Palliative Medicine Physician Practice Profile-interview with HPM Physician John Mulder, MD

Balancing Clinical and Administrative Roles: Interview with HPM Physician John Mulder, MD
(read here for one of Dr. Mulder's thoughtful essays on palliative care)

"I find that my passion to make sure no one suffers needlessly outweighs my desire to go home from work at 5 pm," John Mulder, MD, says to explain how his commitment to hospice and palliative medicine (HPM) shapes his balancing act of clinical and administrative responsibilities for Faith Hospice and the Spectrum Health hospital system, both based in Grand Rapids, MI. Dr. Mulder formed a professional corporation in order to contract with his two primary clients, Spectrum and the hospice's parent company, Holland Home. For Spectrum he provides palliative care consultations in two acute care hospitals (with two to three new consults ordered per day) and fills a variety of administrative roles aimed at promoting and advancing palliative care within the system. These include strategic planning, one-on-one meetings with physicians, and attendance at tumor board and cancer interdisciplinary meetings. For the hospice, he serves as vice president of medical services and sits on its leadership team. Recently, he relinquished to a colleague, Dr. Martha Ording, the responsibility of hospice medical director as spelled out in Medicare's conditions of participation.
His current role emphasizes quality initiatives such as protocol development, a new HPM fellowship program, and medical management of the hospice's freestanding, 20-bed inpatient facility. "That's the daily clinical environment for my hospice physician practice." Dr. Mulder also carries a beeper 24 hours a day ("I've always done that; I feel very possessive of my patients"), although with the option of arranging for back-up as needed. Time management remains an ongoing challenge, and it can be difficult to precisely parse out which is hospice versus palliative care or administrative versus clinical (and billable) time. "But I don't stand on protocol. I feel comfortable with how my time is spent, as do the folks to whom I'm accountable," he says. "At the end of the day, I want to make sure that they have gotten their money's worth. And there is the intangible value of my availability as a hospice and palliative physician - that existential presence, that leadership role brings value in and of itself. It's all about establishing relationships and building trust in my role and in what HPM offers."
Dr. Mulder recently took a phone call from a colleague who is well known as a pioneer in the field of HPM, and is considering a job change from an academic to a hospice setting. "She asked about the business aspects-employed versus contracted, how to negotiate salary and benefits, things like that. These are basic issues for those who are immersed in the business, but they can be confusing if you've never had to deal with them." In Dr. Mulder's previous job as chief medical officer of Alive Hospice in Nashville, TN, the position was structured in a way that allowed him to learn on the job the business and practice management aspects, gaining a clearer sense of what the medical director contributes to hospice and palliative care. "(CEO) Jan Jones understood and fostered the medical component of hospice, and emphasized my education as medical director and medical leader," he relates. One of the keys was attending national hospice educational meetings. "It's not only having a seat at the table for the physician's role, but sharing what I know. Which affects how care is given, and the policies that are developed - just being able to exercise what you know as a doctor to be a partner on the team."
How to Find Satisfaction-and Make a Living - Dr. Mulder was instrumental in convening an informal group of about two dozen HPM physicians practicing in Western Michigan. They now meet every other month to talk about both practice and clinical issues, and they are in discussion with a local managed care company about establishing a contracted physician network that could provide expanded hospice services and covered palliative care benefits, including in the outpatient setting. Several of these physicians work full-time in hospice or palliative care, others are part-time, and a few are board certified in HPM but not currently working in the field. "Two or three others have a deep interest in palliative medicine and want to do it some day," he explains. At the group's first meeting in January, "I could see doctors huddled in groups of three or four. They couldn't stop talking. There was such a hunger for this exchange," Dr. Mulder reports. "We want to communicate through this dialogue how you can make a living, how you can find satisfaction, meaning and personal growth in HPM - but also that the work requires a personal commitment to scientific, cutting-edge medicine and a willingness to be truly present with patients and families." He agrees that it is curious that so many physicians who are motivated to become board-certified in HPM have not gone the next step to full-time positions practicing this specialty. "A lot of part-time hospice docs, because of their hospice compensation and the hospice's lack of commitment to the medical role, don't believe that this can be a career option. It's hard to extrapolate from their experience to how it could turn into a full-time job. And if they don't believe it can be, they will remain shy in their contract negotiations with the hospice - even though a portion of every per diem the hospice collects is meant to cover the medical director's role." Unfortunately, hospice physicians are too often underused, overused, misused or abused. "Their responsibilities are defined by people who may have very little understanding what physicians do - or could do. The physician's role and responsibilities in hospice care need to be viewed in different ways. Not that the doctor is more special than other members of the hospice team, but what he or she brings to the table is different," Dr. Mulder says. "If a hospice wants someone simply to come to meetings and sign documents, that's how it will structure the position. But if you truly want what a physician can contribute to increasing the skill levels of all staff and the quality of the care that is provided, that's a whole different ball game. It requires a different level of commitment by the agency."
Just as palliative care consultations in the hospital more than pay for themselves through decreased length of stay and reduced use of expensive, unbeneficial treatments, the active presence of a substantially full-time physician raises the hospice's exposure in the medical community and can lead to increased referrals and lengths of stay and better decisions about drug therapies and other palliative treatments for hospice patients. "We're fortunate to have a very strong, high-quality hospice program here in Grand Rapids, respected by physicians and the community at large," Dr. Mulder says. In fact, data from the DAI Palliative Care Group, derived from the Dartmouth Atlas of Health, gives the Grand Rapids region an A grade for its end-of-life care. The region has fewer deaths occurring in hospitals or associated with ICU admissions than state or national averages and a higher percentage of decedents (46 percent) enrolled in hospice than national (31 percent) or state (38 percent) averages. Dr. Mulder was trained in family medicine and practiced obstetrics. He was first asked to serve on the Board of Directors of a local hospice in 1985, and became intrigued by its work. "When they asked me to be the medical director, I began learning what a difference hospice made at the bedside."Today, he finds HPM a great field to work in. "I am well compensated, and have never been more satisfied. Who knew?"

Palliative Care Grand Rounds - October edition

Visit here for the October edition of Palliative Care Grand Rounds - a monthly blog carnival highlighting some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. This month's host of Palliative Care Grand Rounds, GeriPal gives its own "spin", incorporating posts that feature the intersection between geriatrics and palliative care. GeriPal (Geriatrics and Palliative care) is a forum for discourse, recent news and research, and freethinking commentary and invites the perspectives of generalists, specialists, gerontologists, palliative care clinicians, and anyone else interested in care of the elderly or palliative care.

Accountable Palliative Care Organizations - Mayo style?

As hard as health insurance reform is, compared to health care DELIVERY reform, that’s the easy part, Mayo Clinic CEO Denis Cortese said at a recent presentation to the National Press Club. Mayo has been frequently cited as a model for health care delivery reform by President Obama and others, but the question of Mayo’s value as a model for overall reform has also generated considerable discussion from both sides.

Cortese cited the significant regional variation in medical practice documented by researchers at Dartmouth (and discussed periodically in this blog, see here and here ) , and he listed several factors common to institutions and regions that produce what he called "high-value care": patient-centric cultures; high levels of physician engagement in leadership and change; much higher levels of teamwork, collaboration, and coordinated care; more "connectivity" and sharing of electronic medical records and information; and much greater use of "the science of health care delivery," meaning systematically looking at how patients flow through an organization in order to reduce waste and standardize processes to reduce errors.

These factors, it occurred to me, are similar to the attributes possessed by Accountable Palliative Care Organizations (see here, here, and here). Producing "high-value care" , whether for an acute episode, in an ambulatory setting, or for late-life care, is a formidable challenge. And it is why, if palliative medicine physicians can incorporate into their practices those skills requisite to success in these emerging delivery models, their practices will be highly sought after.

September edition of Palliative Care Grand Rounds

For an enlightening and interesting summary of the latest from the palliative care blogs, see here.

Redeploying Physician Services at End-of-Life

A recent post (read here) suggesting that the "redeployment" of physician services for end-of-life care is one way to address the health care cost issue at once threatens the income potential of many physicians.

In a statement before the April 2009 US Senate Finance Committee Roundtable on Delivery System Reform, Allan Korn, M.D. ,Senior Vice President and Chief Medical Officer of Blue Cross and Blue Shield Association, called for the creation of "clinical pathways to help physicians provide compassionate and cost-effective end-of-life care." Among patients who died of cancer, Dr. Korn noted, a major contributor to cost and quality-of-life issues is the widespread use of chemotherapy in the last three months of life. Studies show that 15 to 20 percent of patients with incurable, end-stage cancer receive chemotherapy within 14 days of their death, a time when chemotherapy has no benefit. He went on to recommend funding a pilot starting in 2009 to identify the extent of overuse errors in treatment of cancer patients, for example by measuring non-palliative chemotherapy use in the last two weeks of life, and to establish best use of palliative care.

The American Hospital Association identified longer-term cost-containment strategies that will be pursued, as evidence, tools and nationally-endorsed measures emerge. One such strategy advanced by the AHA is to "Promote Efficient Resource Utilization" – more specifically, to promote palliative and hospice care through the use of advanced directives and best practices.

Indeed, palliative care should be better distributed throughout our communities. But palliative care is not an add-on. Rather, its value lies in its offering an alternative, or a substitute for another type of physician care/service already being provided to patients with advanced ilnesses. Lots of revenue/income is at stake. Is it any wonder why critics of health reform are associating palliative care with rationing?

August Edition of Palliative Care Grand Rounds

Palliative care has been much talked about in the context of health care reform. The August edition of Palliative Care Grand Rounds (here) , hosted by Risa Denenberg, offers readers an excellent round-up of the commentaries from the blogosphere.