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Palliative care practice's fate illustrates limits of system

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Posted on October 27, 2011 |
By John Flowers



MIDDLEBURY — Porter Medical Center (PMC) will close its popular and innovative palliative care medical practice at the end of this month, citing the recent resignation of one of the two physicians in the practice and an inability to put together a new business model to continue the service with a smaller workforce.

It was back in 2009 that Drs. Diana Barnard and Will Porter launched Partners in Palliative and Home Care (PPHC), a service delivering medical care to people with advanced illnesses who have in most cases exhausted curative treatment options. These are patients who have declared a preference to live out their remaining days at home with family, and without further testing, hospitalization and dramatic medical procedures.

The practice quickly caught on, to the extent that Barnard and Porter — both hired to 75-percent positions — were soon caring for a combined total of 80 to 100 patients at any one time. These are patients whom the physicians would visit regularly, at all hours of the day and night. Barnard and Porter provided the patients with primary and palliative care, along with solace. Any services they could not provide they coordinated with other local agencies, such as Addison County Home Health & Hospice and Elderly Services Inc.

Around 130 patients lived out the final days of their lives under PPHC care during the two years of its existence, according to Barnard.

“What we did, from the patients’ and their families’ perspectives, proved wildly successful,” Barnard said on Monday.

“We were contemplating whether we would be able to grow.”

Just the opposite is about to happen, however. The practice will close on Oct. 31.

Porter tendered his resignation this summer, explained that the rigors of the job had become too strenuous and emotionally draining. Though they were technically part-time workers, both physicians could be called out at any time to deal with difficult and heart wrenching cases.

“My decision (to resign) was based on the sense that I was exhausted, unable to do the work at the pace I was doing it,” Porter said. “I was really tapped out and couldn’t do it anymore.”

Still Porter will look back fondly on his work with PPHC.

“(My sadness) is tempered by the success we had in helping people in profound ways,” he said.

Porter’s departure left PMC officials with some decisions on how or whether to continue PPHC. Ron Hallman, medical center spokesman, said the hospital board wanted to continue the service and tried to recruit a replacement.

“When (Porter) decided to pursue another path for his career, it obviously created a very serious issue, because the practice was already extraordinarily busy with the two of them,” Hallman said. “It sort of put us in an immediate recruiting mode that lasted for several weeks. That did not yield any results.”

When that effort proved unsuccessful, the board and Barnard tried to develop a new business model that would allow PPHC to function with one physician. In the end, the two entities could not agree on a model that the PMC board felt it could support, Hallman noted.

Barnard had pitched the idea of serving as a palliative care consultant.

“I think there was a diligent effort on everyone’s part to come up with a new model that would be sustainable for the practice and the organization and meet the needs of the community,” Hallman said. “But it became more and more clear over time that it was very complex to meet everybody’s needs within the resources that were available. We just couldn’t figure it out.”

While PPHC proved to be a popular and valuable service, it was not one of the most solvent in PMC’s portfolio, officials acknowledged. That’s in large part due to the fact that PPHC focused on keeping patients comfortable without tests, treatments and hospitalization — services that help improve a practice’s bottom line because they are reimbursed by insurance companies and federal health care programs like Medicare.

“The practice was not self-sustaining, but they are not unique in that,” Hallman said of PPHC. “The one element that is different, in terms of this kind of practice, is a traditional medical practice not only derives income from the care it provides, it also derives revenue from the various tests it orders. The whole point of a palliative care practice — which is wonderful — is that it keeps people out of the hospital and works to keep people from getting that extra CT-scan.”

The palliative model of care, Hallman said, is not made financially whole under the current U.S. health care system that compensates based on fee-for-service.

“Our health care system does not yet fully reward and recognize all of the attributes that are provided by a palliative care practice, in terms of all the time they devote to caring for a patient, the amount of savings that a practice like this can accrue to a system by avoiding hospitalization and additional tests and treatment,” Hallman said. “We are moving in that direction… where we start rewarding on value and take into consideration this more innovative types of practices.”

Hallman said the impending closure of the practice represents “a loss for our community and the organization and I think it is really important that we applaud the incredible work of the providers and the practice and the contributions they made to the patients and the community.”

Barnard promised to lend her voice to those urging Vermont to recognize and reward palliative care as a viable option for some patients. The Vermont Legislature will continue to take testimony this winter as it considers the state’s transition to a single-payer health care system.

“There is no way we can generate the kind of revenue that physicians generate in an out-patient clinic setting,” Barnard said. “Medicare, Medicaid and all of the insurance companies and the whole medical system really isn’t geared for this kind of approach.

“(PPHC’s example) is an example of why we desperately need health care reform,” added Barnard, who plans to pursue other career opportunities in the palliative care field. She said others in the PPHC office will be absorbed within the Porter Medical Center workforce.

PHCC will be missed, according to family members of clients who used the service. Salisbury resident Deb Brighton last year brought her terminally ill dad and stepmother into her home last fall. She credited Dr. Porter’s visits for making her family’s desire for home-based, end-of-life care possible.

“I was so happy that this was the way health care was moving,” Brighton said. “I’m devastated to think they couldn’t pull it off.”

Reporter John Flowers is at johnf@addisonindependent.com.

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