Diane Meier, MD, director of the Center to Advance Palliative Care, has said that the United States must adapt to a “Copernican health care system,” in which care revolves around the patient, in order to meet the growing demand for home-based hospice and palliative care and better serve patients.
A Copernican health care system, named for the 16th Century astronomer who first posited that the earth orbits around the sun, would help the nation address growing demand for home-based care, workforce shortages, and the prevalence of chronic conditions, according to Meier.
“Consider this example,” Meier told Hospice News. “A frail, 80-year-old patient with dementia needs a medical check-up. She and her equally disabled 83-year-old husband-caregiver get dressed and organized, call a taxi for the 30-minute ride to her primary care physician’s office, where they see the doctor for 10 minutes and then reverse the steps. This is the opposite of customer service.”
Meier recently spoke with Hospice News about transforming the health care system to revolve around the patient, rather than the patient moving around the health care system, and what this would mean for hospice and palliative care providers.
You have advocated for a Copernican model of health care delivery. What would that look like?
We now have a pre-Copernican health care system in which the patient revolves around the “planet” of the health care system—these huge marble and glass buildings where all the clinicians are and all the care takes place.
The patients that account for 60-to-70% of all U.S. health care spending are those with serious and chronic illnesses associated with functional and cognitive impairment; expecting them to come to us is the opposite of customer service, and yet that is how the entire health care system is structured.
A Copernican system would organize the resources around the needs of the patient, with most medical care provided in the home. With the exception of things that require an operating room, for example, almost everything else can be done equally well at home. Providing care in the home also gives clinicians a very real sense of what the patient’s living situation is actually like and of the risks they face, more so than an office visit would.
What socioeconomic factors are contributing to the need for more home-based care?
The first is the aging of our population, particularly the baby boomer generation with 10,000 of us turning 65 every day. There are a lot more of us than there are younger people to pay taxes to support us, so we have a genuine financial crisis coming.
People have been talking for years about the financial risks associated with an aging population and medical costs for years, but now the crisis is here. The options are that we either get rational about our health care system, or we start rationing and not providing care to many people who need it.
We have already seen evidence that as a society that we are willing to ration. We have seen rationing health care for the poor as states refuse to expand Medicaid. I am afraid that it won’t be long before we ration care away from older people as well, because we don’t seem to have the political will to reorganize the health care system in a coherent manner.
How does the rising need for community-based services change the business model for hospice and palliative care providers?
More and more hospices are realizing that they have to diversify their portfolio and go beyond reliance on the Medicare Hospice Benefit, because they recognize that there are a lot of patients out there who are not yet eligible for hospice, or who opt out of it, and their needs are not being met.
So there is a desire to be responsive to that group, coupled with the recognition of the likelihood that hospice is going to be carved into Medicare Advantage, which now accounts for roughly 30% of all Medicare beneficiaries. That could mean a big loss because Medicare Advantage plans are at risk for that entire amount of the patient’s care, so there is a chance that lengths of stay will be shorter and that plans will want to negotiate lower rates.
Those reasons are driving hospice leaders across the country to look into how they can care for patients who are very sick but not hospice eligible.
What would health care providers need to do to adapt to a Copernican system?
Many staff would be need additional training. We all train in the hospital. During training we spend much more time in an intensive care unit than we do in an outpatient setting, and most medical residents never set foot in a patient’s home. The training would need to be flipped, so that the majority of clinical time was spent either in office practices or in home visits and much less time in the acute care hospital, because we will expect clinicians to start taking care of people in the patient’s home.
And we have to reassess the model. It can’t be exactly like the hospice model because the organization will be bankrupt if it is trying to provide that level of care for 3-5 years, for example. So it involves figuring out more efficient models, much higher use of telemedicine, much higher use of virtual visits, and much more risk stratification where stable patients may get a phone call rather than a visit. It involves ways of monitoring people at a much lower intensity than hospice care. That is cultural challenge for hospices, but more are doing it.
How will providers need to adapt to changing payment models as the health care system continues to evolve?
The main problem is that many of the providers who are making a profit these days are fully fee-for-service, and they are very rationally saying: “We have positive margins; we are taking care of our community; our shareholders are happy; our community is happy. Why would we start setting up a system that reduces that flow of fee-for-service income, until we have to?”
Right now, the government has not yet mandated things like being a part of an Accountable Care Organization or doing bundled payments or becoming a patient-centered medical home. Those are entirely voluntary. Until it stops being voluntary the health care system writ large is not going to make major investments in paying for value rather than volume.
But in time the faucet is going to be turned off, and it is going to become mandatory to accept capitated rates or a global budget for a patient population. If you are not ready because you haven’t made any of the investments and retrained your work force to think in a non-volume driven way, you won’t make it. Prepare for the inevitable future by starting now.
Do you see some organizations making these kinds of changes?
There are a number of multistate for organizations moving in this direction. [palliative care provider Aspire Health] is an example; Landmark [Healthcare] is another.
Their model is to identify high-cost, high-need patients using health plan data and then intervene and attempt to prevent the rising frequency and intensity of health care utilization that occurs during the last six months of life and sometimes in the last two years of life.
The problem is that it can be really hard to predict who is within that time period.
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