Archive for March, 2011

MedPAC meeting in Washington on Palliative Care

I have always yearned for a Medicare Benefit for palliative care services, so it was with some excitement that I read an e-mail from MedPAC inviting me to a meeting in Washington March 23, to discuss palliative care.

The Medicare Payment Advisory Commission (MedPAC) is an independent Congressional agency established by the Balanced Budget Act of 1997 to advise the U.S. Congress on issues affecting the Medicare program. The Commission’s statutory mandate is quite broad: In addition to advising the Congress on payments to private health plans participating in Medicare and providers in Medicare’s traditional fee-for-service program, MedPAC is also tasked with analyzing access to care, quality of care, and other issues affecting Medicare.

The Commission staff invited a diverse group of palliative care specialists to come to Washington to discuss general issues such as the definitions and scope of non-hospice palliative care, the strength of the evidence that palliative care improves quality, outcomes, and service use, and factors that enable or hinder the delivery of palliative care.

The conference was attended by MedPAC staff, a moderator from the Lewin Group, and Janet Bull (Four Seasons, NC), Lyn Ceronsky(Fairview Services, Minneapolis), Timothy Keay (U Md Ca Center, Baltimore), Randall Krakauer (Aetna, NJ), James Lee (Everett Clinic, Washington), Diane Meier (CAPC , NY), Susan Mitchell (Harvard Aging Research, Boston), Michael Nisco (UC & Hospice, Fresno), Russell Portenoy (Beth Israel, NY), Greg Sachs (U of Indiana Aging Research, Indianapolis), Linda Todd (Hospice and PACE of Siouxland, Indiana), and myself.

It soon became clear that a new benefit for palliative care services is not on anyone’s drawing board, but the inclusion of palliative care services in new initiatives like Accountable Care Organizations, Community Health Teams to Support the Patient-Centered Medical Home, Hospital Value Based Purchasing, or Center for Medicare and Medicaid Innovation at the Center for Medicare Services is a possibility.

It was an energized discussion of wide-ranging aspects of our field, and we all hope the MedPAC staff can use what they learned from us to help Medicare beneficiaries with serious illnesses get the best possible care.

Porter Storey MD

Executive VP, AAHPM

Colorado Permanente Medical Group

Boulder, CO

Getting ready for 2012 AAHPM bookclub: help us pick next year’s book

Medical Humanities has played an important role in my personal development as a physician and palliative medicine doctor. Reading stories, novels, poetry, listening to music, looking at art and movies and plays have helped teach me

  • how to face suffering,
  • how to sit with it,
  • how to be curious about and wonder what will emerge if I stay long enough.

Two years ago, the humanities and spirituality SIG at AAHPM launched a book club – with Drew Dipin Faust’s The Republic of Suffering: Death and the American Civil War. This year, we followed with A. Verghese’s first novel, Cutting for Stone.

At the Academy meeting in Vancouver, we solicited proposals for next year’s book from people who attended the bookclub discussion. Instead of keeping the voting and selection to an insular group, we tapping into the emerging culture of “open access” and social media by opening the voting to the community at large –

To allow everyone time to read the book, we are selecting it early this year. The deadline for voting is coming up quickly. Please vote for your top 3 choices! While we will select the most voted for book for the Annual Assembly, the next most popular books will serve as topics for discussion for each season of the year.

Thanks for participating!

Suzana Makowski – Co-Chair: Humanities and Spirituality SIG

30/30/30 Campaign to Improve Late-Life Care

A Palliative Care Summit was recently convened in Philadelphia by the School of Population Health at Thomas Jefferson University. It was described as the “First National” and the “Leading Forum on Palliative and End-of-Life Care”.

An impressive array of speakers over the two days. Diane Meier,MD, Sean Morrison, MD, Don Schumacher, David Wennberg, MD, Christine Richie, MD, Terri Maxwell, PhD,APRN, James Cleary, MD.,Todd Hultman,PhD,APRN to name but a few. A roster of thought leaders in the field. Compelling cases were made during the presentations on why hospice and palliative care (is/are?) the solution to many of the health care industry’s woes.

Meanwhile, just next door, other industry thought leaders were offering compelling cases on why “medical homes” or ‘expanded chronic care models” or “mobile technology” were desirable solutions for transformation of the health care system.

In other words, competing, or one might say, conflicting visions. These competing/conflicting visions exist across specialties, and within them.

Dr. Morrison addressed this issue when he stated that the public and professionals are confused by references to hospice and palliative care , as if these were two distinct fields or sectors.

While my training is as a health executive, I’ve spent much of my professional career advancing the work of palliative care/hospice professionals and organizations. So I pay closer attention to the hospice/palliative care field, and how it may best fit into the larger health care system. And as Dr. Morrison stated directly, and others commented more indirectly, while progress has been made over the past 15 years, the institutional culture of dying in the US has not dramatically changed. I refer to palliative care as one parts accomplishment for every three parts of potential. Yes, we have a long way to go, indeed.

At the end of the Summit, I was left with a nagging question: If hospice and palliative care are such an obvious solution, then why hasn’t the “art” and “science” of hospice and palliative care spread more quickly and widely than it has? No simple answers to be sure. Yes, many of the speakers offered calls (some powerful) to action. Yet calls for action have been sounded for the past 15 years, with some, but most would argue, insufficient progress. Why? The promise of palliative care to improve late-life care has been stymied by a highly fragmented field of hospice and palliative care where stakeholders are perpetually “staking”out their ground.

Some suggestions for the Second National Palliative Care Summit. Let’s have discussions around:

*How nursing AND medicine can best collaborate to improve access to palliative care in all settings across the community.

*What NEW organizational models might best bring together key stakeholders in late-life care within a community?

*What can be learned from communities whose late-life care practices make them exemplars?

Finally, we need a unifying campaign to improve late-life care in the US. Here’s a suggestion. The 30/30/30 Campaign. A national campaign carried out locally/regionally.

Something like the following:

*No more than 30% of deaths occur in hospitals.

*At least 30% of deaths in hospital are consulted by palliative care specialists.

*No more than 30% of patients who die will be enrolled in hospice for 10 days or less.

Your comments, ideas, feedback are, as usual, invited.

Dr. Allison Lauber Shares a Unique and Inspiring Story about the Board Exam

This past fall my husband had several hospitalizations, culminating with the planned re-admission for surgery which we thought would pretty much clear up his recent problems. The day of surgery, we had no clue that his surgery would take over 7 hours, and end in him being placed in the ICU. But even then, I was positive that it was just overnight after a prolonged anesthetic. It wasn’t, it was the start of a two week nightmare that found me floundering. While I work a a very large Academic Medical center, Palliative Medicine is still in its infancy. So our Service consists of me and my NP( and of course SW and Pastoral Care). At the end of the first week, knowing my husband’s feeling about life prolonging care, I began to get concerned about who would I look to, if I needed advocacy as the patient’s wife? I called Pal Med Connect. I don’t recall the name of the doctor who spoke to me, listened to me cry, and provided both solace and suggestions, but she was great! And she called back several days later, too. I was able to think more clearly and make some plans. I even was able to suck up the courage to take my boards . Yes, he was still on the vent on Nov 16th, when the exam were administered, and my brain was Swiss cheese, but the testing center was only 2 miles from the hospital and my sons stayed with him, while, I played with the computer.
My husband survived, and 3 months later, he is till not well, but slowly improving, by the grace of God. And another Grace? I passed the CAQ! Who knew that taking boards when you’ve had no sleep, not eaten and are maximally stressed could be so efficacious for scores!

A Developing Countries Scholar’s Perspective on the 2011 Assembly

Attending the 2011 AAHPM &HPNA Annual Assembly in Vancouver February 16-19, 2011 was a wonderful experience for me. It would have been impossible without the support from AAHPM for physicians like me who are working in developing countries. I got the opportunity learn new clinical and scientific knowledge of palliative care by attending different sessions on different days including the preconference workshops. It was a good platform to know and to develop personal relationships with palliative care workers from Canada, USA and other parts of the world. I am already benefitting from this new relationship to improve palliative care in Nepal.

I am going to conduct a one-day Palliative Care Workshop for fellows of different departments March 25, 2011. I got the chance to meet Steven M. Radwany during Annual Assembly who is helping to conduct the palliative care workshop by supplying 60 copies of the Primer of Palliative Care 5th Edition with the help of different friends from AAHPM. I met Fraser Black & Robin Love from INCTR who are also helping me. I have already received “INCTR Palliative Care Handbook” from INCTR Head Office, Brussels, Belgium for the participants of this workshop. Frank Ferris from San Diego has shown different opportunities to improve my personal career and to develop palliative care in Nepal. The educational flash drive provided by Laura Davis is very useful to conduct my daily palliative care activities.

Besides I could see the beauty and development of Vancouver and feel the warm hospitality of the Canadian people.

Bishnudutta Paudel, MD

How Often Should Patients with Advanced Illness Be Visited By a Physician?

We [the CMS] believe the role of the physician within hospices has been undervalued, and we would like to see the physician’s participation increase in the care of long-stay patients. That’s one of the messages to take away from the CMS regulation mandating physician (or nurse practitioner) face-to-face encounters to certify a patient’s continued hospice eligibility. The Medicare program reimburses a hospice nearly $30,000 over a six-month period to provide for the total healthcare needs of a patient with advanced illness- a single physician visit to that patient’s residence over that period isn’t too much to require, is it?

To me, it seems likely that such patients would benefit from a care planning visit by a physician. After all, the distinguishing feature of hospice care from most other care covered by Medicare is its collaborative nature, and the primacy of the interdisciplinary team.

Such care, of course, lies at the core of palliative medicine.

Rather than treating this regulation as a compliance issue, hospice executives, and physicians, would do well to incorporate physician recertification visits into their clinical practice patterns. One can be confident that patients, and their families, will appreciate the value of these visits.

Recently, a family member passed away after a broken hip confined her to a skilled nursing facility. A hospice program served her during her final three months. During that time, she was not seen by a hospice and palliative medicine physician. And while her (and the family’s) hospice experience was positive, the interdisciplinary team concept seemed incomplete without a single bedside appearance from the physician.