Q&A with Dr. Tom
You’ve spoken a lot about the role of hospice in value-based care systems. What about palliative care? What role does that play?
Palliative care is care that emphasized comfort in situations where effective treatment and even cure is still an option.
Unfortunately, the service is being increasingly misused as a “gateway to hospice”.
With the fragmentation of healthcare delivery and the commoditization of clinicians, the preparation of the patient for end-of-life issues has lead to the creation of the “Grim Reaper” model of care. You hear about these models over and over from across the country. And it works like this:
Patients whose projected costs may harm the performance of the organization are identified through data mining and other techniques. The “palliative care clinician”, usually a semi-retired or part time physician or nurse practitioner is dispatched to their home to begin the process of getting the patient to think about end of life issues. The clinician appears out-of-the-blue after a single introductory phone call, with no prior experience or relationship with the clinician. Usually the visit is associated with subtle, and sometimes not-so-subtle arm twisting techniques, informed by some basic persuasion training the clinician may have undergone.
The result? Terrified patients who are uncertain how truthful any of their clinicians have been with them—defiant and committed to push for all the healthcare care they can get, or newly depressed and ready to incur additional costs for care that they never would have sought in the first place.
Why aren’t their personal clinicians having these conversations? Fragmented healthcare delivery systems, poorly aligned incentives, lack of autonomy, over-supervision, patient overload, disengagement, burnout. Pick as many as you like.
Whatever the reason, the very presence of the “Grim Reaper” approach is the sign of a poorly executed care delivery system.
Palliative care is best used systematically to provide additional resources to treating clinicians involved in the care of patients with debilitating, uncomfortable conditions that are still treatable--even curable. The palliative care clinician has a critical skill set and, if used appropriately, can generate enormous value for the treating clinician, their patients and the organizations that facilitate their care.