How Do They Do That? - Providing High-Value Late-Life Care

More than 10 years ago, the Robert Wood Johnson Foundation funded a study that analyzed Americans' values, opinions and attitudes concerning end-of-life care. Based on in-depth focus group discussions involving 385 Americans in thirty-two cities as well as two sets of follow-up interviews, The Quest to Die with Dignity identified how Americans then thought about death and dying, how they want to be treated, and how they viewed planning documents such as living wills.

Some suggest that those participating in the study share similar, clearly articulated concerns, hopes and beliefs about the process of dying in America today. Dying well, for most of these Americans, means dying pain-free, relieved from all suffering. For many, it means dying at home, surrounded by loved ones, and untethered to machines.

Are there communities that do a better job of complying with patient preferences? Communities that could be considered "bellwethers" or "exemplars", communities where high-value late-life care is provided? Using data drawn from the Dartmouth Medical Atlas, such communities can be identified.

Recently, the Institute for Health Care Improvement(IHI), an organization led by Don Berwick, MD, who will soon be leading CMS, identified ten communities where high-value care is being provided. We've taken a look at those communities, to analyze whether there's a connection between their success stories in providing high-value health care and their performance around late-life care. and we've found that some regions do provide high-value health care and patient-centered late-life care.

A previous post on this blog took a closer look at Asheville, North Carolina, one of 10 communities identifed by IHI in their How Did They Do That? study. Among the lessons from the IHI study:

Some patterns: a culture of collaboration to put patients first; considering finances as a constraint, not a goal; the importance of physician leadership; the real or virtual integration of delivery systems across the continuum of care; the importance of strong primary care; the value of electronic health records and the information-sharing it makes possible; and an emphasis on measuring and reporting data on quality and utilization.

We'll take a closer look at some of these communities, in an effort to better understand why some regions' late-life practices produce outcomes that match patient preferences better than other regions.

Compensation Conundrum

I'm asked from time to time what are the prevailing compensation rates for HPM physicians. The follow-up to that question is often, "what are the most common compensation models?"

The most common compensation model for HPM Practitioners is a guaranteed (straight) salary. Guaranteed base salary is straightforward, thus simple to implement. Its greatest value is in its simplicity. But one of the results of straight salary is that often role confusion emerges, because expectations are not clearly articulated, and often misaligned.

We are beginning to see variable (incentive) pay used more frequently than in the past. Base salary with incentive (or what we refer to as a hybrid model) is becoming more common -- where base salary is set, we've found, is critically important to how meaningful are the incentives. Conventional wisdom suggests that at least 20% of compensation should be at risk for the incentives to alter behavior.

Choosing metrics to be used for incentive pay, however, is a daunting process, and it is why straight salary remains the most common plan today. Yet, choosing metrics is a highly valuable process, and the mere exercise of that process yields substantial benefits. In a compensation plan with incentives, the key stakeholders will sit down and eventually come to an agreement on which metrics are most important, and then quantify those metrics. It is a process we refer to as "valuing physician activity".

Incentive pay is typically based upon a work effort metric (such as RVUs, collected revenue, patient visits/encounters). There are metrics in addition to work effort, although at present their use in HPM compensation plan design is uncommon. I'm familiar with a couple of hospices that require a quality gate be passed through before incentives kick in. I'm familiar with plans in which exceeding certain scores in family satisfaction surveys will trigger a bonus payment. And there are a small but growing number of compensation plans that reward what we refer to as group citizenship -- or activities such as committee participation, or mentorship.

The metrics that are used, in the end, are not as important as the process of valuing physician activity.

Different Paths, But Same Destination

I've learned that there are many paths to a full-time practice in Hospice and Palliative Medicine(HPM).

Two physicians (Drs. Cote and Martin) with thriving hospice and palliative medicine practices are profiled in the most recent issue of HPM Practitioner. Both started in private practice, one in internal medicine and the other in family medicine. One put down roots in his native Rhode Island after completing his residency, started working part-time for the local hospice and gradually increased his role until the hospice position became full-time 21 years later. The other has practiced in diverse hospice settings and moved his family cross-country several times in pursuit of opportunities for career development. But both are doing the work they love in hospice and palliative medicine full-time, seeing patients while building innovative end-of-life care programs.

Evolving Role of the HPM Physician - What Will the Third Generation Look Like?

Most would agree that the role of the Hospice and Palliative Medicine (HPM) MD is evolving – or moving into a second generation. The first generation has been characterized by contractual relationships, usually hourly pay, for a part-time medical director role. That role describes, by the way, the predominant arrangement today. It is giving way to the full-time MD, and to compensation arrangements that are typically 100% guarantee, accompanied by subsidies.

But we are starting to see pushback by program sponsors to continued subsidization – and I would respectfully submit that a physician specialty cannot be sustained when it is dependent upon subsidies. Look no further than geriatrics, if you need an example. There are 5% fewer certified geriatricians (7,345) today than 10 years ago, or, put another way, roughly half the number currently needed, according to estimates by those who have studied this workforce issue. Why is that? Surely not because there is less of a need for geriatric specialists. Geriatric services are no longer subsidized by hospitals at the rate, and amount, that they were just a decade ago, and a result compensation has not risen to levels that make the field attractive.

What will be the next (third) generation role of HPM physicians? And, how will those physicians be paid? I would watch closely to what Medicare Advantage plans are doing when it comes to reimbursement. Think bundled payments, or global capitation. What other likely scenarios do you see?

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.

Palliative Care Grand Rounds - April MMX

A grand welcome to the April edition of Palliative Care Grand Rounds (PCGR), a monthly (first Wednesday) summary, or mash-up, of thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere. For a look back at year-to-date PCGRs, see here, here, and here. Now, onward.

With the landmark health reform bill commanding news throughout the past month, I’ll focus on blog posts relating to palliative care that any of us might have overlooked. First, a summary of how health reform may impact hospice via Larry Beresford’s post .

A higher than usual volume of current blog postings concern futile care. To wit, the Happy Hospitalist writes in his Unfiltered Hospital Medicine Blog about a recent case that highlights for him, just as for many who posted comments, the ethical issues surrounding futile care. So is this particular case an extreme example? Or is it more common than you or I realize? Decide for yourself.

Meanwhile, a neurologist with the blogger moniker of Dr. Grumpy writes about another example of futile care that’s sure to give pause to each reader.

Then there’s Joanne Kenen, a veteran journalist who logged more than a decade covering health policy on Capitol Hill. As Senior Writer in the Health Policy Program at the New America Foundation, Ms. Kenen’s blog focuses on the intersection between health policy and health politics. Read here for her reaction to an essay “Shock Me, Tube Me, Line Me” penned by an
Emergency Medicine specialist in the esteemed journal Health Affairs. Its author, Boris Veysman, an ER doc at a New Jersey academic medical center, describes caring for a terminally ill woman suffering from metastatic cancer. Her wish—to have a low-tech death, free of tubes and machines—both countered and confirmed his to have “everything” done to prolong life when his time comes. A provocative read.

Larry Beresford, host of last month’s PCGR, posted recently about the discussion circulating more widely these days on declining enrollment at hospices. A decline in hospice referrals, Larry posits, may correlate to what the economists refer to as a necessary market correction.

The critical nexus of death and religion often fascinates Ann Neumann. In her blog Otherspoon, she weighs in with a thoughtful piece on the role that three institutions (church, state, and health care industry) play in the national structure of late-life care.
Concurrently, her post grapples with the racial disparities prevalent in hospice enrollment.

I’m indebted to Christian Sinclair for facilitating my role as Grand Rounds host in his post . It nicely crystallizes several blog posts that have deservedly garnered much attention and discussion.

Dr. Michael Kirsch asks in his blog “Are Feeding Tubes Futile Care or Morally Obligatory?” See where you stand.

A family medicine physician who writes a blog, Musings of a Dinosaur, posted last month that “Palliative Care is an Unnecessary Specialty”. Well, as you’d expect, this view generated considerable discussion throughout the blogosphere. Some came from Buckeye Surgeon, who comments occasionally about palliative care, posting these comments.

On Geripal, Alex Smith writes about how his “What is palliative care?” response has evolved. Today, he starts by saying, "Palliative care is about matching treatment to patient goals." Hard to argue with that.

Are you curious how physicians choose to practice in hospice and palliative medicine? In the first edition of Pallimed’s new feature, Origins, Pam Harris, who recently passed her Physical Medicine and Rehabilitation boards and is HPM-certified, details what drew her to the HPM specialty.

Suzana Makowski joined Pallimed last month as a blogger, posting about emergency room use by patients with cancer approaching end of life. Dr. Makowski adds her suggestions to those of the study’s author on how ER visits could be reduced. One notion: establishing “palliative care medical homes” that provide palliative care seamlessly across healthcare settings.


Risa’s Pieces has been a blog whose posts have been regularly featured in PCGR. In this post,
Risa writes about her new roles in and out of end-of-life care.

Over at the blog Death Club for Cuties, look for a new feature titled Memorial Monday.
Blogger Jerry Soucy visits a site called Find a Grave, searches through its database to find the people who died on the particular date of a given Monday, and then selects an entry that has some relevance to palliative care, or that otherwise resonates with him personally.

Next month’s host is Thaddeus Pope, at his blog http://medicalfutility.blogspot.com/. Lots of March posts on the subject of yes, medical futility. Among these posts you'll find many video links, one of them of a short film nominated for Best Animated Short Film at the 2010 Academy Awards. I think you'll find it worth eight minutes of your time. And while on the subject of the connection between the arts and death and dying, have a look at Pallimed's Arts and Humanities blog and postings by Drs. Christian, Clarkson, and Wollesen.


Of course, your comments are, as usual, invited.