Unarguably, HPM practices are not, and will not be, sought after because of their revenue-generating capacities, either from direct patient care services (home visits, hospital consults, inpatient hospice management) or ordering tests, performing procedures, or utilizing a hospital's facilities. To be sure, hospital palliative consults have proven to be effective cost avoidance services for hospitals. This effectiveness, however, is subject to the law of diminishing returns, in that the "savings" are front-loaded in the first few years following introduction of the palliative care service. Once the "new" standard of care is firmly in place, savings become more difficult to squeeze out of the palliative care service. Some counter that eliminating the palliative care service would return costs to the hospital. While that may be the case to some extent, I don't know of many health care CEOs and CFOs who would "recount" savings that had already been accounted for.
The Dartmouth Medical Atlas has shown that there is enormous variation in late-life care, among and within communities. In fact, it is not unusual to find wide variation in practice from one IDT to another within a hospice provider. Reducing clinical variation, simply put, is not a quality improvement priority for most hospices and palliative care organizations.
Tightly integrated delivery systems have proven to be effective in reducing clinical variation. These delivery systems may soon serve as models for the development of Accountable Care Organizations (ACOs). A recent article highlighted Dartmouth-Medical Clinic, a 900-physician group practice in New Hampshire, which has earned $13 million so far in the Medicare Physician Group Practice Demonstration, the model for accountable care organizations. The Clinic focused on reaching out to patients with chronic illness, improving coordination of care for patients transitioning between care settings, and more aggressively monitoring patient between physician visits.
For these activities, surely HPM physicians, palliative care nurse practitioners, and hospices play a vital role. A network of physicians and palliative care clinicians will be extremely valuable to these ACOs. Why? Because these networks will already be in place to provide timely, patient/family centered, and evidence-based care to those with advanced illnesses. Such care will likely cost less, as fewer days are spent in ICUs and hospitals, and more at home, under hospice and palliative care.
You may be thinking, ACOs aren't called for in the health reform legislation until January 2012. Keep in mind, building an effective delivery network is a years-long process, so yesterday was the best time to start. There are at least three steps, each of them formidable, to building a tightly integrated network to deliver advanced-illness care:
- applying clinical protocols proven to reduce clinical variation,
- electronic capture and transfer of clinical information across settings,
- "internal transfer" of reimbursement.