Use of Hospice Benefit has Slowed – What This Means for Palliative Care

A recent analysis of Medicare claims by Healthcare Market Resources found that enrollment onto the hospice benefit has plateaued (see blog post Hospice Utilization: Is Hospice Stuck in a Rut?). When one considers that the hospice benefit has been the principal source of reimbursement for palliative care, and that Medicare-certified hospices have been the principal delivery model for palliative care, these findings should raise concern among advocates of palliative care and those dedicated to improving its access.

What does the evidence suggest? States that historically have had among the highest utilization rates (such as Florida and Arizona) are now experiencing declines in utilization rates, suggesting that the utilization rate of those states may have reached the natural peak of hospice enrollment. Of course, low-utilization states have growth opportunities, as  states in the top quartile of hospice utilization rates use the hospice benefit 75% more often as states in the bottom quartile: 3.23% (on average) versus 1.85% (on average).  The key question to be asked: is growth in hospice benefit use in those lower quartile states sufficient to drive the spread of, and improve access to,  palliative care? I think not.

To be sure, efforts by organizations like Center to Advance Palliative Care (CAPC) have yielded impressive results, especially among hospitals and more recently through outpatient practices, in disseminating the science (and art) of palliative medicine. Yet, when the primary vehicle for reimbursing and delivering palliative care stalls, it may be time to look at newer vehicle models. Perhaps the time has arrived for Accountable PalliativeCare Organizations.

As always, your feedback and thoughts are invited. And more will follow on this subject.

Medical Staff Development Plan - Why It's Essential to a Hospice's Growth

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:

• identify the opportunities and risks of the current medical staff complement relative to the development of a community APCO ;
• define a reasonable range of investment required to meet recruitment needs; and
• 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:

1. Community Assessment of palliative care practices - identifies improvement opportunities and provides competitive intelligence about peer and neighboring programs,
2. Three-Year Staffing Plan - translates community needs into physician staffing requirements and associated financial commitments, 
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, 
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, 
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.

Building Blocks of a High-Performing Hospice Medical Staff

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 2010) 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.

The Evolving Role of Hospice and Palliative Medicine Leadership

As hospices and palliative care services evolve into accountable 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 (and nurse practitioners) come to grips with  rules around eligibility and face-to-face recertification requirements, 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 HPM leadership in exemplar communities across America (some of which have featured in this blog) -  assembling the right mix of intellectual capital, at the right time (what we refer to as bellwether practices) becomes one of the must-have competencies of late-life care organizations.

Hospice and Palliative Care - Are We Giving a Mixed Message?

Is there a difference between Hospice and Palliative Care?
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.

Valuable Experiences of a Hospice and Palliative Medicine (HPM) Fellowship

When asked by HPM fellows what experiences one should seek to strengthen skill set, I'll recommend the following (a currently practicing HPM physician would also do well to gain these experiences):

-Actively participating in any end-of-life care coalitions in the community, and if one doesn't exist, assemble several HPM practitioners in the community to start a coalition. Coalitions working to change the model of  late-life care in the community are a common element in those regions known for their exemplar practices in late-life care.

-Engaging in initiatives aimed at reducing late-life care clinical variation within the community. These often take the form of  interdisciplinary work groups standardizing protocols or tools, either within a palliative care organization or the community at-large.

- Joining with other clinicians in institutional or community-wide intiatives to ensure safe transitions across settings and reduce hospital readmissions. There is a strong palliative care component in prevailing readmission  reduction programs, among those the commonly used Interact (Interventions to Reduce Acute CareTransfers) tool.


The skills and competencies gained from these experiences will hold an HPM physician in good stead in securing the most attractive professional opportunities emerging in the HPM sector (see this previous post  for more on the emerging role of HPM physicians).

I'm curious to hear from current and recent fellows about what experiences you've found most valuable.