New Jersey is considered to be home to the most aggressive medical care for those facing advanced chronic diseases. But that doesn't mean that patients are getting better, or experiencing a higher quality of life.
Around the state, health care providers are working on new ways to integrate palliative care — a holistic approach to managing advanced diseases — to see if costs for the most expensive patients can be reduced while increasing patient satisfaction.
Last May, Meridian Health launched a Centers for Medicare and Medicaid Services demonstration program that coordinates care for more than 400 Medicare patients. Meridian is one of four providers around the nation participating in the demonstration.
The Dartmouth Atlas of Health Care has reported that, as of 2007, New Jersey patients spend more days in the hospital, and specifically the intensive care unit, during the last six months of life than anywhere else in the U.S. This hospitalization means inpatient spending in the last six months of life in New Jersey is nearly 1.35 times that of the national average, adding up to more than $247 million beyond the national average.
"We provide the most aggressive care, we provide the most expensive care and there's never been a study that shows a corresponding benefit for our patients," said Dr. Amy Frieman, medical director of palliative care for Meridian.
"The costs are, to some extent, focused on a small group of patients that have multiple co-existing problems," said Dr. Steven Landers, president and CEO of the Visiting Nurses Association Health Group. "And in spite of all the spending for this group, there's a lot of suffering and a lot of unaddressed pain and unaddressed psychosocial concerns."
Palliative care is designed to address comfort issues, including mental and spiritual issues, for patients with advanced diseases. Teams can include social workers, pain management specialists, clergy, home care givers and sometimes massage or acupuncture therapists.
Landers said when you reduce suffering you also reduce the cost of care by lowering readmissions to hospitals and keeping people independent longer.
The VNA Health Group offers both palliative and hospice care options to their patients. Hospice care can be a form of palliative care offered during the last six months of life, but palliative care is not strictly end-of-life care — it can be provided long before a terminal diagnosis and concurrent with curative therapies.
"It is often about symptom management within the patient's own designs for care," said Dr. Richard Scott, senior vice president of medical affairs for Meridian. "When they're not engaged in their care management, then others start to define it for them. And that probably leads to an overabundance of care."
Frieman said Meridian's palliative specialists consult with patients to free primary care physicians to focus on the disease without adding more to the doctor's plate.
"Their primary physician remains the 'quarterback,'" Frieman said. "We, as a palliative care team, feed all of our information and recommendations back through the primary doctor," in order to continue the patient-doctor relationship.
Scott said that while other demonstrations attempt to "bend the cost curve," the palliative care demonstration is focused around patient satisfaction. If the demonstration can prove patient satisfaction, he said the "other end will take care of itself."
Hackensack University Medical Center's palliative program takes a different approach. Hackensack is using nurses to implement a "train-the-trainer" program, so any caregiver can initiate conversations about comfort care or end-of-life choices. Dr. Jose Contreras, director of pain and palliative care, said it is almost "inappropriate" to add an additional team to consult, without a relationship, on difficult choices.
"We developed a comfort care order set that any physician can have access to that is a drop down menu with all sorts of options … to help facilitate that process with the very thought in mind that everybody should be able to do this, and you don't need a special team to come in and get the orders going," said Contreras.
Palliative care is still in its infancy, according to Contreras. Hackensack became the first hospital in the state to receive advanced certification in palliative care from the Joint Commission accrediting body late last year. CMS began using billing codes for palliative care in 2008, and this will be the first year that palliative care subspecialists will be required to do a fellowship to complete their training.
Expansion of the field has been set back, by the "dangerous, dark message" sent by politicians when discussing end-of-life care, Contreras said. Palliative and hospice care were labeled in national debates on health care reform as "death panels" as the field was misconstrued as withholding potential curative treatments.
"Physicians across the country found it abhorrent that the sickest and most vulnerable became a political football … it was very disappointing," Scott said.
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