Palliative Care and the Stimulus Bill

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.

Successful Palliative Medicine Practice Business Models -Are There Any?

I regret that my posts have been irregular of late. I don’t wish to be circumspect, so please know that my recent silence around health reform is not born of indifference, but a result of my participation in a group studying issues around health reform and whose participants have been asked not to reveal its deliberations until its work has been submitted. So while I haven’t been forthcoming about my thoughts around health reform and its impact on palliative medicine, I’m confident that what hypotheses I might offer hereon will be better informed. And while predicting the outcomes of highly charged and politicized issues such as those surrounding the nation’s health care system is surely not my intent, if I can help frame the key issues for those of us seeking to advance the profession and field of palliative medicine, then perhaps we can better prepare for the sweeping changes that will engulf us.

Back to the question I’ve contemplated a great deal over the past couple of months – will health reform accelerate or stall the progress of palliative medicine? It seems to me that the answer depends upon whether one believes that there exists today a business model that pretty much guarantees a livelihood to a physician practicing palliative medicine full-time. In other words, the practice can sustain itself through patient revenues without having to rely upon subsidies from a hospital or other sponsoring organization (if a hospital , for example, wishes to support a practice because it recognizes the value of a palliative medicine practitioner, by all means such support should be accepted). But there is a big difference between HAVING to GO back to a sponsor to request additional subsidies to relieve the growing pains of a palliative medicine practice, and operating a practice whose value (financially and clinically) is so widely acknowledged that the practice is actually “sought after” by other providers. And while palliative medicine physicians are surely in demand, just as surely palliative medicine practices are not. Therein lies the great disconnect.

As we have learned, it is very difficult to disengage the success (or lack of ) of a palliative medicine practice from its related program. More later on why practices are not in great demand. For now, just ask yourself, how many physicians have you recently heard mention that they planned to start an independent practice in palliative medicine?

Will Health Reform be Kind to Palliative Care?

Were I a betting person, I'd wager a princely sum on our getting within the next year a major reform of the health care system. Why am I so confident? Because the auto makers financial crisis will highlight the nation's health care cost issue. The "car czar" will make sure of it. And while the implications and ramificiations of "reform" will undoubtedly be wide-ranging, I've given to wonder what reform will mean for palliative care in general, and palliative medicine practices specifically. Mounting signs suggest that reform will be, indirectly, unkind to palliative care. In upcoming posts, I'll offer my take this subject. In the meantime, I invite yours.

Exceptional Palliative Medicine Practice Opportunity

Earlier this year, I was asked by a journalist who covers the hospice industry to comment on the future practice opportunities awaiting physicians interested in practicing palliative medicine.
I commented in that piece that the traditional role of hospice medical director was in the midst of evolution, to which I added that was a positive development since this traditional role would not suffice (no matter how well paying) in attracting talented physicians to the field. Some interpreted my comments as an assault on the fine work done by hospices in this country. On the contrary, I see physicians serving as the keystone for the development of Advanced Palliative Care Organizations - below, I describe a current practice opportunity with which I'm working that typifies the sort of position that will become prevalent in communities across the US.
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You'll showcase both your clinical expertise and business savvy as you implement clinical and business development strategies for our client’s palliative care service. The service was initiated in 2005, backed by several years of assessment and development, and promises to redefine how end-of-life care is provided in the flagship hospital of one of the most highly regarded health systems on the East Coast. This service has generated significant interest among key stakeholders, who are eager to integrate these palliative care protocols into their practices.

This hospital-based palliative care service accounts for one of the most important strategic initiatives over the next 24 months. While some strategy is in place and activities have been underway for some time (currently about 70 consults/month), you'll put your personal stamp on these programs as you expand development efforts and provide palliative services to patients in acute and long-term care settings.

The success of this program will provide impetus for more palliative services within the health system.

What You'll Bring to the Table

MD or DO, Board certification in primary specialty and palliative medicine
Experience in delivering hospital-based palliative care services, including a successful track record of advancing palliative care programs through clinical development.
Deep knowledge of clinical practice guidelines for quality palliative care and understanding of quality improvement methodology
Ability to effectively lead, manage, and participate on multi-disciplinary teams.
Strong interpersonal, public speaking, written communication skills.

Your Unique Opportunity

This position offers many unique benefits:

Stability – the palliative care service has received senior management (of both the sponsoring hospice and health system) authorization, and has been well received by clinicians throughout its introductory period

High visibility -- your visibility to hospital executive team is a "given;"

Exceptional work environment -- each employee is expected to contribute toward shared goals, to sustain a working environment that is team-oriented, professional, challenging and friendly.

Career development -- your purview will include both development and implementation, and an opportunity to develop a thriving practice in palliative medicine throughout the health system

High impact -- your success in building out the palliative service within the will enhance our client’s reputation as a leading provider of care for those with life-limiting illnesses

About the Organization

One of the largest not-for-profit hospice and palliative care enterprises (more than $60 million in patient service revenues) serving multiple counties in Virginia and the DC metropolitan area. This organization is highly regarded in its communities for its end-of-life care, and receives considerable philanthropic support. It serves daily more than 600 patients through its certified hospice, inpatient hospice unit, and its facility-based palliative care service.

Compensation

Total earnings potential will top $150,000
In addition to a salary guarantee, this position offers a comprehensive array of benefit programs designed to meet the needs of you and your family, including medical, dental, vision, STD and LTD insurance, 403(b) investment options, paid vacations and holidays, and employer-paid professional malpractice insurance,

More About Your Role

Reporting to the Senior Medical Director, in addition to direct patient care, your activities will include:

Identifying tension points to aid in marketing palliative care services to clinicians
Developing strategies to build sustaining relationships with community partners
Establishing palliative care as a recognized service within the affiliated hospitals, nursing homes, and community clinics
Serving as physician member in education and training of clinical staff, and oversight of palliative program staff
Planning timetables and budgets for program development.
Traveling to clinical affiliates throughout the service area to deliver and oversee palliative care services

Keys to Success

To excel in this role, you will:

Apply your clinical knowledge of palliative consultations and experience with program development to drive the palliative care service forward quickly
Leverage your understanding of the nuances of success in the development of palliative care programs
Be recognized throughout the hospital as the leader (subject matter expert) of palliative care

Hospital Palliative Performance Profiles, part 2

I'm often asked to describe the key elements behind the success of Advanced Palliative Care Organizations, and to cite specific examples across the country. Similarly, I'm asked how we determine the performance of communities and hospitals around palliative care. Simply put, we use the Dartmouth Medical Atlas, and seven outcome measures in the study considered by those whose palliative care knowledge I hold in high regard to be reliable indicators of the prevailing end-of-life care practices of hospitals and communities. These measures relate to place of death, referrals to hospice, use of intensive and acute hospital care during the final six months of life, and the coordination of physician care during those final months.
We then examine the hospital's performance in these palliative outcome measures, against local, state, and national performance data. Hospitals are assigned points based upon their performance against these standards, which when aggregated reflect their Palliative Performance Score. Hospitals are then graded, as follows, based upon their score.

100 - plus A best practice, exemplar
75-99 B solid performance, commendable, aspiring leader
50-74 C common performance, middle-of-the-road
25-49 D below-average performance, needs considerable improvement
less than 25 E complete overhaul necessary of current practices


Curious about your hospital(s) performance in palliative care? Drop me a line at tcousounis@digital-action.com.

Hospital Palliative Performance Profiles

Since 1996, the Dartmouth Atlas of Health Care has tracked patterns of health care delivery, practice and quality across the country. Its massive pool of national, regional, local and provider-level health care utilization and cost data, derived from the Medicare database, has documented striking geographical variations in the delivery of health care services. But it has also changed our understanding of the efficiency and effectiveness of health care delivery and demonstrated that more medical care does not necessarily mean better care—that the wide disparities in health care spending and utilization do not track with measurable improvements in health care quality. In fact, higher utilization at the end of life may represent both harm to patients and billions of dollars in wasteful and unnecessary health care spending.

The Dartmouth Atlas Project, founded by Dr. John E. Wennberg, is based in the Dartmouth Institute for Health Policy and Clinical Practice at Dartmouth University. Its databases are used by health care policy-makers, analysts, health care executives, researchers, and, increasingly, palliative care advocates seeking to plan or justify the need for palliative care services to help their hospitals better manage these high-need, high-cost, high-utilization patients.
“Concern about overly aggressive care for patients at the end of life has sparked increased interest both in palliative care and in aligning the kinds of services provided to dying patients with their well-informed preferences,” the report states. “Patient wishes may have less influence on intensity of care than the practice patterns of the hospital where the care is given.”

Taken together, these figures start to sketch a picture of how much potentially futile or ineffective care a hospital or a region provides to patients during their final months of life or during the hospitalization in which death occurs—as well as creating an opportunity to compare performance on these variables among peers.

Our analyses show there is great variation in end-of-life care across regions and states. Digging deeper, our research group has identified that those hospitals with high performance scores (100 or above) have adopted advanced palliative care organizational (APCO) principles in which there are what we refer to as “learning communities”. This learning community is essentially a group of palliative care stakeholders who "join" together and are driven by a desire to share problems, knowledge, experiences, insights, templates, tools, and best practices around palliative care.

I'm interested to hear from those involved in learning communities sponsored by APCOs.