Medical News: Looking back on the past year, how has the healthcare system changed and what is the physician community doing to adapt to the changing environment?
Jim Gaffney, MD: The healthcare system continues to move, in general, towards incentivizing quality and controlling the rapidly increasing costs of the current system. Some examples of these initiatives include MACRA and MIPS to attempt to measure quality; increasing use of at risk contracts between health systems and insurers; along with Alternative Payment Models (APMs) that incentivize value. Value for Hosparus Health will be measured as quality divided by cost with the intent to lower costs without compromising quality. We are working with two national affinity groups in support of piloting an APM for Palliative Care currently under review by CMS.
We are also investing capital to start a Home-based Palliative Care program to help patients manage their serious illness at home. This interdisciplinary program is an investment in providing and modeling a benefit that is currently not reimbursed by Medicare or Medicaid. Early outcomes from our pilot already illustrate savings for the healthcare system while improving the quality of life for our seriously ill patients.
MN: End of life is a challenging time for families and physicians. How would you like to change the dialogue?
JG: End of life will always be a challenging time, but this time can be made easier through earlier and recurrent discussions. Our healthcare system needs to normalize dying by admitting that all illness cannot be cured and that death is not necessarily a failure. We should be talking more, in healthcare and as a society, about what is important to each of us when we become seriously ill. Ongoing discussion about what is important to a person will often make decisions about how aggressively to treat specific situations clearer, and align these treatments with a person’s goals for their life and death. All of this requires time and energy to have these discussions about possibilities and prognosis, throughout the course of a person’s illness; not just once in the last days of life.
MN: What recommendations do you have for the physician community as it relates to end-of-life care?
JG: Physicians and nurse practitioners must start the conversation earlier in one’s disease process about the possible trajectory of their illness. Patients, as a rule, want to know what their options are and what their prognosis is. There is training available on having these conversations, and the more they happen, the easier they become. In fact, reimbursement codes for Advanced Care Planning are now available. In addition, we are devoting resources to educate consumers about Advanced Care Planning.
Physicians can also consider a palliative care referral earlier in a serious illness. Repeated studies have shown palliative care improves patients’ perceived quality of life, reduces unwanted tests and treatments and increases length of life.
MN: How has the practice of medicine changed over your career? How would you like to see it continue to change?
JG: In over thirty years in medicine, I have seen innumerable changes, including improvement in available treatments for many conditions through medications, surgery and technology. Treatment guidelines for chronic diseases like diabetes, heart disease, hypertension and cancer prevention have slowed the progression of these diseases. While patients have benefitted from these changes often; they have also suffered side-effects of treatments, often close to the end of life, when the potential benefit of these guideline-directed treatments is no longer evident.
While I would hope for ongoing improvement in our ability as a profession to prevent and treat disease, I also feel that we need to be judicious in our use of guidelines and preventative medicine as a patient becomes increasingly ill from an incurable disease. When a patient’s prognosis is measured in months, we and they, for example, should not be focused on strict control of blood sugar or blood pressure as this tight control can cause more problems than it solves. Likewise, screening mammograms and checking cholesterol levels in a hospice patient accomplishes nothing but increased anxiety and cost. Unfortunately, I have seen all these situations over my career.
As we and our patients take advantage of new technology and medication, we need to have frank discussions about the benefits and risks of any given treatment or procedure, and how that benefit-risk ration may change with serious illness. Hence, the importance of having frequent conversations about advanced directives and quality of life to provide the most opportunities for compassionate quality care, until the very end of life.
MN: What are the biggest challenges to practicing medicine in Kentucky? What are the benefits?
JG: As a hospice physician treating most patients in their homes, our rural population is a huge challenge. In order to help seriously ill people stay in their homes, our interdisciplinary teams travel to our patients wherever they are. Last year our Hosparus Health team members drove over 2.2 million miles to see our patients. I have driven through creeks, forty miles around flooded creeks and up scary, snow-covered hillsides in a four-wheel drive vehicle to see patients in their home.
The benefit is meeting genuinely grateful people where they live. Putting their lives in context helps focus discussions on what is important to patients and families as they deal with their illness. The trust people put in our teams at this stage of life brings great rewards.
MN: What can Kentucky do to create a better environment for physicians?
JG: Kentucky, and all of America, must continue to improve the system of care to reward value-based care. This in turn encourages our physicians to spend the time and energy talking with patients and families about what their medical condition means to them and what their goals for treatment are, along with what trade-offs they are willing to make to accomplish those goals. Increased availability of palliative care and availability of training in palliative care for all physicians would promote the Quadruple Aim of improved patient experience of care, improved population health, reduce healthcare costs, and improve the physician experience of providing care.
One technological example of improved access for physicians in Kentucky would be expanding access and compensation for telehealth across the state to reach into patient homes to deliver care quickly and efficiently.
Hosparus Health continues to work in Kentucky and Washington, DC to improve access to palliative care through numerous projects. Examples include teaching and sponsoring a Fellowship in Hospice and Palliative Medicine at the University of Louisville, initiating the Pediatric Palliative Care Coalition and working on the Telehealth committee in Frankfort, and in DC the National Partnership for Hospice Innovation and the Coalition to Transform Advanced Care.