APCOs and Palliative Care Performance

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?

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

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