Thanacare CEO Michael Madison: Increased ACP Could Change the Health Care System

If more patients were to document their end-of-life wishes, it could effectively transform aspects of the nation’s health care system, generating cost savings and better outcomes, according to Minnesota-based physician Dr. Michael Madison.

Madison is a neurovascular surgeon whose practice has focused on treating stroke and brain aneurysm. He is also the founder of the advance care planning platform Thanacare. His experience treating advanced neurological illness opened his eyes to the need for advance care plans and the adverse impact that a lack of planning can have on families.

Hospice News spoke with Madison about the importance of upstream planning and how hospice and palliative care providers can leverage their skills to help ensure a better experience for patients and families at the end of life.

Thanacare CEO Dr. Michael Madison

What drew your attention to the issues surrounding the end of life?

It was really through my experience with treating stroke patients that it became most apparent to me how little preparation most people put into their in inevitable death, and their end-of-life experience

A classic example for me was when I would be called, often in the middle of the night, to treat an 88-year-old female with moderate dementia who was in a memory care unit. There had been no conversations that have taken place about advance care planning or what she would have wanted when she could have made those decisions for herself. Her family was unprepared. And because they’ve not been given any guidance or direction, they almost inevitably choose more treatment.


At that point, I explain to them that the best that is going to happen is that she’s going to return to the memory care unit and die of dementia. And I’ve gotten so many phone calls six to eight months later saying that the family wishes they would have listened. The treatment experience is not positive in any way. That kind of stimulated my interest in trying to do better at the end of life in our country. I just don’t think that we die well at all.

What needs to change when it comes to medical decision making as patients age?

We all fear death. We all want to live as long as possible. So we tend to choose to live in denial of the fact that it’s happening or that it will happen at some point. That denial is not helping us. Unlike so many other parts of our life where we are actively engaged in choosing and making decisions, we just simply abdicate our choices at the end of life. The result of that is overtreatment and medicalization of death.

We are in a place where patients too often are dying in hospitals. During COVID they were alone in the ICU, which was just terrible, heartbreaking. As practitioners, we’re in the business of trying to help people. We’re in the business of trying to make them live longer and better, and we embrace that role. But we also understand when the situation is such that whatever medical intervention we’re proposing isn’t going to make that patient live longer or better.

And right now, in the absence of any prior conversations, clear directions or any declarative statements about who is going to be their medical surrogate, it simply is not working. We need to change the ethic in our country where people are making these decisions and making plans ahead of time and communicating who is going to be their medical power of attorney or medical surrogate in the event that they’re incapacitated.

How does value-based care fit into the issues we’re discussing?

The hope would be that as we transition to value-based care, where we’re trying to treat patients to stay healthy, as opposed to just doing a fee-for-service intervention, that we have the opportunity to reimagine what health care looks like. We have the opportunity to fix some of the problems within the current system — of which there are so many. But one of the problems we have is that only a small percentage of patients have advanced care planning documents completed.

The Medicare Advantage patient population is a progressively increasing patient population. I see it as one that is not going to go backwards. The government is progressively going to try to make it more difficult for any of us to survive in this way. But I still think that we have a responsibility to do so. There are shared savings, which helps you then add more services so that you are better able to compete in the marketplace.

One of the parts of that conversation in terms of appropriately managing a Medicare Advantage patient population is their end-of-life experience. If they plan ahead, if they define what their advanced care planning documents are and have a clear understanding of what they want or don’t want, then the patient can have a better end-of-life experience. The patient’s family has a better experience. They often then are better able to make better decisions, and they don’t necessarily choose the path of medicalization of death.

What are the implications for hospice and palliative care providers?

I’ve had enough experience with hospice and palliative care to understand that at the moment, in a fee-for-service world, they’re looked at as a cost center. They struggle to find resources and the funding to hire more people. But, by definition, they are the experts at this point in time within the health care delivery system on the end-of-life experience.

They should be advocating for themselves within their health care systems to have a greater role in the care management of those Medicare Advantage patient populations. It’s kind of a win-win for everybody.

Shared savings and value-based care is not as easily understood as fee-for-service, but it’s not going away. It’s only going to expand, and there’s nobody better than hospice and palliative care to jump into this space and not only improve the situation for their patients and their families, but also improve the financial performance of the health care system, and justifiably be rewarded for the services they’re providing.

How can providers position themselves to take on this kind of expanded role when working with a Medicare Advantage plan, or other value-based stakeholders?

You partner with the population health representative within your health care system, and then you advocate for yourself being the end-of-life care management solution, starting by targeting the patients with the highest risk scores.

We’ll start with the patients who we know are the sickest to try to get their documents done first, because they’re likely going to need that with the most urgency.

My mission at this point is simply to change the ethic in our country to take responsibility for getting this stuff done ahead of time.

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