Independent Physician Associations and Outpatient Palliative Care: Challenges and Opportunities

The demand for early palliative care (PC) involvement has never been greater in the setting of capitated healthcare delivery systems. The review by Alesi et al is timely in that it illustrates innovative practice partnerships with oncology groups during a time when PC is being thrust into mainstream outpatient care.[1] In January 2011, the American Society of Clinical Oncology released a bulletin establishing that the appropriate time for PC delivery is when a patient is diagnosed with advanced disease.[2] In addition to professional medical organizations, the media also have demonstrated new advocacy for PC in the wake of a recent study showing correlation between outpatient PC and prolonged survival.[3] Nonetheless, Medicare and other payers have yet to define new reimbursement options, leaving the problem of access to hospitals, managed care, and patients themselves.

While academic institutions and healthcare maintenance organizations (HMOs) can facilitate outpatient PC through grants and shared capital, the independent practice association (IPA) must find a unique collaboration between provider groups. One type of collaboration is illustrated by Alesi et al: the embedment of a PC team into an existing oncology clinic.[1] This collaboration is mutually beneficial in that the oncology clinic improved patient and provider satisfaction while helping the PC provider avoid high overhead costs. A major drawback, however, is that it may not be practical to have an interdisciplinary team moving from one oncology practice to another. In addition, a multidisciplinary presence is challenging given that non-physician disciplines are often unable to bill adequately for outpatient clinic services.

A second and more comprehensive strategy is outpatient PC delivery at the patient’s residence. As most patients with advanced illness have impairment of their functional performance status, many already qualify for home-based visits, even if they are still making clinic visits. While this model invariably excludes high-functioning patients upstream, it can better serve the advanced-disease population for whom the risk of inpatient resource utilization is high. Initially care may seem more fragmented between clinic and home-based visits, but the care is less fragmented as disease becomes more advanced. Healthcare delivery under this model in the HMO system has been shown to reduce rates of patient re-hospitalization and emergency department use.[4]

Besides cost avoidance, there are several other advantages to home-based PC delivery. Because patients can be seen at home, the ability to address family and caregiver challenges becomes more feasible. Such challenges may include caregiver fatigue, family conflict, and unsafe medication access. Here, an interdisciplinary presence is not only essential, but also is likely readily accessible through a home-based nursing agency (hospice or home health). Most hospice agencies have a social worker, chaplain, and pharmacist, though their services are not accessible to PC patients not yet enrolled under their health insurance hospice benefit. An IPA is well positioned to contract with a hospice agency to concurrently provide care to patients who are still receiving treatment for advanced disease. This is in contrast to the clinic setting, in which a physician practice cannot sustainably hire professionals from non-physician disciplines through Evaluation/Management code reimbursement. Finally, a challenge regularly faced by many oncologists is the inadequate management of non-cancer diagnoses. While a clinic-based PC practice is likely to focus on oncologic diagnoses, a home-based provider is positioned well to extend services more comprehensively. Here, chronic disease ailments such as urinary tract infections and symptomatic hypertension can be identified and managed before the need for hospitalization arises.

Though several models of PC delivery exist, it is important for provider groups to recognize the benefits and risks unique to their organizational structure. IPAs do not have the shared capital of HMOs, nor the grant funding of academic institutions, but they are ideally suited for creating custom-tailored collaborations with home-nursing agencies. While such an undertaking is more elaborate than an outpatient specialty clinic, it comes with the advantages of interdisciplinary involvement and chronic disease management.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.

References:

References

1. Alesi ER, Fletcher D, Muir C, et al. Palliative care and oncology partnerships in real practice. Oncology (Williston Park) 25(suppl Nov 30):XXX-XXX, 2011.

2. Peppercorn JM, Smith TJ, Helft PR, et al. American Society of Clinical Oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol. 2011;29:755-60.

3. Temel JS, Greer JA, Muzikanski A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363:733-42.

4. Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.