Accountable (Palliative) Care Organizations - A Call for Comments

Blogs Pallimed and GeriPal have posted very recently about an opportunity to influence the development of  an organizational model that some consider to be a prototype of the next decade's health care delivery system. Accountable Care Organizations (or ACOs).    The shift accountable care organizations will bring from pay-for-volume to pay-for-value — and their focus on total population management, closely aligned incentives and a degree of coordination among providers not typically seen in most markets — cuts to the heart of  the health care institutions within most communities . In the cards, some suggest, are:  fewer hospital admissions, shorter lengths of stay, fewer emergency department visits, and fewer procedures and tests. Hospice and palliative care advocates, take note, this is our opportunity.
There is a special request for comments regarding certain aspects of the policies and standards that will apply to ACOs participating in the Medicare program under section 3021 or 3022 of the Affordable Care Act. The request can be found at regulations.gov under the document number: CMS-2010-0259-0001.


The dealine for comments is December 3rd, so there is little time to act.  Diane Meier has offered some guidance in formulating a response to three main questions posed in this call for public comments. Here are her possible talking points that you can consider putting in your comment:

Question 1: How should we assess beneficiary and caregiver experience of care as part of our assessment of ACO performance?

•Require evaluation of patient and family goals of care, using for example POLST and advance care planning

•Determine patient-family recall of discussions about care goals, and degree to which care actually received is concordant with goals

•Require access to quality palliative care and Medicare-certified hospices as a condition of participation in an ACO.

•Assess penetration of and receipt of palliative care among high need high cost patient populations across diagnostic categories.


Question 2: The Affordable Care Act requires us to develop patient-centeredness criteria for assessment of ACOs participating in the Medicare Shared Savings Program. What aspects of patient-centeredness are particularly important for us to consider and how should we evaluate them?

•The most important aspect of "patient-centeredness" is the degree to which informed and achievable patient and family goals for care are elicited, documented in an accessible and retrievable manner, and actually followed in the care plan.

Question 3: In order for an ACO to share in savings under the Medicare Shared Savings Program, it must meet a quality performance standard determined by the Secretary. What quality measures should the Secretary use to determine performance in the Shared Savings Program?

•Quality measures should include advance care planning; occurrence and timing of palliative care services among appropriate patient subgroups; occurrence and timing of hospice services among appropriate patient subgroups; symptom burden; patient confidence that someone on the team knows them and can be reached after hours; degree to which patients families believe they know what to expect and are prepared to handle their illness; degree to which family needs are assessed and addressed among appropriate patient subgroups

Dr. Meier makes clear that the goal of our comments should focus on making the point that an ACO must require access to quality palliative care for its sickest high need and high cost patients in order to assure that care is directed by and concordant with patient and family goals, and not by strong ACO incentives for cost containment.

There is little time to act. Just click here and submit a comment. To make your lives a little easier, the following is a draft outline that you can use in your comment:

1.Introduce yourself as palliative medicine clinician or health professional.

2.Define palliative care as medical care focused on best possible quality of life, delivered from point of diagnosis of serious or advanced illness whether the goal of care is cure, life prolongation, or achieving a peaceful dignified death. In practice, consists of expert assessment and treatment of symptom distress including pain, anxiety, and depression; conduct of in-depth discussions with patients and families to establish achievable care goals and a care plan that meets those goals; and commitment to continuity of care and relationships across the many care settings that seriously ill patients must traverse over the course of an illness. Palliative care includes end of life care (hospice) but is not limited to it- it is especially important among Medicare and Medicaid beneficiaries with advanced disease and/or multiple chronic conditions with functional impairment- a group who are not predictably dying and who may live for many years with a significant burden of disability and medical needs.

3.The core strategy of palliative care is to help informed patients and families determine their achievable goals for care and then helping to make sure that medical care received helps patients achieve those goals.

4.The goal of ACOs is to incent quality and not quantity and to coordinate the full range of providers. Because of ACO-associated changes in financial incentives that will reward efficiency and "doing less", the risk of undertreatment- reduced access to needed care- and consequent poor quality of care is greatest for high need high cost patients. To counter that risk, ACOs should be required to provide access to specialists trained in care of this complex high need patient population across diagnostic categories, and specifically trained in the skilled communication necessary to elicit achievable care goals throughout the course of illness. Providers with this training work in palliative care programs (mostly hospital-based) and in hospices.


More on Accountable Care Organizations, and the role of hospice and palliative medicine, in future posts.

Disruptive Innovation in Health Care - Has It Arrived At Last?

The authors of the 2000 Harvard Business Review article Will Disruptive Innovations Cure Health Care? suggested that organizational delivery models were in need of  modernization, or as they put it, "the health care industry is trying to preserve outmoded institutions". New organizations to "do the disrupting" need to be created, the authors went on. 

 What few could have predicted was the timing of the modernization. Organizational structures to deliver health care have largely remained static over the past decade, outside the ascendancy of  stand-alone ambulatory surgery centers. If Accountable Care Organizations (ACOs) do little else, they will be considered as successful because the spectre of their implementation has brought parties together who likely would have otherwise remained apart.

In future posts, we'll take a closer look at the role of one of those parties - palliative
medicine -  in a post-acute network.

Is Palliative Care A Disruptive Innovation in Health Care?

It's been a short (or is it long?) ten years since the September-October 2000 issue of Harvard Business Review published the article "Will Disruptive Innovations Cure Health Care?  In that piece, the authors (Clayton Christensen, Richard Bohmer, and John Kenagy) argued that powerful institutions fight simpler alternatives to expensive care because those alternatives threaten their livelihoods. If history is any guide, the authors posited, the health care system can be transformed only by creating new institutions that can capably deliver lower-cost, higher-quality, and more convenient care, rather than attempting a tortuous transformation of existing institutions (read that as acute-care hospitals) that were designed for other purposes. They went on to comment that our major health care institutions have together overshot the level of care actually needed or used by the vast majority of patients. Has much changed  during the intervening decade? And, it set me to wondering, is  palliative care  considered a disruptive innovation?

James Cleary, MD (palliative care chief at the University of Wisconsin Hospital and Clinics), referred to hospital-based palliative care as a disruptive innovation in a 2008 keynote address to an audience of hospice and palliative care professionals. And as one considers that disruptive innovations "sneak in from below",  start by meeting the needs of "less-demanding customers", and enable "less-expensive professionals to do progressively more sophisticated things in less expensive settings", the case sharpens  for palliative care as a disruptive innovation.

So why doesn't palliative care always feel like a disruptive innovation? Surely one reason
is that new organizations to do the disrupting have not sprung forth  the palliative care sector. That is likely to change soon, as  the formation of Accountable Care Organizations (ACOs),  encouraged by the health reform bill,  reconfigure the delivery models of health care over the next decade. And within the ACOs will emerge Advanced Palliative Care Organizations (APCOs), proven to be  successful models for improving delivery of chronic and late-life care because their characteristics encourage processes of care that are:

Timely - delivered to the right patient at the right time (early identification of patients)


Patient-centered - based on the goals and preferences of the patient and family, articulated in goals of care conversations


Beneficial and effective - demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)


Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

I invite our readers to weigh in.  Is palliative care a disruptive innovation? And if so, what steps will best advance its influence within the larger health care system?

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.

Accountable Palliative Care Organizations (APCOs)

Recently I was asked by a client to describe the role of Accountable Palliative Care Organizations (APCOs) in creating exemplar practices around "late-life" care within a community (see here for a previous post describing exemplar communities). The client is situated near a shopping mall that had been struggling until it recently brought in a major department store - a topic which had been a subject of an earlier conversation that day. An APCO, I replied, is like an "anchor tenant" of the palliative care community, setting norms to encourage the free-flow of ideas and collaboration, producing enduringly successful communities.

Within these APCOs, physicians , hospices, hospitals, and long-term care facilities adopt measures to blunt harmful financial incentives, thus taking collective responsibility for improving care for those with advanced illnesses (what I'm terming late-life care). Much has been written and commented of late about the role of financial incentives in the health care system, and what provisions in the health care reform bill could bring about better outcomes while containing costs.

I'm curious to learn your thoughts and experiences, as we explore this subject in greater depth in future posts.