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Betsy McCaughey, champion of the hyperbolic 'death panel' myth, published an op-ed in the Wall Street Journal this week detailing concerns she had in the House version of the Health Care Reform Bill (aka HR 3962, aka Affordable Health Care for America Act).  The one concern regarding hospice and palliative care reads as follows:

Sec. 1114 (pp. 391-393) replaces physicians with physician assistants in overseeing care for hospice patients.

Here is what the bill actually says:

SEC. 1114. PERMITTING PHYSICIAN ASSISTANTS TO ORDER POST-HOSPITAL EXTENDED CARE SERVICES AND TO PROVIDE FOR RECOGNITION OF ATTENDING PHYSICIAN ASSISTANTS AS ATTENDING PHYSICIANS TO SERVE HOSPICE PATIENTS.

(a) Ordering Post-hospital Extended Care Services- Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended--

(1) in paragraph (2) in the matter preceding subparagraph (A), is amended by striking `nurse practitioner or clinical nurse specialist' and inserting `nurse practitioner, a clinical nurse specialist, or a physician assistant'.

(2) in the second sentence, by striking `or clinical nurse specialist' and inserting `clinical nurse specialist, or physician assistant'.

(b) Recognition of Attending Physician Assistants as Attending Physicians to Serve Hospice Patients-

(1) IN GENERAL- Section 1861(dd)(3)(B) of such Act (42 U.S.C. 1395x(dd)(3)(B)) is amended--

(A) by striking `or nurse' and inserting `, the nurse'; and

(B) by inserting `or the physician assistant (as defined in such subsection),' after `subsection (aa)(5)),'.

(2) CONFORMING AMENDMENT- Section 1814(a)(7)(A)(i)(I) of such Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by inserting `or a physician assistant' after `a nurse practitioner'.

(3) CONSTRUCTION- Nothing in the amendments made by this subsection shall be construed as changing the requirements of section 1842(b)(6)(C) of the Social Security Act (42 U.S.C. 1395u(b)(6)(C)) with respect to payment for services of physician assistants under part B of title XVIII of such Act.

(c) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2010.

So does it 'replace' or 'allow'?  I guess it is open to interpretation, but I have to agree with the letter written by Sean Morrison and Gail Cooney to the Wall Street Journal Editors.

This portion of the bill allows nurse practioners and clinical nurse specialists the same rights as physician assistants where state laws allow.  With the shortage of qualified specialists in palliative care, all disciplines need to work together to provide the most comprehensive care for the most patients.

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MedPAC (Medicare Payment Advisory Commission) released a brief and a presentation from a November 5th meeting from a session covering frequency of hospice visits and extrapolating that information to the Medicare reimbursement structure for hospice agencies.  Since most hospice agencies have a large majority percentage (around 80-85%) of patients on Medicare any tinkering of the reimbursement structure is bound to get some administrator's attention.

The fact of MedPAC examining this issue is not new for they have been doing so for the last several years.  In early 2009 they made a recommendation to increase payments at the beginning and end of a hospice stay.   The purpose was to reflect the higher care needs around admission to hospice and near the time of death.  Bloggers and organizations commented on this:

• here (Pallimed)
• here (NEJM-free full text)
• here (NAHA)
• here (About.com)
• here (Larry Beresford)
• and here (NHPCO)

Any hospice staff should read the brief and the presentation (it will take you all of 20 minutes) and many palliative care providers who are not in hospice should understand these issues on the surface at least.  Here are a few key facts from each since I have a feeling not everyone will go read it like I suggested.  (Hey, we are all busy!)

Background:

• In March 2009 MedPAC recommended increasing reimbursement at beginning and end of hospice stays (a U-shaped pattern)
• Medicare currently pays hospice in a flat per-diem, thus making long admissions more profitable
• This was based on data from VITAS a national for-profit hospice

New Info:

• Since the reimbursement recommendation was based on data from one hospice, the recommendation may not have the strongest scientific/economic foundation.
• They now have two new data sources: Medicare claims data from 7/08-12/08 & 17 non-profit hospices visit data from 10/05-09/08 

What MedPAC Found (some great graphs for this in the presentation):

• # of visits does not differ by diagnosis when adjusted for length of stay
• # of visits and visit hours are increased for short stays when compared to long stays
• Patients in nursing homes and assisted living get more visits than home patients*

The data did not make much comparison between the for-profit and non-profit data.

If you leave any comments here I will be happy to forward them on to MedPAC unless you tell me otherwise.  If you want to comment directly to MedPAC you can email them.

*At first I was surprised at this fact, but then I guess it makes sense that nursing home patients would get more visits because of the increased efficiency in seeing multiple patients in one central location.

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My apologies to email subscribers who are getting only one article when more than one is posted.  We have made some adjustments and it should be fixed with upcoming posts.

For those of you who want to know the details, our email service 'picks up' the posts from the blog usually between 2400 and 0100 allowing us to write in the evening after we get home from a hard days work.  But with the time change it seems to be picking up between 2300 and 2400 thus splitting one evenings worth of posts into two separate email deliveries.

We have adjusted and adapted so you should expect less frequent deliveries with more content.  RSS and website visitors please ignore this post it does not pertain to you.  This is not the post you are looking for [hand wave].

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Just in case you do not subscribe to Pallimed: Arts & Humanities you may have missed the Palliative Care Grand Rounds posted over there last week.  If you are not familiar with this, it is a monthly collection of best posts from the palliative care blogosphere.  Check it out.

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A few weeks have passed since I went to the Fall board meeting for the AAHPM and I wanted to report back to everyone.  I don't think this has ever been done from an insiders perspective and when I thought of running to be on the board, frankly I wasn't quite sure what actually being on the board entailed.  So this is my attempt to pull the curtain back and invite Pallimed readers in on the process.  For the official report on board actions you can check out your AAHPM e-news from November 1 in your email inbox.

First off, thank you very much to the few people who emailed me with comments and questions to bring up during the board meeting.  Most of the questions given to me before the meeting were about a getting feedback on salary/workload issues for physicians in palliative care, hospice or a hybrid position.  I will say the board approved part of the budget to support to get a professionally administered survey done and published before the end of 2010, so this information should be coming very soon.  BUT ONLY IF YOU FILL OUT THE SURVEY!

Interestingly, 'palliative medicine salary' or some similar phrasing is often in the top 10 searches that land on Pallimed, even though we do not have a ton of information here about it.  Many will recall a recent attempt (2007?/2008?) to get salary information via standardized MGMA survey, but so few were turned in that the information was not credible.  One big factor was the complexity of filling out a non-customized survey that did not accurately reflect variations in palliative care/hospice job responsibilities.  The only other publicly available salary report I am aware of is from Tim Cousounis from DAI Palliative Care Group was offering several months ago.

The meeting was a lot of business mixed in with a little bit of creativity and some thought provoking discussions.  Instead of meeting in a traditional location, the Board held it's Thursday evening session at a Cooking School.   The first part of the evening was focused on looking at emerging trends for our field and society.  This 'generative' session provided a good foundation for interesting discussions about social media, trust in media, government and organizations/medical societies.  For me it was especially fun since I was able to present on social media to the group.  I have posted my presentation to Slideshare if you are interested in my thoughts on this digital revolution.  (I plan on posting more here about themes from that presentation in the next few weeks here.)

While the Viking Cooking School was not your typical place for a board meeting I do think the presentations followed by a team building exercise and enough time for informal discussion led to a more productive next day which was much more focused on the important strategic business decisions for the Academy.  Overall I thought it was a good environment for the members of the board and executive committee get to know each other outside of 'motions to approve' and 'I second' types of conversation.  It was a real treat to talk to many smart and accomplished leaders in our field and I had some very interesting discussions about the past and future of our field and some of the political issues in health care today.

The next day the Board Members met at the AAHPM offices and the large focus was discussing budgetary issues.  I have to say I am very impressed with the financial foundation the AAHPM has at this time.  Sound investment strategies and strong growth in membership has allowed the Academy to maintain a good balance when other medical associations are having difficulties.  The reserves have grown steadily and should provide a solid cushion for many years to come regardless of the environment of the financial markets.

The funniest part of the trip was when my 3.5 year old son ate a dog treat at Steve Smith's house (AAHPM CEO).  He lives less than a mile from where my Aunt lives and where we were staying during the trip.  Small world.

Overall my first 6 months on the board have taught me the many responsibilities of the AAHPM staff and board of directors.  There are so many activities the Academy participates in through a wonderful group of member volunteers.  It has really been revealing to see all the successful programs and see the board is really there for oversight and not to control the outcomes.  The Academy President, Gail Cooney, would always remind us what was board level oversight and what could be sent back to the various task forces and committees for further refinement.  The board really responded well to this which allowed us not to get lost in details best left to those working on the projects. 

If you have more questions about what the board does or issues that you think should be raised I would be happy to chat with you. (ctsinclair@gmail.com)  If you are not already involved with a task force, SIG or a committee I would love to point you to one that suits your interests.

I am really looking forward to the next 2.5 years of service and hoping that someday some Pallimed readers will join me on the board.  Maybe we should nominate Drew next year?  Or Lyle?

Also congratulations to the new board members:
Jean Kutner, MD MSPH FAAHPM
John Manfredonia, DO FACOFP FAAHPM
Christine Ritchie, MD MSPH FACP

and our new executives:
President-Elect: Ron Crossno, MD CMD FAAFP FAAHPM
Treasurer: Tim Quill, MD FAAHPM
Secretary: Kate Faulkner, MD FAAHPM

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In the House version of the Health Care Reform Bill submitted last week, the provision for physician reimbursement once every 5 years for Advance Care Planning (also erroneously known as Death Panels) was kept in.  Apparently the sound and the fury of this summer did not deter the Democrats from including it and may have even helped keep it in once all the fire died down.  The provision is supported by numerous medical groups including the AAHPM, AMA and even AARP.

I am including the text as copied from HR 3200 here for posterity.  (obtained from Opencongress.org) (Sorry for the long post but hey this is history here.)

‘Advance Care Planning Consultation

‘(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to. CommentsClose CommentsPermalink


‘(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses.


‘(C) An explanation by the practitioner of the role and responsibilities of a health care proxy. CommentsClose CommentsPermalink


‘(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965). CommentsClose CommentsPermalink


‘(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title. CommentsClose CommentsPermalink


‘(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include-- CommentsClose CommentsPermalink


‘(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the individual’s family and thereasons why such an order should be updated periodically as the health of the individual changes; CommentsClose CommentsPermalink


‘(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and CommentsClose CommentsPermalink


‘(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy). CommentsClose CommentsPermalink


‘(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State-- CommentsClose CommentsPermalink


‘(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and CommentsClose CommentsPermalink


‘(II) that has in effect a program for orders for life sustaining treatment described in clause (iii). CommentsClose CommentsPermalink


‘(iii) A program for orders for life sustaining treatment for a States described in this clause is a program that-- CommentsClose CommentsPermalink


‘(I) ensures such orders are standardized and uniquely identifiable throughout the State; CommentsClose CommentsPermalink


‘(II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional’s authority under State law) may sign orders for life sustaining treatment; CommentsClose CommentsPermalink


‘(III) provides training for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and CommentsClose CommentsPermalink


‘(IV) is guided by a coalition of stakeholders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association. CommentsClose CommentsPermalink

‘(A) a physician (as defined in subsection (r)(1)); and CommentsClose CommentsPermalink


‘(B) a nurse practitioner or physician’s assistant who has the authority under State law to sign orders for life sustaining treatments. CommentsClose CommentsPermalink

‘(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care; CommentsClose CommentsPermalink


‘(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual; CommentsClose CommentsPermalink


‘(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and CommentsClose CommentsPermalink


‘(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual. CommentsClose CommentsPermalink

‘(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems; CommentsClose CommentsPermalink


‘(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting; CommentsClose CommentsPermalink


‘(iii) the use of antibiotics; and CommentsClose CommentsPermalink


‘(iv) the use of artificially administered nutrition and hydration.’. CommentsClose CommentsPermalink


(2) PAYMENT- Section 1848(j)(3) of such Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting ‘(2)(FF),’ after ‘(2)(EE),’. CommentsClose CommentsPermalink


(3) FREQUENCY LIMITATION- Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended-- CommentsClose CommentsPermalink


(A) in paragraph (1)-- CommentsClose CommentsPermalink


(i) in subparagraph (N), by striking ‘and’ at the end; CommentsClose CommentsPermalink


(ii) in subparagraph (O) by striking the semicolon at the end and inserting ‘, and’; and CommentsClose CommentsPermalink


(iii) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink


‘(P) in the case of advance care planning consultations (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;’; and CommentsClose CommentsPermalink


(B) in paragraph (7), by striking ‘or (K)’ and inserting ‘(K), or (P)’. CommentsClose CommentsPermalink


(4) EFFECTIVE DATE- The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2011. CommentsClose CommentsPermalink

(1) Physician’S QUALITY REPORTING INITIATIVE- Section 1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2)) is amended by adding at the end the following new paragraphs:‘(3subparagraph: CommentsClose CommentsPermalink


‘(E) Physician’S QUALITY REPORTING INITIATIVE- CommentsClose CommentsPermalink


‘(Ai) IN GENERAL- For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment. CommentsClose CommentsPermalink


‘(Bii) PROPOSED SET OF MEASURES- The Secretary shall publish in the Federal Register proposed quality measures on end of life care and advanced care planning that the Secretary determines are described in subparagraph (A) and would be appropriate for eligible professionals to use to submit data to the Secretary. The Secretary shall provide for a period of public comment on such set of measures before finalizing such proposed measures.’. CommentsClose CommentsPermalink

(i) An explanation of advance care planning and advance directives, including-- CommentsClose CommentsPermalink


(I) living wills; CommentsClose CommentsPermalink


(II) durable power of attorney; CommentsClose CommentsPermalink


(III) orders of life-sustaining treatment; and CommentsClose CommentsPermalink


(IV) health care proxies. CommentsClose CommentsPermalink


(ii) A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives, including-- CommentsClose CommentsPermalink


(I) available State legal service organizations to assist individuals with advance care planning, including those organizations that receive funding pursuant to the Older Americans Act of 1965 (42 U.S.C. 93001 et seq.); CommentsClose CommentsPermalink


(II) website links or addresses for State-specific advance directive forms; and CommentsClose CommentsPermalink


(III) any additional information, as determined by the Secretary. CommentsClose CommentsPermalink

(B) UPDATE OF PAPER AND SUBSEQUENT VERSIONS- The Secretary shall include the information described in subparagraph (A) in all paper and electronic versions of the Medicare & You Handbook that are published on or after the date that is 1 year after the date of the enactment of this Act.