Short-Stay Hospice Patients? Intractable?

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

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

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

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

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

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

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.

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

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

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.

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

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


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.

Compensation Conundrum

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

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

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

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

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

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

Different Paths, But Same Destination

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

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

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

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

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

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

Palliative Care Grand Rounds - April MMX

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

Next month’s host is Thaddeus Pope, at his blog 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?

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?