Combined palliative care and medical care in hospice’s future?

Hospices are as close or as far as they want to be’ 

For the past 20 years, hospices have operated under the Hospice Medicare Benefit model — people get sick and exhaust their curative options, and a hospice is there waiting to take care of them. Hospices, like other health care providers, are situated on a continuum that patients move along as they navigate the health care system.

So much for the present. The future of hospice is shaping up to be quite different from a static point on a line that patients travel while moving from one provider type to the next. Instead, hospices may well be the agent moving along the continuum to meet patients where palliative care services are needed.

The latest development in the movement to provide combined palliative and curative care is a report issued by Promoting Excellence, a national program office of the Princeton, NJ-based Robert Wood Johnson Foundation. Promoting Excellence researchers did a study tracking the financial performance of hospice programs that have been offering concurrent care on a limited basis. They learned that those who finance health care, such as Medicare, could reap savings in reduced emergency room visits, hospital length of stay, and overall patient cost by adding palliative care to the treatment plan of patients diagnosed with potentially fatal diseases.

Concurrent care consumes fewer resources

"Our goal is to improve access to hospice and to provide quality care, but in the process of looking at concurrent care we tracked utilization of resources and we are noticing that [hospice programs that provide concurrent care] are consuming fewer resources," says Ira Byock, MD, director of Promoting Excellence and director of The Palliative Care Service in Missoula, MT.

Promoting Excellence, which has provided $15 million in grants and technical support to innovative programs that promote improved care for the dying, conducted a study in 2002 at seven sites to measure the financial implications of combining palliative care with medical intervention. Following are summaries of what the researchers discovered at three of the sites:

Lower hospitalization costs

The Hospice of Michigan and the University of Michigan Comprehensive Cancer Center.
This Detroit-based program, which provides hospice care to patients who receive cancer treatment, recorded fewer emergency room visits and lower hospitalization costs than other programs. Compared with patients receiving only cancer treatments, patients receiving both palliative care and cancer therapy had fewer emergency room visits per patient (0.8 vs. 1.07), fewer hospital admissions per patient (1.65 vs. 1.83), and shorter hospital stays per patient (7.7 vs. 9.9 days).

Average hospitalization costs for patients receiving only cancer care were $13,126 per patient, compared with $8,974 for those receiving both cancer care and hospice care. Average total costs for patients receiving only cancer treatments were $19,790 per patient, compared with $12,682 for those receiving both forms of care.

The Kaiser Hospice and Home Health.
This Downey, CA, hospice program provides hospice care along with curative and restorative care to patients with congestive heart failure, respiratory disease, and cancer. Most patients have as much as a year to live. A team of physicians, social workers, nurses, and aides makes home visits to patients, develops treatment goals, and provides care. In addition, the team provides respite care and emotional and social support to the family. The goal of the program is to prevent unnecessary hospitalizations and to allow patients to die at home, if possible.

Patients reported higher satisfaction

Based on a two-year comparative study involving 300 patients who died, patients who were in the program reported higher satisfaction with the care they received compared to a control group. More than 87% of the program patients died at home, compared with less than 57% of the control group patients. The average daily cost for a patient in the palliative care program was $62, compared with $133 for a patient receiving usual care. Total per-patient costs for those in the program were 45% lower than for those receiving usual care ($7,990 vs. $14,570).

The Lillian and Benjamin Hertzberg Palliative Care Institute at Mt. Sinai Medical Center.
By allowing palliative care nurses and physicians to consult with hospital providers, this program netted more $750,000 in hospital length of stay savings.

The New York City-based program provides a team of nurses and physicians that advise hospital providers on pain management and consult with family members regarding decisions concerning life-sustaining care. Aside from showing symptom improvement among patients experiencing pain, nausea, and breathing problems, cost savings from palliative care were $757,555 for those patients who stayed more than 14 days in the hospital and $455,936 for those who stayed more than 28 days.

"Preliminary study findings as cautiously interpreted suggest that earlier introduction of hospice care improves quality of life and caregiver burden and potentially reduces cost," says John Finn, MD, medical director for the Hospice of Michigan (HOM) and lead author of an upcoming paper that discusses HOM’s three-year research project.

While Finn is optimistic about the financial benefit that may be attached to concurrent care, he says larger demonstration projects would be necessary to definitively declare that concurrent care was cost-effective.

"If these demonstration projects show improved access, reduced caregiver burden, and reduced cost, then we would have hit a home run," Finn adds.

Byock echoed Finn’s call for demonstration projects and urged the hospice industry to take the lead in designing and developing demonstrations, rather than placing the blame on the Centers for Medicare & Medicaid Services, federal lawmakers, and private insurers for standing in the way of progress. Hospices are in a position to prove the value of combined medical treatment and palliative care to payers.

"Hospices are as close to or as far from making [concurrent care] a reality as they want to be," Byock says.

The revenue streams will come’

Are the road signs signaling a new direction for hospices? Byock, a 16-year provider of hospice care and a well-regarded hospice expert, seems to think so. More importantly, he says individual hospices should start adopting changes to their business model so that they can begin to offer concurrent care even in the absence of reimbursement.

"I truly believe the revenue streams will come," he says.

The idea of combining palliative care and curative care has been pushed for years by the hospice industry. Advocates have argued that payers should find a way to finance hospices’ foray into providing care alongside physicians trying to fend off life-threatening illnesses. Their efforts have had limited success.

Byock, however, suggests a new approach: entrepreneurship. Like companies looking to expand their customer base, hospices should approach concurrent care as a product they are trying to promote to consumers.

If hospices expect the combination of palliative care and medical intervention to change the way the health care industry cares for the dying, it would be reasonable to expect hospice itself to change, as well. The current hospice business model will have to change in order to adjust to the "new patient."

"If they don’t do it, someone else will," says Byock. "Hospitals, nursing homes, residential care facilities, even the Marriott Corporation will provide these services. Hospices need to be bold and courageous, just like in the early 80s."

To borrow a business phrase, hospices need to be "first to market" if the industry intends to remain a leader in the provision of palliative care. This requires hospice to take on some risk by providing concurrent care to payers who are willing to study its benefits. It likely means hospices will have to provide concurrent care absent any reimbursement.

Patients don’t want to forgo curative care 

Still, Byock says it’s sound business and good health care. Hospices, he says, would be responding to consumer demands. Specifically, he says patients have said that while they believe hospice care is valuable, the reason most of them elected hospice in the latter stages of their illness was because they didn’t want to give up the care they were already receiving.

In the end, a bold hospice industry would be speeding up the shift in consumer demand. Once consumers begin to expect concurrent care, payers will find a way to finance the growing demand. "Any shift creates winners and losers," Byock says.

How the shift in practice will shape up is anyone’s guess. But hospices will certainly have to implement a number of programmatic and cultural changes to implement a system that bridges medical intervention with hospice care.

"It will be a dramatic change for hospices," Finn says.

At Hospice of Michigan, Finn observed cultural hurdles that both hospice staff and non-hospice personnel had to overcome. For example, treating physicians were wary of hospice staff. There was a fear that hospice workers would try to convince patients to give up treatment.

"To address this and related issues, meetings were initiated early on by the project director and investigators, the hospice medical director, and billing departments within the participating institutions and offices," Finn wrote. "We assured the oncologists that the project would not impact their ability to provide care and receive compensation for their services."

Finn and researchers encountered challenges in integrating oncology treatment and hospice care among participating different professional cultures, including a comprehensive cancer center, hospital-based cancer centers, and private oncology offices.

"Despite our efforts in the project to create a seamless transition from standard medical care to palliative care, the two models do not meld easily," Finn wrote.

The culture clashes led to patients receiving conflicting messages. For instance, a cancer patient may have been encouraged by an oncology clinic nurse to eat more to keep up her strength. The hospice nurse, on the other hand, told family to accept waning appetite as part of the natural disease process.

Palliative care coordinators bridge the gap

To prevent conflicting messages and miscommunication, HOM assigned a hospice worker to the position of palliative care coordinator, whose role was to bring the two perspectives together. The responsibility to provide education and promote understanding of the dueling perspectives went both ways, meaning the palliative care coordinator directed his or her efforts to colleagues as well as to non-hospice workers. For example, hospice staff were taught how differentiate treatment toxicities from the natural progression of disease.

Palliative care coordinators were given further training in the discipline of oncology, which was later conveyed to the hospice staff. According to Finn, the training proved to be invaluable. In fact, there were several documented episodes of hospice field staff circumventing visits to the emergency room after identifying and reporting early symptoms to attending physicians.

On the non-hospice side, the palliative care coordinator gave suggestions to clinic or office staff on how to discuss palliative matters more tactfully and realistically than might have been customary practice.

"Over time, the participating oncologists became more accepting of, and even came to prefer, this type of comprehensive palliative care to conventional oncology care," Finn wrote.