included the five questions from Engage With Grace below. Think about them, document them, share them.

Over the past year there’s been a lot of discussion around end of life. And we’ve been fortunate to hear a lot of the more uplifting stories, as folks have used these five questions to initiate the conversation.

One man shared how surprised he was to learn that his wife’s preferences were not what he expected. Befitting this holiday, The One Slide now stands sentry on their fridge.

Wishing you and yours a holiday that’s fulfilling in all the right ways.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team. )

Why Intellectual Capital Matters to Growth of Palliative Care Programs

2009-11-24T14:28:00.001-05:00

Our experience and research within palliative care have shown that "program champions" have been successful not so much because of what they bring to the role, but what the organizational program sponsor brings to the program champion. Certainly, a multi-talented physician champion increases the chances of success, but we've found it is the tools (intellectual capital) that she/he has to work with that are the primary determinants of success. The physician starting a practice (which is essentially what the program champion will be doing) needs to have strong clinical skills and knowledge, to be sure, but will need also to create goodwill (to build solid referral patterns), establish business processes, workflow, and databases, and generate revenue to produce a sustainable program. Organizational sponsors typically don't possess this intellectual capital specific to palliative care, and so, champions often find themselves stretched to produce results with little "infrastructure". As a result, the program champion finds her/himself spending time toward "marshalling" resources, at the expense of "deploying" those resources to grow the program.

Palliative Medicine Physician Compensation

2009-11-06T14:42:00.004-05:00

In delivering current information to help clients and candidates and make informed recruitment and career decisions, DAI Palliative Care Group compiles and updates compensation information for physicians with a full-time practice in hospice and palliative medicine (HPM). We know how important the latest trends in physician salaries and compensation are to the negotiation process. These statistically evaluated results pinpoint mean (average) and median HPM physician compensation by:

§ Region
§ Title
§ Size of organization
§ Gender

Earlier this year, DAI Palliative Care Group made available for purchase, for the first time, the 2008 report for HPM physician compensation. We are currently updating this compensation information, and will soon have available the 2009 Report. As you might expect, compensation rose nearly 10%. And as you might also expect, compensation for full-time HPM physicians continues to lag behind other primary care sub-specialties - that of family practitioners by 9% , and internists and hospitalists by nearly 15%.
While overall numbers do not yet suggest a groundswell movement, more employers/practices are shifting away from straight salary to a combination of income guarantee and productivity incentives.

Drop me an email at tcousounis@digital-action.com , mention that you saw a reference to the Report on this blog, and I'll arrange to have the 2009 Report sent to you electronically (in PDF format) at a professional courtesy rate. It could be worth thousands to you.

Palliative Medicine Physician Practice Profile-interview with HPM Physician Amy Mohler,MD

2009-11-05T21:34:00.003-05:00

Grand Junction, CO, was recently lauded in the news media and at a town-hall meeting with President Obama as "a health community that works" -- "-for controlling health care costs while maintaining high quality. Data from the Dartmouth Atlas and from the DAI Palliative Care Group show it to be an exemplary palliative care community as well, based on metrics such as lower rates of in-hospital deaths, fewer hospital readmissions, less reliance on ICU care and higher hospice enrollments. (For more information on DAI's palliative care community metrics, see www.DAIpalliativecaregroup.com.)

"We can't take all of the credit," quips Dr. Amy Mohler, a board-certified hospice and palliative physician and the Chief Medical Officer of Hospice and Palliative Care of Western Colorado (HPCWC). The local medical culture emphasizes the role of primary care physicians. Grand Junction's non-profit hospitals and health plan came together 16 years ago to establish HPCWC as hospice provider for the entire community. "Those entities have been in Grand Junction for decades, and our medical culture has grown from the ground up. But for the past 16 years, HPCWC has been an integral part of that system," Dr. Mohler says. "I see great collaborative relationships here, and our local physicians are very open to our palliative expertise and to getting calls from us whenever we see opportunities to improve our patients' symptoms and quality of life." The hospice's census has grown to 250 in a metropolitan area of less than 140,000 people. HPCWC also offers in-hospital and community-based palliative care consultations, community bereavement services, grief programs for children and teens, and a cadre of 1,200 volunteers. It also operates three satellite hospice teams an hour or more from Grand Junction. "Grand Junction is like the poster child for primary care, and this is fertile ground to be passionate about your work," says HPCWC CEO Christy Whitney. "Even before our hospice existed, there was a very active non-profit HMO, Rocky Mountain Health Plans, that closely monitored hospital days. But I believe we have helped considerably to lower hospital days at the end of life, which means lower end-of-life costs. Having excellent hospice physicians who are available for teaching other physicians has also helped us make inroads."

Scheduling, Compensation and Call

Dr. Mohler and two physician colleagues work full-time for HPCWC, dividing up medical responsibilities for 12 hospice interdisciplinary teams based in home settings, nursing homes and assisted living facilities. Four days a week, Dr. Mohler sees patients at the hospice's freestanding 13-bed inpatient unit, which opened last October. The other doctors put in four-day work weeks heavily tilted toward direct patient visits, which are scheduled and geographically bunched by an administrative assistant. They generally make four or five home care or six to eight facility-based visits per day, and the local geography does not impose long driving times. "We try to get all of our new hospice patients seen early in their admission, especially since we see 30 percent of them for seven days or less," Dr. Mohler says. Each physician spends about an hour a week on interdisciplinary team meetings, with each team coming together every other week for a tightly structured reporting format to get through 20 to 25 patients within 30 minutes. "We used to be quite fantastic about allowing the IDT to run for hours, which wasn't helpful to anybody," Dr. Mohler says. Regular contacts between IDT meetings include "mini-team" updates and frequent phone calls. This year HPCWC implemented a productivity model for compensating its staff physicians, based on their billable visits, with a base salary to cover essential administrative activities. "I think everyone is happier with it, in terms of their workload. If they want to make more money, they know they can work harder and make more visits. If they like their balance of quality of life versus workload, that's okay too. The expectations are clearer and there's a feeling of shared responsibility," Dr. Mohler says. Between them, the three doctors also divide up evening on-call coverage, "physician-of-the-day" responsibilities, including first response for palliative care consultations, and three-day weekend call, including daily patient visits at the inpatient care center. The three-day weekend shift is designed to give the doctor on call more time to acclimatize to the needs of those patients. That may seem like a lot of call responsibilities, especially with the spectacular scenery of Western Colorado so close at hand. But it really isn't as bad as it sounds, Dr. Mohler says. "We find the schedule is still reasonable, because of the emphasis on primary care physicians in this community, their investment in what happens to their patients, and our commitment to supporting that relationship. That translates, when we are on call, into serving more as specialists consulting on their patients, so that our responsibilities aren't such a huge deal," she explains. "Our staff knows that when something is going on with a patient, their first line of help is the primary care physician. They still may call me to spend a few minutes running through the scenario and what might be most helpful for the patient, before they call the physician. I tell the nurses they need to know what they want to ask for from the doctor in a given clinical situation before they place that call." Still, the hospice is finding that three physicians are not enough to cover everything that needs to be done, especially since a nurse practitioner who made most of the in-hospital palliative care consultation visits moved away earlier this year. "When you are the doc of the day, you're in the hot seat. You may get the consultation call that comes in at ten minutes before five. But we're not doing a huge volume of inpatient palliative care consultations right now. We also have a community-based nurse and social worker palliative care team that uses more of a case management model, with a current census of 58," she says.HPCWC hospice teams in the three satellite offices draw upon local community physicians in part-time or volunteer roles to staff their hospice teams. The three full-time hospice doctors in Grand Junction are HPM-certified, but the four part-time satellite physicians, who have full-time clinic practices in internal medicine or family practice, are not. The satellite team physicians don't make many home visits. "If there are complex patients who need to be seen, we try to make special arrangements for seeing them out of this office," Dr. Mohler says. The agency also has a medical suite available at its inpatient unit to see patients who may be in central Grand Junction for other medical services. Dr. Mohler would like to have more time for visiting the satellite sites and working hands-on with their physicians and teams, rather than doing that by phone and email. Current plans are to recruit a fourth full-time physician for HPCWC while perhaps involving other Grand Junction physicians in on-call coverage and encouraging the satellite office physicians to enhance their palliative care skills through occasional shifts at the inpatient unit.

A Representative of Hospice

Although Dr. Mohler's job is largely clinical, covering the inpatient unit Monday through Thursday, Friday is spent in the hospice office on administrative functions. These include supervising the other physicians, participating in quality improvement activities and on the hospice's senior leadership team, teaching in a local family practice residency program, staff teaching, educating the local physician community and the public about hospice care, and "quite a lot of social networking as a representative of hospice."
"We have made a big investment in physician services. At our best we cover only 50 percent of medical costs from billing revenues," Whitney says. "But we decided to make that commitment, and having Amy, with her geriatric background, has been fabulous for our patients. My feeling is that hospice and palliative medicine is a specialty. Having our physicians available by phone supports our nurses, who sometimes have a hard time reaching the attending physician when they're out in the field. It brought a higher standard of care to our patients, and it gives us the opportunity to truly practice evidence-based medicine."
Dr. Mohler has been with HPCWC for seven years and its Chief Medical Officer, a position created to oversee the medical care provided by the other hospice physicians, for the past 18 months. An Arizona native, she trained as an internist and did a geriatrics fellowship at Good Samaritan Hospital in Phoenix. "I always knew that I would do geriatrics and, specifically, long-term care. But I became interested in end-of-life care during my residency," she says. "I spent so much time in the hospital and ICU and attended so many deaths there that I just felt there had to be a better way."

Future of Palliative Medicine Practices

2009-10-29T12:31:00.006-04:00

Will reform help or hinder the practice of Hospice and Palliative Medicine(HPM)?

Help, if HPM physicians reconfigure themselves into "sought-after practices". The reconfiguration must be willful and carefully planned, and in advance of implementation of national health reform. In other words, bets must be placed now that the health care delivery system will be restructured, and payment for health services will be revamped.

In upcoming blog posts, we'll take a close look at likely scenarios, and how the organizational alignment we've identified as Advanced Palliative Care Organizations will evolve into Accountable Palliative Care Organizations (APCOs). And, we'll examine the likely role of HPM physicians in APCOs, or what we refer to as the emerging role of the Chief Palliative Care Officer. This blog will be one forum for this discussion, so your comments and experiences are invited.

Also, we plan a regular publication (HPM Practitioner) that will offer you insights into "bellwether" practices. An upcoming issue will feature the HPM practice in Grand Junction, Colorado, about which I have posted previously.

From our study and research into best practices of palliative care, we've developed theories of what differentiates exemplar palliative care communities from others. How HPM physicians are utilized is one distinguishing feature. How they are organized is another. And under health reform, how they are paid will likely be another. Think bundling, and the value of a "network of HPM physicians" tightly organized to increase negotiating (with both payors and providers) clout.

As always, your comments are invited.

Building a Hospice and Palliative Medicine (HPM) Medical Staff

2009-10-29T12:24:00.002-04:00

A former colleague with many years of hospital executive experience recently accepted a position as the chief executive of a mid-sized, not-for-profit hospice (115 ADC). Upon review of employee staffing, she noticed that the hospice had half-dozen "arrangements" with physicians (with varying commitments but all under 15 hours per week) to provide largely unspecified clinical and administrative services. She asked if medical staff planning customary in hospitals had applicability and relevance for hospices. Of course, I replied, the "planning process" has great relevance, although there are several differences in scope and scale.

To prepare a Hospice Medical Staff Development Plan, we follow a systematic five-step process:
Step1 – analyze HPM professional fee billings and Activity/Effort reports and job descriptions for physician roles,
Step2 – conduct interviews with key stakeholders (including all physicians practicing HPM in any capacity and commitment),
Step3- compile Hospital and Community Palliative Performance Profiles using Dartmouth Medical Atlas,
Step4 – review Hospice strategic plan and contracts/agreements between the Hospice and physicians,
Step5 – using Responsibility Charting process, define professional expectations, metrics, and accountability.

Through this five-step process, we gain insights that address the most common questions posed by hospice executives (administrators and physicians) about medical staff development: To what extent may nonphysician providers be used to meet additional clinical demands?When will additional physician staff be needed, and what are the anticipated time requirements to recruit these individuals?When should recruitment occur given practice ramp-up time and total recruitment budgets?Are there sufficient resources and the political will to build a hospice-sponsored HPM physician group?In what communities and health provider sites do we place physicians to meet our organization’s strategic objectives?

Are there other questions regarding building of a medical staff on your minds? I invite your comments on what challenges each of you face in building a hospice medical staff?

Grand Junction - an Exemplar Palliative Care Community

2009-10-07T14:07:00.003-04:00

President Obama held a town hall recently in Grand Junction, Colorado. To healthcare reformers, Grand Junction, CO., is one of the areas of innovation -- a place that provides high-quality healthcare at a fraction of the costs in most other communities. And, according to some experts, Grand Junction chalks up some impressive statistics. Only 12% of Medicare patients required readmission 30 days after a hospital visit, as opposed to the nationwide rate of 20%. Children on Medicaid in the HMO are four times as likely as other Colorado Medicaid children to receive all immunization treatment -- and adults on Medicaid were up to 10 times as likely to get comprehensive diabetes care. How does Grand Junction stack up for its palliative care practices? The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of lowest percentages of deaths occurring in a hospital (20.7%). And hospice enrollment nearly 30% greater than the national average. Is it mere coincidence? We think not, as a profile of one of the senior palliative care physicians in Grand Junction will show in future posts.

Palliative Medicine Physician Practice Profile-interview with HPM Physician John Mulder, MD

2009-10-07T13:50:00.004-04:00

Balancing Clinical and Administrative Roles: Interview with HPM Physician John Mulder, MD
(read here for one of Dr. Mulder's thoughtful essays on palliative care)

"I find that my passion to make sure no one suffers needlessly outweighs my desire to go home from work at 5 pm," John Mulder, MD, says to explain how his commitment to hospice and palliative medicine (HPM) shapes his balancing act of clinical and administrative responsibilities for Faith Hospice and the Spectrum Health hospital system, both based in Grand Rapids, MI. Dr. Mulder formed a professional corporation in order to contract with his two primary clients, Spectrum and the hospice's parent company, Holland Home. For Spectrum he provides palliative care consultations in two acute care hospitals (with two to three new consults ordered per day) and fills a variety of administrative roles aimed at promoting and advancing palliative care within the system. These include strategic planning, one-on-one meetings with physicians, and attendance at tumor board and cancer interdisciplinary meetings. For the hospice, he serves as vice president of medical services and sits on its leadership team. Recently, he relinquished to a colleague, Dr. Martha Ording, the responsibility of hospice medical director as spelled out in Medicare's conditions of participation.
His current role emphasizes quality initiatives such as protocol development, a new HPM fellowship program, and medical management of the hospice's freestanding, 20-bed inpatient facility. "That's the daily clinical environment for my hospice physician practice." Dr. Mulder also carries a beeper 24 hours a day ("I've always done that; I feel very possessive of my patients"), although with the option of arranging for back-up as needed. Time management remains an ongoing challenge, and it can be difficult to precisely parse out which is hospice versus palliative care or administrative versus clinical (and billable) time. "But I don't stand on protocol. I feel comfortable with how my time is spent, as do the folks to whom I'm accountable," he says. "At the end of the day, I want to make sure that they have gotten their money's worth. And there is the intangible value of my availability as a hospice and palliative physician - that existential presence, that leadership role brings value in and of itself. It's all about establishing relationships and building trust in my role and in what HPM offers."
Dr. Mulder recently took a phone call from a colleague who is well known as a pioneer in the field of HPM, and is considering a job change from an academic to a hospice setting. "She asked about the business aspects-employed versus contracted, how to negotiate salary and benefits, things like that. These are basic issues for those who are immersed in the business, but they can be confusing if you've never had to deal with them." In Dr. Mulder's previous job as chief medical officer of Alive Hospice in Nashville, TN, the position was structured in a way that allowed him to learn on the job the business and practice management aspects, gaining a clearer sense of what the medical director contributes to hospice and palliative care. "(CEO) Jan Jones understood and fostered the medical component of hospice, and emphasized my education as medical director and medical leader," he relates. One of the keys was attending national hospice educational meetings. "It's not only having a seat at the table for the physician's role, but sharing what I know. Which affects how care is given, and the policies that are developed - just being able to exercise what you know as a doctor to be a partner on the team."
How to Find Satisfaction-and Make a Living - Dr. Mulder was instrumental in convening an informal group of about two dozen HPM physicians practicing in Western Michigan. They now meet every other month to talk about both practice and clinical issues, and they are in discussion with a local managed care company about establishing a contracted physician network that could provide expanded hospice services and covered palliative care benefits, including in the outpatient setting. Several of these physicians work full-time in hospice or palliative care, others are part-time, and a few are board certified in HPM but not currently working in the field. "Two or three others have a deep interest in palliative medicine and want to do it some day," he explains. At the group's first meeting in January, "I could see doctors huddled in groups of three or four. They couldn't stop talking. There was such a hunger for this exchange," Dr. Mulder reports. "We want to communicate through this dialogue how you can make a living, how you can find satisfaction, meaning and personal growth in HPM - but also that the work requires a personal commitment to scientific, cutting-edge medicine and a willingness to be truly present with patients and families." He agrees that it is curious that so many physicians who are motivated to become board-certified in HPM have not gone the next step to full-time positions practicing this specialty. "A lot of part-time hospice docs, because of their hospice compensation and the hospice's lack of commitment to the medical role, don't believe that this can be a career option. It's hard to extrapolate from their experience to how it could turn into a full-time job. And if they don't believe it can be, they will remain shy in their contract negotiations with the hospice - even though a portion of every per diem the hospice collects is meant to cover the medical director's role." Unfortunately, hospice physicians are too often underused, overused, misused or abused. "Their responsibilities are defined by people who may have very little understanding what physicians do - or could do. The physician's role and responsibilities in hospice care need to be viewed in different ways. Not that the doctor is more special than other members of the hospice team, but what he or she brings to the table is different," Dr. Mulder says. "If a hospice wants someone simply to come to meetings and sign documents, that's how it will structure the position. But if you truly want what a physician can contribute to increasing the skill levels of all staff and the quality of the care that is provided, that's a whole different ball game. It requires a different level of commitment by the agency."
Just as palliative care consultations in the hospital more than pay for themselves through decreased length of stay and reduced use of expensive, unbeneficial treatments, the active presence of a substantially full-time physician raises the hospice's exposure in the medical community and can lead to increased referrals and lengths of stay and better decisions about drug therapies and other palliative treatments for hospice patients. "We're fortunate to have a very strong, high-quality hospice program here in Grand Rapids, respected by physicians and the community at large," Dr. Mulder says. In fact, data from the DAI Palliative Care Group, derived from the Dartmouth Atlas of Health, gives the Grand Rapids region an A grade for its end-of-life care. The region has fewer deaths occurring in hospitals or associated with ICU admissions than state or national averages and a higher percentage of decedents (46 percent) enrolled in hospice than national (31 percent) or state (38 percent) averages. Dr. Mulder was trained in family medicine and practiced obstetrics. He was first asked to serve on the Board of Directors of a local hospice in 1985, and became intrigued by its work. "When they asked me to be the medical director, I began learning what a difference hospice made at the bedside."Today, he finds HPM a great field to work in. "I am well compensated, and have never been more satisfied. Who knew?"

Palliative Care Grand Rounds - October edition

2009-10-07T10:51:00.003-04:00

Visit here for the October edition of Palliative Care Grand Rounds - a monthly blog carnival highlighting some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. This month's host of Palliative Care Grand Rounds, GeriPal gives its own "spin", incorporating posts that feature the intersection between geriatrics and palliative care. GeriPal (Geriatrics and Palliative care) is a forum for discourse, recent news and research, and freethinking commentary and invites the perspectives of generalists, specialists, gerontologists, palliative care clinicians, and anyone else interested in care of the elderly or palliative care.

Accountable Palliative Care Organizations - Mayo style?

2009-09-27T22:16:00.010-04:00

As hard as health insurance reform is, compared to health care DELIVERY reform, that’s the easy part, Mayo Clinic CEO Denis Cortese said at a recent presentation to the National Press Club. Mayo has been frequently cited as a model for health care delivery reform by President Obama and others, but the question of Mayo’s value as a model for overall reform has also generated considerable discussion from both sides.

Cortese cited the significant regional variation in medical practice documented by researchers at Dartmouth (and discussed periodically in this blog, see here and here ) , and he listed several factors common to institutions and regions that produce what he called "high-value care": patient-centric cultures; high levels of physician engagement in leadership and change; much higher levels of teamwork, collaboration, and coordinated care; more "connectivity" and sharing of electronic medical records and information; and much greater use of "the science of health care delivery," meaning systematically looking at how patients flow through an organization in order to reduce waste and standardize processes to reduce errors.

These factors, it occurred to me, are similar to the attributes possessed by Accountable Palliative Care Organizations (see here, here, and here). Producing "high-value care" , whether for an acute episode, in an ambulatory setting, or for late-life care, is a formidable challenge. And it is why, if palliative medicine physicians can incorporate into their practices those skills requisite to success in these emerging delivery models, their practices will be highly sought after.

September edition of Palliative Care Grand Rounds

2009-09-03T08:21:00.003-04:00

For an enlightening and interesting summary of the latest from the palliative care blogs, see here.

Redeploying Physician Services at End-of-Life

2009-08-20T11:21:00.002-04:00

A recent post (read here) suggesting that the "redeployment" of physician services for end-of-life care is one way to address the health care cost issue at once threatens the income potential of many physicians.

In a statement before the April 2009 US Senate Finance Committee Roundtable on Delivery System Reform, Allan Korn, M.D. ,Senior Vice President and Chief Medical Officer of Blue Cross and Blue Shield Association, called for the creation of "clinical pathways to help physicians provide compassionate and cost-effective end-of-life care." Among patients who died of cancer, Dr. Korn noted, a major contributor to cost and quality-of-life issues is the widespread use of chemotherapy in the last three months of life. Studies show that 15 to 20 percent of patients with incurable, end-stage cancer receive chemotherapy within 14 days of their death, a time when chemotherapy has no benefit. He went on to recommend funding a pilot starting in 2009 to identify the extent of overuse errors in treatment of cancer patients, for example by measuring non-palliative chemotherapy use in the last two weeks of life, and to establish best use of palliative care.

The American Hospital Association identified longer-term cost-containment strategies that will be pursued, as evidence, tools and nationally-endorsed measures emerge. One such strategy advanced by the AHA is to "Promote Efficient Resource Utilization" – more specifically, to promote palliative and hospice care through the use of advanced directives and best practices.

Indeed, palliative care should be better distributed throughout our communities. But palliative care is not an add-on. Rather, its value lies in its offering an alternative, or a substitute for another type of physician care/service already being provided to patients with advanced ilnesses. Lots of revenue/income is at stake. Is it any wonder why critics of health reform are associating palliative care with rationing?

August Edition of Palliative Care Grand Rounds

2009-08-06T18:36:00.002-04:00

Palliative care has been much talked about in the context of health care reform. The August edition of Palliative Care Grand Rounds (here) , hosted by Risa Denenberg, offers readers an excellent round-up of the commentaries from the blogosphere.

Palliative Care Grand Rounds Vol 1, Issue 6

2009-06-29T13:47:00.032-04:00

Welcome to the sixth edition of Palliative Care Grand Rounds, a monthly (appearing the first Wednesday of each month) summary of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.

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Health reform has been at or near the top of the news this past month, so it's hardly surprising that health reform and palliative care has found its way into the blogosphere. Usually within the context of rationing and futile care.

The blog Practical Bioethics addresses this issue in a well-reasoned way on a regular basis. In one of last month's posts, Dr. John Landos comments on one particularly useful way to think of the debates about rationing. Nearly 30 years ago, early in my career as a health care executive, one of the must-read publications for us was an insightful piece on rationing by the noted health economist Uwe Reinhardt. The title is as clever as it is fitting: Table Manners at the Health Care Feast.

What should a doctor recommend for a 90 year old man with pancreatic cancer and liver metastases? Palliative care? An Ohio surgeon thought so. Read the experience of Buckeye Surgeon in his blog . KevinMD picks up on this notion of futile care in his post.

Maggie Mahar offers an edifying piece around who should be responsible for defining futile care. In this post, she presents the case that " we also need to “pay more” for certain vital services such as primary care, chronic disease management, and palliative care. "

Are financial incentives for providers properly aligned with good palliative care? A New England Journal of Medicine article offers up a report on this matter, and Drew Rosielle, MD captures its highlights in his post. In a similar vein, Pallimed picks up on the hospice cap issue, as well as a recent press release from the National Alliance for Hospice Access. Access to the hospice benefit is a vital issue for patients, clinicians, executives, and policymakers, and has stirred up conflicting position statements and controversial points of view. To this blogger, the key question has been submerged. How should health care providers best organize to better assure open access for those with advanced illness, is what we ought to figure out.

Rationing versus futile care. Reading the blogosphere, and particularly comments to postings, leaves one with the impression that advanced illness management is either one or the other.

Prompted by President Obama's interview reply on the subject of the American approach to the end of life, David Tribble, MD, blogs about the "absurdity" of spending scarce resources on therapies known to be ineffective, but which Dr. Tribble adds, "we employ simply because we cannot stand not to."

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Alex Smith, MD, posts in the blog Geripal of the challenges of incorporating geriatric and palliative care into the Emergency Department. Dr. Smith asks "How can we integrate the vast experience and strengths of palliative and geriatric medicine in a setting such as the emergency department to meet the needs of older adults with serious illness, and contain costs?" No easy answers, to be sure, but a question every ED director and hospital executive should be asking. We know the HPM MDs and geriatricians have been asking questions like this for the past 15 years.

In his Medical Futility blog, Thaddeus Mason Pope comments on the disappointing, but unsurprising, survey results that Advance Directives are followed SOME of the time. Should we be doing more to make POLST documents a national standard?

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For patients and families seeking answers about palliative care, there are a handful of worthy blogs. In one, Dr. Pedro Calves relates an encounter with a patient who found the "pal" in palliative care. In another, written from the perspective of a patient under the care of hospice, the blogger/hospice patient comments on her health plan's reversal of an earlier denial and her change of hospice providers. When the author first started this blog, it was mainly to keep the people in her life up to date on how she was doing; now, it seems that she has picked up readers outside her immediate circle of family and friends. Angela Morrow brought this blog to my attention in last month's Palliative Care Grand Rounds.

Dr. Drew Roselle posts that most patients with advanced illnesses prefer to have hospice discussions, yet a recently published study found that only half of patients in this study had such discussions, and in a separate yet related post that understanding of CPR outcomes and code status is poor among hospitalized patients.

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Mort Kondracke is the Executive Editor of Roll Call, the newspaper of Capitol Hill. While technically not a blog (it's actually a column), Mr. Kondracke pays tribute to his mother's example of living - and also a "public policy" tribute to the manner of her death, in HOSPICE care. As health reform moves through Congress, a voice like that of Mr. Kondracke can be very powerful.

Veteran journalist Larry Beresford, who has written extensively about palliative care, discusses the emotional barriers to hospice access for people with terminal illnesses in a thought-provoking piece . Referring to several recent research studies, Mr. Beresford notes that
"this kind of research can help us understand some of the nuances of such encounters at the end of life, but I wonder if they take us closer to solving hospice's Flying Dutchman status in our society."

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Jessica Knapp writes in her blog The Good Death that she gives a two thumbs-up to the film, Departures, which, without much fanfare, won this year's Academy Award for Best Foreign Film. Then again, how many foreign films (award-winning and not) are greeted with great fanfare?
Glad that Ms. Knapp brought it to our readers' attention.

For a peek into the week of a hospice nurse, see Dethmama Chronicles. And Pallimed directs us to a week in the life of a palliative consult service, via Twitter.

Christian Sinclair, MD, co-editor of Pallimed and one of the prime movers behind Palliative Care Grand Rounds, announced a social media marketing venture and a sabattical from Pallimed. But not before he posted a useful summary of legislative and regulatory issues concerning palliative care.

On the arts/technology side, Amy Clarkson, MD reports on the complimentary blog of Pallimed about The Digital Afterlife, the legacy lockers and digital memorials brought to us by digital technology.

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Thanks to all who sent me suggestions for this month's Grand Rounds! And if you're interested, here's where you can find issues 1 , 2, 3, 4, and 5.

PCGR now has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Next PCGR will be out August 5 and will be hosted by Risa Denenberg http://risaden.blogspot.com/- forward suggestions or links to risaden@gmail.com .

Palliative Care Blog Wrap-Up

2009-06-26T22:16:00.004-04:00

I'll be hosting next month's Palliative Care Grand Rounds. Sign up here for a feed... and you'll have next month's, and the ones following, delivered to your desktop.

Advanced Palliative Care Communities (APCCs) - What Distinguishes Them?

2009-06-22T10:29:00.005-04:00

What is it about Advanced Palliative Care Communities (APCCs) read here that distinguishes them from other communities (or regions) when it comes to providing care to those with end-stage disease? One is the presence of an organized provider network collaborating on the delivery of palliative care in many settings of care throughout the community. Another is the documentation of, and adherence to, patient preferences. Think POLST or similar tools. Surely, these attributes do not come about on their own. We’ve looked more closely at the deployment of palliative medicine specialists in these communities (APCCs) and have found greater numbers (than in other similar communities) of physicians practicing palliative medicine and greater use of those physicians in clinical consultative roles in multiple settings throughout the community. What does not matter, we've found, is the organizational sponsor (or employer) of these palliative medicine physicians.

Palliative Care Grand Rounds 1.5

2009-06-03T10:17:00.005-04:00

The latest edition of Palliative Care Grand Rounds is up today on Angela Morrow's blog. Excellent summary of last month's most interesting posts about palliative care and related topics. For issues 1-4, visit the Grand Rounds Blog.

I will be hosting July's Grand Rounds (July 1) - send your suggestions to
tcousounis@digital-action.com.

Physician Services at the End-of-Life - Are We Now Ready for REDEPLOYMENT?

2009-06-02T21:11:00.008-04:00

Los Angeles, California; Manhattan, New York; and New Brunswick, New Jersey, had very high physician labor inputs for both Academic Medical Centers' (AMCs) end-of-life cohorts and the region’s Medicare population. Minneapolis and Rochester, Minnesota (home of the Mayo Clinic), had low regional and AMC physician labor effort. This correlation suggests that the variation observed across regions cannot be explained by differences in health status, adequacy of care, or patients’ preferences but is linked to idiosyncratic patterns of labor input found in both AMCs and their associated regions. So concludes a 2006 study "End-Of-Life Care At Academic Medical Centers: Implications For Future Workforce Requirements", David C. Goodman, Thérèse A. Stukel, Chiang-hua Chang and John E. Wennberg.
[Health Affairs 25, no. 2(2006): 521–531; 10.1377/hlthaff.25.2.521]

The authors also observe that in several of the low-input regions, much of the care is provided by large, multispecialty group practices (for example, the Mayo Clinic) or integrated delivery systems (for example, Intermountain Health Care). What is it about such practices and delivery systems that lower the barriers to palliative care, in fact, may encourage more appropriate use of palliative care for those with advanced AND chronic illness? Just a hunch, but I'd surmise that a key element is a shared or common compensation system among palliative medicine physicians, primary care physicians, and specialists. What might support the design of new compensation systems to promote the sort of physician collaboration essential to this redeployment? The likely prospect of payment bundling , a payment reform which has been advocated as a means of reducing readmissions.
Surely there must be other factors besides compensation incentives at play. I'm curious to learn what other possibilities come to your mind?

End-of-Life Care and Physicians: Shortage or Surplus?

2009-06-02T19:41:00.004-04:00

If fewer physicians are needed to care for the growing numbers of seniors, as this article concludes, then how will physician services be redeployed? In favor of palliative medicine physicians, to be sure. Yet, other specialists can not so readily be expected to relinquish their current roles in end-of-life care. Or, is there plenty of room for many "specialists", each applying their own competencies in close coordination with their medical and nursing colleagues. I'm curious to learn your views on the surplus/shortage issue (especially as it relates to end-of-life care) and suggestions on how to best hasten the redeployment of physician services so that it is factored into health reform.

Choosing Where to Live Based Upon End-of-Life Preferences

2009-06-02T19:23:00.004-04:00

A health executive new to hospice asked the other day, in advance of assuming an executive role of a palliative care organization in a resort community, what role should physicians play in the end-of-life care in the community? I replied a small one (relative to the role that specialists were presently serving). But a larger one for palliative medicine physicians. He asked why that wasn't the case at present. Because patients don't choose their regions they live in based on the amount of care they wish to receive in their last six months of life, I replied.
I wonder, will there be a day when those choices are made?

Performance Management and Palliative Medicine

2009-05-14T23:16:00.008-04:00

I hear from palliative medicine physicians whose experiences suggest that their successes often go unrecognized, or at best taken for granted, while their failures are highlighted, particularly during times of program evaluation or subsidy renewal. What prompts these misguided views and feelings? Is it numbers-driven executives who see these palliative medicine practices producing revenue that in best cases meets no more than half of the practitioners' salaries? Or is it underperforming physicians whose practices fail to meet productivity standards? Or is it quite simply a misunderstanding of the value of palliative medicine programs in general, and of palliative medicine physicians specifically?
Our study suggests that another factor is at play here. Call it a misalignment of expectations, a misalignment that manifests itself in role confusion. What is role confusion, and why should palliative medicine be more vulnerable than others to this rather abstract influence? The short answer is that most palliative medicine programs were launched on the proverbial shoestring, and when met with growing demand for their services, turned their attention to their most recent referring sources. These new referring sources, of course, were not the ones behind the launch of the program. Additional MD or NP resources to serve this growing demand are months way from being hired, if at all. And so we find role drift, which inevitably leads to role confusion. This is the time, we find, for the introduction of performance management programs.

Showcasing Advanced Palliative Care Communities

2009-05-14T09:16:00.003-04:00

To detractors of health reform, universal health care is code for rationing, or "less care". And for those detractors, palliative care is associated with less care. Reform opponents use the argument of rationing because they know that there is little political will to provide "less care".
Yet this argument falls short on two counts. Less care ,or rationing, takes place in the current system, for those who are uninsured, or underinsured. And less care does not have to mean substandard care, as data from the Dartmouth Medical Atlas has shown. Interestingly, those opposing health reform are the same who oppose comparative effectiveness studies, and their deployment to guide clinical practice.
The promises to contain costs advanced recently by the coalition of hospitals, physicians, and pharmaceutical manaufacturers, among others, are surely commendable. But one has to wonder what can these providers and organizations do that hasn't already been tried? Their promises were surely short on details.
When it's time to fill in the specifics, it will be time to take a close look at Advanced Palliative Care Communities (APCCs) see here and here , and how palliative medicine physicians in those communities practice their specialty to produce better outcomes at lower costs.

Responsibility Charts for Palliative Medicine Practices

2009-05-11T21:04:00.005-04:00

Palliative medicine programs, and by extension the practices associated with them, are characterized by conflicting demands for their resources. Role confusion often is the result.

The symptoms of role confusion we often find within palliative medicine services are:
-Concern over who makes decisions
-Out of balance workloads
-Lack of action because of ineffective communications
-Questions over who does what (clinical and administrative)
-Multiple “stops” needed to find an answer to a question or gain approval.

Responsibility charting is a management tool we've used effectively to reduce or avert role confusion. This tool can be used either in program development or in established programs. We've found it to be especially useful where an Advanced Palliative Care Organization (APCO) is being assembled through the collaboration of several health organizations and many stakeholders.

Reducing Hospital Readmissions: A Role for Palliative Medicine Physicians

2009-05-04T19:50:00.005-04:00

Rehospitalizations among Medicare beneficiaries are prevalent and costly. So concluded a recent study published in the April 2, 2009 issue of NEJM - excellent synopsis here from the Commonwealth Fund. The study found that 20% of Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days, and 34.0% were rehospitalized within 90 days; 67.1% of patients who had been discharged with medical conditions and 51.5% of those who had been discharged after surgical procedures were rehospitalized or died within the first year after discharge. Is there a role for palliative medicine physicians? Th experience of Advanced Palliative Care Communities(APCCs), with lower than average rates of hospital readmission and percentage of deaths in a hospital, suggests indeed there is. As does the modest study (abstract cited) below:

Increased Satisfaction with Care and Lower Costs: Results of a Randomized Trial of In-Home Palliative Care
Richard Brumley, MD * , Susan Enguidanos, PhD, MPH † , Paula Jamison, BA † , Rae Seitz, MD ‡ , Nora Morgenstern, MD § , Sherry Saito, MD ‡ , Jan McIlwane, MSW § , Kristine Hillary, RNP * , and Jorge Gonzalez, BA †
* Kaiser Permanente Southern California Medical Group, Downey, California; † Partners in Care Foundation, San Fernando, California; ‡ Kaiser Permanente Hawaii Medical Group, Honolulu, Hawaii; § Kaiser Permanente Colorado Medical Group, Aurora, Colorado.

OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home.
DESIGN: A randomized, controlled trial.
SETTING: Two health maintenance organizations in two states.
PARTICIPANTS: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months.
INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services.
MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care.
RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment (P<.05) and were more likely to die at home than those receiving usual care (P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department (P=.01) or be admitted to the hospital than those receiving usual care (P<.001), resulting in significantly lower costs of care for intervention patients (P=.03).

In APCCs, we've found that Palliative Medicine physicians assume a major role in the care (in any setting) of older patients with a hospitalization. What makes these APCCs different? They structure care for those advanced illnesses around the principles of palliative care, rather than hospice eligibility.

Palliative Care Grand Rounds

2009-04-14T22:02:00.002-04:00

The third edition, like the first two, of Palliative Care Grand Rounds merits a look. This month's host is Jessica Knapp at her blog, The Good Death.

APCOs and Palliative Care Performance

2009-03-23T22:39:00.003-04:00

In a recent article Slowing the Growth of Health Care Costs — Lessons from Regional Variation http://content.nejm.org/cgi/content/full/360/9/849 authors Elliott S. Fisher, M.D., M.P.H., Julie P. Bynum, M.D., M.P.H., and Jonathan S. Skinner, Ph.D. describe research findings in which physicians in higher-spending regions were much more likely than those in lower-spending regions to recommend hospital admission for an 85-year-old patient with an exacerbation of end-stage congestive heart failure. And they were three times as likely to admit this patient directly to an intensive care unit and 30% less likely to discuss palliative care with the patient and family. Put another way, differences in the propensity to intervene in such gray areas of decision making were highly correlated with regional differences in per capita spending on health care.

Not surprised, you say. Perhaps one shouldn't be. After all, data from the Dartmouth Medical Atlas has long shown there are huge differences in health care spending from one region to another that are best explained by intensity of practice patterns rather than intensity of illness. This same article goes on to say that a consensus is emerging that integrated delivery systems that provide strong support to clinicians and team-based care management for patients offer great promise for improving quality and lowering costs.

Similarly, our studies of palliative care in high-performing communities (and health systems) have shown that Advanced Palliative Care Organizations (APCOs) possess attributes similar to those of integrated delivery systems, while being led by chief palliative care officers. Who are these chief palliative care officers? Mostly, physicians (sometimes nurses) with training, experience, and expertise in palliative medicine.

What difference can APCOs make? For starters, they can deliver care to patients with life-limiting illnesses that is consistent with the preferences of these patients and their families. Residents of Sarasota, Fla. (a high-performing palliative care community) are nearly 30% less likely than the average American to die in a hospital, and will spend during their last six months of life nearly 25% fewer days in a hospital than the national average.

So why aren't there more APCOs? The answer is complex and will be better addressed in future posts, but let's just say for the moment that one of the reasons is that there is more competition than collaboration among this country's hospices and hosptials. Yet another possible explanation is that there is an acute shortage of qualified HPM physicians who are interested and willing to practice palliative medicine on a full-time basis.

Do Hospices Need Medical Staff Planning?

2009-03-16T22:56:00.003-04:00

Hospices are evolving into advanced palliative care organizations (APCOs)in which care spans organizational and professional boundaries and physician services are integrated into a collaborative model that reconfigures a traditional nurse-centric organization,. Such a convergence will, unsurprisingly, strain an organization’s resources and its roles. For organizational strategic considerations, meeting community needs, and regulatory compliance, medical staff planning improves the likelihood of hospice success.

However, shortages of experienced, fellowship-trained, and Board certified Hospice and Palliative medicine (HPM) physicians and the growing need for such physicians in specific practice areas (long-term care, hospital consultative, home visit) will lead to increased frustrations among hospice executives, clinical staff, and physicians and hinder the achievement of hospices’ strategic goals.

Given the “not if, but when” trends surrounding the role of HPM physicians in a community’s end-of-life care practices, hospices that initiate a medical staff planning process in the short term will provide themselves with the time required to muster and develop the necessary financial and other resources to align their medical staff plan with their strategic objectives. Such a medical staff resource planning service will also help identify potential opportunities to enhance market position through physician recruitment.

Palliative Care and the Stimulus Bill

2009-02-11T08:45:00.000-05:00

Those interested in how palliative care makes out in health reform (and stimulus bill) discussions should keep an eye on a small (relatively, at $1.1 billion) item in the House version related to effectiveness comparison research.

The $1.1 billion in research funding would be doled out primarily to the National Institutes of Health. President Obama supported research into comparative effectiveness during his campaign. He could launch a new federal Comparative Effectiveness Institute along the lines of the British National Institute for Health and Clinical Excellence (NICE). Surely, palliative care would be viewed favorably in this context, would it not?

Meanwhile, the drug and medical-device industries are mobilizing to gut this provision in the stimulus bill, portraying it as the first step to government rationing. Interesting, because discussions around "best" end-of-life care inevitably get around to "rationing", as if palliative care were merely a stripped-down version of full-fledged medical care.

Reminds me of the "effectiveness research" done in the mid-90s, when the government's Agency for Health Research Quality suggested that there were too many unnecessary back surgeries. Of course, certain industry groups attacked the conclusion, and Congress at the time slashed the agency's budget and stripped its authority to make Medicare-payment recommendations.