Reimburse Doctors For Helping Patients Plan End Of Life Care, Experts Say
Posted on Monday, March 23rd, 2015 at 6:44 pm by lifemediamatters
This piece was first published in Reuters Health. President Randi Belisomo is a contributor.
Physician incentives are needed to improve end of life care in the U.S., health experts said Friday at an Institute of Medicine (IOM) forum.
The forum convened at the National Academy of Sciences to discuss action on the recommendations of the IOM’s seminal fall report, Dying in America.
“Our current system is not equipped to deal with these challenges,” said IOM President Victor Dzau, citing a rising number of elderly with multiple chronic illnesses, too few palliative care services to keep pace with demand, and time pressures that keep providers from having conversations with patients about end of life preferences and values.
“We need to make sure that healthcare providers do not shy away from these discussions,” said Senate Aging Committee Chairman Susan Collins (R-Maine). “Until we solve the reimbursement issue, I don’t think we are going to make true progress.”
Senator Mark Warner (D-Virginia) said he regretted his failure to talk with his mother, an Alzheimer’s patient, about the end of life care she desired. He lost the opportunity to have this conversation when she lost her ability to communicate, nine years before her death.
“I was an informed citizen at the time, the governor of Virginia, and yet my family and I didn’t have a full understanding of everything that was before us,” said Warner, indicating that he will reintroduce a measure to create a Medicare and Medicaid benefit for end of life planning.
When people fail to plan for end of life care, they may suffer through ultimately futile, invasive and often unwanted treatments, advocates say. Surgeon and author Atul Gawande detailed the “medicalization of mortality” occurring over the past several decades, noting that the most likely time for Americans to undergo surgery is the last week of life.
“We fail to recognize that people have goals and priorities in their lives we need to serve besides just living longer,” Gawande said. “The way you learn what people’s priorities are is by asking.”
Last year, the Centers for Medicare and Medicaid Services rejected an American Medical Association request to create a billing code for doctors to use when they spend time helping patients plan for future care. Patrick Conway, chief CMS medical officer, said the coding would be considered this year.
If physicians will be reimbursed, work remains to ensure the quality of care patients receive. “Metrics in this area are not easy to develop, but they’re not impossible,” said Christine Cassel, president of the National Quality Forum. “Payers need to know they are paying for the right kind of care.”
Doctors, Nurses Begin To ‘Measure What Matters’ For Hospice Patients
Posted on Tuesday, March 3rd, 2015 at 8:01 pm by lifemediamatters
For the first time, the quality of hospice and palliative care will be held to quality measurements developed by nurses and doctors who specialize in end of life care.
The American Academy of Hospice and Palliative Medicine, which includes some 5,000 physicians, and the Hospice and Palliative Nurses Association, which has more than 11,000 members, are pushing the health care industry to consider 10 key quality indicators to guide fellow providers in evaluating palliative and hospice care.
Calling their effort the “Measuring What Matters” project, the physician and nurse groups hope to use the selected measures to “systematically evaluate our effectiveness and develop strategies to keep improving our practice to ensure patients and families get the very best care possible across settings,” said Sally Norton, co-chair of the Measuring What Matters Project and a professor at the University of Rochester School of Nursing.
The groups say measuring quality hospice and palliative care is important, yet there are no standard quality indicators in the U.S. Among the key measures is the need among providers to respect patient wishes about life-sustaining treatments, as well as discussions with patients and families about their emotional and spiritual needs.
“We are thinking about quality and looking carefully at what we do and how well we do what we do,” said Dr. David Casarett, co-chair of the Measuring What Matters Project and a professor of medicine at the University of Pennsylvania’s Perelman School of Medicine. “We should all be encouraged to do better.”
Hospice is generally considered medical care provided for those facing illness near the end of their lives. It can be provided in a patient’s home or in hospice centers, or within hospitals, nursing homes or other long-term care facilities. There are more than 1.5 million dying Americans who receive care from hospice providers each year, according to the National Hospice and Palliative Care Organization.
The hope in the measurements of hospice care is for providers and health systems to “see these measures and start using them,” Casarett said. “Health care providers can take the lead.”
It’s the latest in an escalating trend and evolution toward bringing more accountability to health care through performance measurements and value-based care. Under the Affordable Care Act, for example, hospice providers are already required to report certain quality measurements to the government or lose out on a 1 percent increase in Medicare reimbursement.
Pain control is one of the major quality measures under the government’s “Hospice Quality Reporting Program” that hospice providers must report. The measure “reflects the number of patients who report being uncomfortable because of pain at the initial assessment” and whether “that pain was brought to a comfortable level within 48 hours,” according to the Centers for Medicare and Medicaid Services.
The Medicare pain measure is similar to one of the AAHPM and HPNA quality indicators of prompt administration of pain treatment.
The nurses and doctors involved with the Measuring What Matters project say these measures are critical for providers to consider and get out in front of other efforts by insurance companies and government health programs under the domain of the Centers for Medicare and Medicaid Services.
Private and government payers are moving more toward paying providers for quality care and outcomes and moving away from traditional fee-for-service medicine. Critics of the fee-for-service model say it allows doctors and hospice providers to get paid no matter the quality of care provided.
While accountability and paying for performance in the hospice and palliative care arena have a long way to go, AAHPM and HPNA want providers to be ahead of the issue.
“We don’t want to wait for CMS to come up with a measure but begin to do this ourselves,” Casarett said.
AAHPM and HPNA hope providers use the measures to compare against each other and learn through shared practices. The groups worked on developing the measures for about a year and a half, using input from myriad provider groups and existing data on quality of end of life care.
For now, however, AAHPM and HPNA want to get providers thinking about ways to improve, even if they just adopt a couple of the first 10 measures, Casarett said. Eventually, they hope to hone and broaden the list they have.
“Although this set serves as an initial starting place for standardizing U.S. measurement and benchmarks for care, more development and partnerships with organizations to develop benchmarking is needed, and additional or revised indicators may be needed for particular settings or populations,” Casarett and fellow palliative care providers wrote in the February issue of the Journal of Pain and Symptom Management. “Further research is needed to evaluate how best to define palliative care populations of interest for quality measurement, and how to measure the quality of hospice and palliative care both overall in different settings and for patients served by hospice and palliative care services.”
A link to the entire abstract and article can be found here.
Bruce Japsen is an independent journalist and contributing health care columnist to Forbes and author of “Inside Obamacare: The Fix For America’s Ailing Health Care System.” He is a regular analyst to Fox News Channel’s Forbes on Fox show, WBBM Newsradio 780 and 105.9 FM in Chicago as well as WTTW’s Chicago Tonight public affairs program. He can be reached at firstname.lastname@example.org
LMM President Randi Belisomo: “America Is Ready To Talk About Death”
Posted on Monday, March 2nd, 2015 at 9:17 am by lifemediamatters
As millions of baby boomers age and health costs continue to rise, Americans are ready and willing to have open and honest discussions about death and dying, Life Matters Media President Randi Belisomo told a crowd gathered at a Chicago conference exploring end of life care.
“Americans are not talking about end of life issues as much as we should be,” said Belisomo Saturday during “Dying to Know: Life Affirming Conversations About Living and Dying Well,” a day-long event hosted by the Replogle Center for Counseling and Well-Being at Fourth Presbyterian Church. “But through the proliferation of information, education, media and community building, we can begin telling real-life stories about death and dying.”
If Americans become more comfortable with talking about the inevitable, patients nearing death may be more likely to enroll in hospice care and share their end of life care wishes with close family and friends, she said. Just as breast cancer, colon cancer and same-sex marriage were once rarely discussed and considered taboo, a cultural change is now making discourse surrounding mortality more common.
“There is ample evidence of the public’s desire for information,” she said. “Look at The New York Times’ bestseller list;” Belisomo pointed to Being Mortal, by Dr. Atul Gawande, Smoke Gets in Your Eyes, by Caitlin Doughty, and Roz Chast’s Can’t We Talk About Something More Pleasant?
Belisomo opened her speech with her own experiences facing death and terminal cancer. In 2010, her husband, Carlos Hernandez Gomez, died of complications associated with colon cancer. She said the two did not discuss his end of life care preferences.
“Doctors told us his cancer was ‘treatable,’ even though it was incurable. We went full-steam ahead doing whatever we could to elongate whatever time we had left,” she said. “If metastatic cancer is a fight, it’s not fair. If it is a war, it’s not winnable. All of the militaristic language is misleading.”
He continued to receive chemotherapy and other treatments instead of enrolling in a hospice or palliative care program. Belisomo said she did not want to give up hope or take away his own.
“Ours was just one more example of failure to take all the steps we should have taken,” she said. “We didn’t think about how Carlos would do his own dying.”
Months after his death, Belisomo and his oncologist, Dr. Mary F. Mulcahy, were inspired to launch Life Matters Media. She hopes news and information provided by the nonprofit will inspire Americans of all ages to talk about death.
“Stories like mine are not outliers, they are the norm.”
Dying In America
Much of the latter half of her speech was devoted to the Institute of Medicine’s widely circulated report, Dying in America.
The 2014 report cited the present as the best time to normalize conversations about death and dying, as millions of aging baby boomers will soon face difficult end of life care decisions for themselves and for their family members.
“Many Americans don’t know how to bring up end of life conversations. It needs to become the norm to have these conversations with family and doctors,” Belisomo said. “Death is not how it used to be. The stakes are gigantic.”
The IOM’s report also emphasized the urgent need for increased palliative services– medical care that provides pain relief and centers on enhancing the quality of life among the chronically or seriously ill.
A shift towards comfort care could save Medicare billions of dollars over the next decade. Seventy percent of U.S. deaths are paid for by Medicare, and 30 percent of Medicare spending is used on patients in their last year of life.
“Much of that care is unwanted and wasteful and futile in scope,” Belisomo said. “There is an urgent need for health care overhaul. The IOM calls for more person-centered care that minds the needs of patients, families and their values.”
End Of Life Care For Children Is Different
Posted on Friday, February 6th, 2015 at 8:23 am by lifemediamatters
End of life care for terminally ill children differs significantly from therapies designed for adults nearing death, said a palliative care physician and bioethicist this week at the University of Chicago’s MacLean Center for Clinical Medical Ethics. Each year in the U.S., thousands of seriously ill children continue with curative therapies while enrolled in hospice or palliative medicine programs, even when cure is unlikely.
“The pattern of death is pretty different from adult patients,” said Dr. Joel Frader, medical director of the Bridges Palliative Care Program at Lurie Children’s Hospital. “There is a very low density of dying children, even in places like Chicago. As a result, there are very few expert pediatric palliative care providers.”
Palliative medicine is designed to alleviate symptoms of disease and curative treatments.
Out of the nearly three million U.S. deaths each year, only 55 thousand involve individuals under 18. More than 50 percent of child deaths are a result of catastrophic illness or rapid trauma, such as congenital abnormalities, homicides and accidents. Most non-acute deaths that require prolonged care involve complications associated with cancer or neuromuscular diseases.
Unlike adults, most terminally ill children have healthy cardiovascular systems and lungs until their final moments. Clinicians can offer pediatric patients simpler treatments, such as blood platelets or nutritional supplements, while still ensuring good quality of life until the final days or hours.
It is not unusual, Frader said, to care for a child “who is actively playing and happy until the last couple of days of his or her life. That’s pretty different from what it looks like in adult medicine.”
However, it is also much more difficult to predict a child’s life-expectancy and enroll him or her in one of the nation’s few pediatric palliative care or hospice programs.
“A lot of what we do is technically more difficult, or at the very least, unfamiliar to people who care for dying adult patients,” he added. “Medical directors in hospices who are geriatricians or internists or oncologists really don’t want anything to do with caring for children, even if their organization is the only one in the limited geographic area that provides in-home end of life services. It presents serious barriers, and our team spends an awful lot of time getting hospices to accept the care of a patient who lives outside of Chicago.”
Hospice care is designed to help comfort terminally ill patients in their last months of life. The goal is not cure, but pain and symptom management.
The Medicare Hospice Benefit provided to adults with a life expectancy of six months or less requires that patients stop receiving curative treatments, such as chemotherapy, blood transfusions and radiation. But federal law mandates that terminally ill children receive “concurrent care” consisting of both comfort and curative treatments. Pediatric programs are far less likely to be reimbursed.
While all palliative and hospice care programs are interdisciplinary, pediatric care typically involves music, art and animals to relax patients.
But many clinicians face depression, because they often provide care and emotional support to parents, siblings and even classmates. It can be frustrating to care for teens unable to make their own decisions, Frader offered, and difficult helping parents or guardians explain disease to young children.
“The emotional toll represents a psychological burden on the staff, and it’s not easy stuff to do,” he added. “There is a high turnover rate.”
Talking About Death
Posted on Thursday, January 1st, 2015 at 6:16 pm by lifemediamatters
Medical Societies Spearhead End Of Life Care
This piece was first published in Chicago Medicine (page 18-19). LMM President Randi Belisomo is a contributor.
Bernard “Bud” Hammes, PhD, has spent a lot of time on the phone lately. The balding, spectacled but tireless medical ethicist for La Crosse, Wisconsin, Gundersen Health System has been enthusiastically fielding calls from medical societies, health executives and policymakers nationwide, wondering if they can turn their system or town into one like his own—dubbed in recent headlines as “The Town that Talks About Death.”
Since 1991, Dr. Hammes has been refining his Respecting Choices program, engaging patients in informed discussions about end of life decision-making. More than two decades later, he is witnessing tremendous benefits. Ninety-six percent of those who die in La Crosse have advance directives; nationally only 30% of adults do. “It’s a part of the social fabric here,” Dr. Hammes said of La Crosse, where studies show Respecting Choices has led to the high prevalence in honoring patient preferences, reduced use of hospital services, and no change in mean length of life.
The program is no silver bullet, he acknowledges, calling it instead, “a central tool in the complex tool kit for improvement of health systems and the care of patients.” However, that “central tool” for care may be more aptly described as an axe when applied to health spending. According to the Dartmouth Atlas of Health Care, La Crosse spends less on patients at the end of life than any city nationwide. A finding like that is something health leaders notice, since the Affordable Care Act encourages simultaneous spending reduction and quality improvement.
“We used to shy away from cost questions,” Dr. Hammes said. “We are certainly more comfortable saying something improves care. That it saves money is a blessing and unexpected event, and it gives us the ability to carry out this work.”
It turns out that when asked, most patients opt against high-intensity end-of-life care. But more than a quarter of Medicare spending is spent on just that. The particulars of patient preferences aren’t what matters to Dr. Hammes. What matters is that patients are asked what those preferences are, and that they are honored.
“Chaplains, social workers and nurses are among those being trained within health systems to guide patients in determining what they value at the end of life.”
Now, his work is being replicated worldwide, as Respecting Choices programs are popping up across the globe—in Australia and Singapore—and as close to home as Minnesota. A common denomi- nator underlying these initiatives is leadership from local medical societies, organizations Dr. Hammes calls “excellently positioned” to empha- size advance care planning, so patients may speak up and spell out the care they want. The work costs time and money, Dr. Hammes warns. “We do it, because it’s the right thing to do.”
The Respecting Choices Program At A Glance
Dr. Hammes’ Respecting Choices paradigm trains non-physician facilitators to guide patients in advance care planning within First Steps, Next Steps and Last Steps programs staged to individuals’ health. “The program is physician-friendly,” said John Ropp, MD, a family physician on the board of the South Carolina Medical Association, which is planning First Steps implementation next year. “It makes sense from a clinician standpoint what we’re trying to accomplish, but it takes more than doctors to accomplish meaningful things in the community.”
Chaplains, social workers and nurses are among those being trained within health systems to guide patients in determining what they value at the end of life. Time-strapped physicians refer patients of all ages and stages of health to facilitators to explore fears and experiences as witnesses to loved ones’ deaths. Religious beliefs shaping preferences are also unraveled, and patients choose trusted surrogates to execute decision-making in the event they cannot.
“It’s a way for patients to develop their own insight about why end of life planning is important, figure out what they want, and understand what their values, goals and preferences are based on other experiences,” Dr. Hammes said. Patients typically leave discussions with advance directives completed; in La Crosse, directives are stored in medical records shared among the city’s two health systems.
Why Medical Societies Are Suited To Lead The Charge
Though Respecting Choices has taken hold in northeast Florida with hospice leadership, Dr. Hammes says medical societies are ideally positioned for sponsorship. “They stay out of provider competition,” Dr. Hammes said. “They represent physicians at all institutions and have clear leadership.”
Leadership was something the Twin Cities Medical Society was after in 2008, while seek- ing a project to make its own. End-of-life care needed improvement, members agreed, when they voted to attempt a replication of La Crosse’s success. They dubbed the initiative “Honoring Choices Minnesota.”
“It’s been a blur since,” said Sue Schettle, Twin Cities Medical Society CEO. Four local executives contributed $25,000 each. The medical society did too. Seventeen pilot sites formed between 2010 and 2013, and facilitators now work in clinics, churches and community centers. “It’s gone viral,” Schettle said.
Though Respecting Choices is Wisconsin-born, Minnesotan success prompted the Wisconsin Medical Society towards implementation. “Members wanted a project benefitting everyone, and this had obvious broad-based benefit,” said John Maycroft, director of initiatives.
“Honoring Choices Wisconsin” launched last year in six systems from Madison to Milwaukee. Though insurers contribute to the $350,000 annual budget, members know they are positioned to
lead. “The message from physicians is important,” Maycroft said. “If it came from government or insurers, it wouldn’t be as strong.”
The work isn’t easy. Success requires coordination ensuring conversations are offered, sched- uled, conducted and recorded. Three thousand have been facilitated so far. “We found incredible pent up energy,” Maycroft said. “People have come out of the woodwork to help.”
Energy was also apparent among Richmond Academy of Medicine members, who were concerned about late hospice referrals. They agreed something similar to “Honoring Choices Minnesota” might work in Virginia; early intervention, said director Deborah Love, was more “palatable” than the current approach—one members believed amounted to “waiting until crises develop.”
Thirty facilitators from three systems begin First Steps training this September. Those organizations contributed financially, each establishing three pilot sites. Community outreach begins next year, when facilitators are ready to respond.
In South Carolina, implementation of the Physician Orders for Scope of Treatment (POST) project exposed what state medical association members believed was lacking: earlier advance care planning. POST, similar to Illinois POLST, is intended for patients expected to die within one year. “There’s a lot more to it,” Dr. Ropp said. Members plan a First Steps project across five health systems.
Dr. Ropp expects that typically competitive systems will be quick to collaborate. “Competition works both ways,” he said. “It breaks down markets, but on good projects, it serves as positive peer pressure.”
South Carolina Medical Association leadership, however, is essential, Dr. Robb says. “Insurers or state agencies would be seen as attempting to save money by limiting care,” he said. “Being physician- led is a moral, ethical high road.”
Is Chicago Next?
Chicago’s large, diverse population and numerous health systems, end of life experts say, underscore the need for an advance care planning initiative; however, those factors may present challenges so far unaddressed by Respecting Choices programs. “In Chicago, we are densely populated with health systems that don’t communicate with each other,” said Julie Goldstein, MD, an Advocate Illinois Masonic palliative specialist and Chicago End-of-Life Care Coalition founder. “We need a common language for patients to communicate their wishes across the spectrum of care.” With a six-hour online module and one full-day class, Advocate Health Care has trained 130 case managers in Respecting Choices First Steps facilitation.
Achieving buy-in from Chicago’s health systems may be difficult, but Dr. Goldstein says it is pos- sible. “Many health care institutions are coalescing into larger systems, and that should make it easier to collaborate and coordinate for uniform practice,” she said.
Such a citywide initiative, however, would be complex, requiring culturally sensitive outreach. Much work would need to be community-based, setting a model precedent across a diverse municipality.
NorthShore University palliative specialist Mike Marschke, MD, is attempting one such model within his own system. Nine months ago, he designed advance care planning pilot projects within outpatient oncology and cardiology clinics. In September, 800 physicians and 2,000 nurses, chaplains and social workers received advance care planning facilitation training via 20-minute online videos, produced for roughly $4,000.
“Chicago’s large, diverse population and numerous health systems, end
of life experts say, underscore the need for an advance care planning initiative.”
His short-term goal is for NorthShore’s seriously ill patients to engage in discussions about care goals. In first addressing the most vulnerable patients’ needs, Dr. Marschke acknowledges he starts with the “lowest lying fruit.” Patients will be asked to assign a power of attorney for health care. Documentation of discussions and directives will be recorded in EPIC; the electronic medical record with a new end-of-life care navigator was tested within NorthShore this year.
“You need to change culture,” Dr. Marschke said. “Culture can only change from within.” He maintains Respecting Choices is unnecessary; time, effort and leadership are what’s required. “Hospitals have to figure out how advance care planning can work for them,” Dr. Marschke said. “You shouldn’t have outside agencies telling them how to do it.” Where Drs. Marschke and Goldstein agree, however, is that such work must be done.
“We are at a tipping point in this region, a time of crisis in health care and resources,” Dr. Goldstein said. “It’s time to realign them with patients at the center.”
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