Jason Black, MD, trained in family medicine, worked for Kaiser Permanente, and subsequently completed a fellowship in geriatrics. Today, he treats frail elderly patients, mostly residents of nursing homes and assisted living facilities or living in their own homes, for Gilchrist, a hospice and palliative care organization serving Baltimore and central Maryland.
"I'm practicing family medicine to the extent that I'm treating the family unit, including the anxieties of the adult children, and finding solutions for the parents," said Black, who is one of Gilchrist's 62 employed providers, one third of whom are physicians. One of his most important roles is medication reconciliation and deprescribing.
Palliative care, a medical specialty that focuses on clarifying the treatment goals of seriously ill patients, helping with end-of-life planning, and emphasizing pain and symptom management, has been growing in recent years. Already well-established in most US hospitals, it is also expanding in community settings, often as an extension of hospice programs.
Now, by adding primary care physicians and practices to their service mix, palliative care groups are better meeting the needs of a neglected — and costly — population of frail elders. In doing so, they also are better able to find a niche in the rapidly evolving alphabet soup of value-based care and its varieties of shared savings for providers who post positive outcomes.
Most patients Black sees find it difficult to visit their doctor in a clinic setting, although they face a variety of medical needs and chronic conditions of aging. They may have a prognosis of several years to live and, thus, do not qualify for hospice care. To him, a palliative approach offers the satisfaction of focusing on what is most important to patients at this difficult time in their lives, rather than predetermined clinical metrics like blood pressure or blood glucose. "It takes a lot of work, but it feels important and rewarding," he said.
A recent survey of community-dwelling older adults in Ontario, Canada, found most patients fail to receive this treatment homes in the final 3 months of life.
Continuums of Patients and Models
Gilchrist started as a non-profit, hospital-affiliated hospice program in 1994 and in 2000 took on the management of a geriatric medicine practice for its parent Greater Baltimore Medical Center. Today, its physicians and nurse practitioners see a range of patients in geriatric primary care, palliative medicine, and hospice, according to its chief medical officer, Mark Gloth, DO.
"As people progress in their disease, their location — where they call home — may change as well," Gloth said. "We offer a continuum of care in order to not lose people through those transitions. That's the core of our mission — making sure we are there to escort people through the difficult moments in their lives."
Models for value-based care encompass accountable care organizations (ACOs), including the ACO REACH (Realizing Equity, Access, and Community Health) high-needs model for traditional Medicare patients, and Medicare Shared Savings Programs for fee-for-service beneficiaries. These value-based models offer a variety of opportunities for the palliative care organization to share in savings resulting from keeping the patient out of the hospital or emergency room and other quality and cost benchmarks.
Coming Together to Meet Needs
Gilchrist is one of nine hospice and palliative organizations that have joined to form their own multistate ACO, Responsive Care Solutions, focused on the clinical needs of frail elderly Medicare beneficiaries. Hospice of the Valley in Phoenix has Geriatric Solutions, a frail elder physician practice. And Capital Caring Health, a hospice and palliative care agency serving metro Washington, DC, has deployed several physicians and nurse practitioners on the road doing primary care at home, said Heidi Young, MD, its Primary Care at Home Lead Physician.
"Five years ago, we started our primary care practice under the umbrella of a 40-year-old hospice organization because we thought we needed to prepare for the changes that are coming to the hospice model," Young said. "The thought was that we're not just a hospice organization; we're an advanced illness organization. We will come to your home, whatever that is, and provide your primary care."
Heidi Young, MD
We're an advanced illness organization. We will come to your home, whatever that is, and provide your primary care.
The greatest potential gains for a hospice organization are from assuming 100% risk for a large population of patients, keeping them out of the hospital to lower the costs of their care, then reaping those gains under a value-based profit-sharing model, Young said.
"Our program is still new and working toward getting more patients aligned into value-based models," she said. "It's a work in progress."
A Foot in Each World
Agencies like Capital Caring and Gilchrist derive the largest share of their physician income from billing Medicare Part B and other insurers per visit. But that billing is not enough to break even on physician services.
With hopes for a value-based future, Gilchrist also gets grants from elder-facing charitable foundations to cover up to 40% of the costs of its home-based primary care, according to its president, Catherine Hamel. Hospice care continues to be paid on a per-diem basis by Medicare for eligible terminally ill patients, including Medicare Advantage patients, although CMS is reportedly considering new models for the hospice benefit.
The National Partnership for Healthcare and Hospice Innovation (NPHI) is a trade group representing more than 100 non-profit, hospice-based organizations participating in palliative care and value-based care.
For a hospice to be successful in the evolving post-acute care/end-of-life care landscape, it can no longer rely solely on its hospice line of business, no matter how high-quality, said Ethan McChesney, policy director for the Washington, DC-based nonprofit.
NPHI members have developed their own palliative care programs, and perhaps, a quarter have primary care at home practices, McChesney said. Some of them acquired existing primary care practices in their service area with which they already had relationships; others created their own.
For hospice organizations building a continuum of services for the seriously ill, adding a primary care at home practice is a natural fit, he said. "You can provide all the services you would as a traditional primary care practice while you have the opportunity to establish long-term relationships with patients and their caregivers that lend themselves to palliative care referrals and then hospice referrals downstream [when the patient becomes eligible for hospice care]." Often, this primary medical care is a mix of in-person and telehealth.
Cameron Muir, MD, NPHI's chief innovation officer, noted that the hamster wheel for primary care doctors has been spinning faster and faster, with reimbursement going down and costs going up.
But with home-based primary care for frail elders under value-based models, Muir said, the clinician is paid not for making more visits but for taking great care of the patient: "And I'm actually saving Medicare money and getting credit for the hospitalizations that were avoided."
Oakland, California, based medical journalist Larry Beresford covers hospice and palliative care, hospital medicine, and emergency medicine, including contributing feature articles to the Quarterly Newsletter of the American Academy of Hospice and Palliative Medicine.