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

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.

Bellwether Hospice and Palliative Medicine (HPM) Practices

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 of Palliative Medicine Practices

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.