A physician working in the field of palliative care discusses how pharmacists and physicians can work together to help address issues pertaining to polypharmacy through deprescribing.
Pharmacy Times interviewed Andrew Esch, MD, MBA, a senior education advisor at the Center to Advance Palliative Care (CAPC), on problems surrounding overmedication, particularly among older adult patients, and how pharmacists and physicians can work together to help address polypharmacy through deprescribing.
Alana Hippensteele: Hi, I’m Alana Hippensteele with Pharmacy Times. Joining me is Andrew Esch, MD, MBA, a senior education advisor at the CAPC, who is here to discuss the issue of overmedication and how pharmacists and physicians can work together to help address the issue.
So, Andrew, what are some known areas where overmedication is an issue such as disease states or conditions, and how can deprescribing help address the issue?
Andrew Esch: Yeah, I think more than specific to certain diseases, I think as we age, and the older population in general, really is at the highest risk for polypharmacy and the problems that are associated with that. So I think of it more age-related than I do disease-related.
But the things that affect people most commonly—heart disease, lung disease, cancer, stroke, those sorts of issues—generally come with a lot of prescribing and risks for polypharmacy and issues that come along with that.
Alana Hippensteele: Absolutely. What is the role of the pharmacist in making decisions around deprescribing, and how can pharmacists and physicians better collaborate to address this issue?
Andrew Esch: Yeah, so I've been lucky. I've worked in both settings. I've worked closely with pharmacists, and I've worked in settings where you've been a lot on your own. I will say this—I think if you have the luxury of being able to work with a pharmacist, I think my advice to my physician colleagues would be take advantage of that—they are so good at knowing anticholinergic burden issues and the potentially damaging meds that people can be on in a way that we don't. So I think they can actually be an active participant in the deprescribing plan.
I think pharmacists also have a huge role, at least from the physician standpoint, of educating prescribers like me on the risks of polypharmacy. What do you do about it? How do you evaluate a patient's medication list, and do that in a way where you're finding problematic medications or potential interactions? So I think they can have hands on clinical input—if you're at a site and you have them, I think that that is a great role for them. And I think if you don't, you still probably know a pharmacist you’ve worked with, at some point, so pick up the phone and have them educate you. I still do it all the time with my pharmacy friends. So, I come at this from a physician's perspective, I'm not a pharmacist, but what I know about this subject, has its origins in education from the pharmacy colleagues along the way. So, I'm thankful for that, and they taught me what I know.
Alana Hippensteele: That is really interesting. Yeah. What are some signs that reliable delivery of palliative care may be lacking in a healthcare organization, and is the issue often widespread within an organization perhaps policy based in nature?
Andrew Esch: It's a fairly new field. So I think anytime something is new, there's always a curve of adopting it. So I still think we're probably somewhere in the mass adoption of us as a field. So I think there's some slow uptake on that.
From a policy standpoint in hospitals, I think it's more lack of awareness than I think there's any policy issues to it. I think, for the most part, the hospitals that have had palliative care the longest, the problem palliative care teams have now is too many patients to see. And the ones that are new palliative programs, when they come to us for advice at the Center to Advance Palliative Care, they're asking, ‘How do we increase referrals?’ So to me, a good strong palliative care program in an institution does need institutional backing, there's financing that goes along with that. But it's really about relationship building and just actually doing good medicine. And so, if you build relationships, you take really good care of patients—the consults will come. And, organizationally, I think health systems that make a commitment to palliative care know the value, and those that don't haven't made that commitment yet, but the those, those institutions are becoming rarer.
Alana Hippensteele: That's really interesting. Regarding palliative care being relatively new, how new is it exactly in terms of its development as a field and also it's relative adoption within health systems?
Andrew Esch: Yeah, so the field is probably about 25 maybe 30 years old. Board certification in recognition of it as a medical specialty was really around 2007-2008. So, we're not talking a huge history dating back decades. So, in medicine, to me, that's still a pretty new field.
Alana Hippensteele: Absolutely. How is the Center to Advance Palliative Care working to inform the public about palliative care as an option they can ask for when diagnosed with a serious illness?
Andrew Esch: Yeah, one of the interesting things I think the Center to Advance Palliative Care does is it offers clinical training, technical training, and technical assistance to palliative care programs. So we help train providers, and we show them how to build a sustainable palliative care program. And so we sort of address it from the clinician end.
We also have a website that is patient facing and caregiver facing called getpalliativecare.org, and we educate patients and family about what palliative care is being really thoughtful about the language of it being an extra layer of support that you can get with all your other medical treatments to help improve quality of life. So we teach the clinicians and we teach the patients, and then we also do a significant amount of policy work. We're trying to move the needle on meaningful and sustainable payment for the types of services that palliative care can bring to patients and families. Because at this point, most of us still operate in a fee for service world. And that payment model for what's done in palliative care is not the best fit.
So policy work, patient facing work, clinician facing work—those are the things we're trying to do to address the problem of people's needs not being met with serious illness. When that happens, that's when suffering happens, and our goal is to make sure that palliative care is available to everyone everywhere. I think to effectively do that we are teaching and we're trying to educate and inform.
Alana Hippensteele: Right. You mentioned some of the unmet needs for patients, would you mind elaborating a little bit more about what that might look like or examples of where patients may have unmet needs in this palliative care setting or in the potential for palliative care?
Andrew Esch: Yeah, so palliative care—the work we do is done as a team, because patients are pretty complex. So to think that one physician or nurse practitioner or social worker could address all the needs of a patient, really, it's unrealistic. So palliative care is set up as a team because the needs are often great when somebody gets diagnosed with a serious illness. I say all the time, my role is easiest. So suffering can be in the form of pain and symptom management—things that I can address as a physician, those are easy. We have great pain medications; we have great symptomatic medications for nausea and vomiting and constipation and things like that. So, those are the obvious sources of suffering. But what do we do about social isolation? What do we do about people who are in pharmacy deserts who can't get the meds that they need, or patients, where palliative care is not available, rural settings, maybe some of the inner-city settings, like there are still some equity issues and availability issues with palliative care.
So, that team really tries to identify and address all of those the financial strains, people are feeling the decisions they're making between paying a copay for their medication or feeding their pet—these might not be the things that are on my mind as the physician, but a good palliative care program is thinking of these things, because our patients are thinking about those things. And that's really what it's about.
Alana Hippensteele: Right, absolutely. So you were talking about some of the points around potential financial challenges and decisions patients make—why might reliable financing of palliative care services pose difficulty and do all health plans provide coverage for such services?
Andrew Esch: But the short answer to that is, it does get paid for in fee for service. I submit a bill I get reimbursed like any other physician. What doesn't get reimbursed in the hospital setting is the nurse on my team that probably spent an hour or more with the patient, the social worker, the chaplain, and the core palliative care team gets to submit one bill under the prescribing provider, whether that's the NP or the doc. So it's a payment. So I guess that would if you ask the question like, does insurance pay for it? Well, yeah, I get paid. It's just what I get paid needs to cover an entire team and all the overhead. And so it doesn't make us whole.
So we often need support from the health system or some other source to be able to do that work. A sustainable payment mechanism, would it—I think the question you asked me is, could it pose difficulty? I don't know, I think would make things easier. I'd love to find out. I think it would be great if we had a sustained payment mechanism to provide people palliative care in their home outside the hospital. I think patients would benefit a lot from that. But I suppose everything is at risk for fraud? I don't know, I'd like to find out, I guess is my short answer.
Alana Hippensteele: Sure, absolutely. So I think you answered my question actually with how reliable financing around palliative care can potentially be difficult with needing to divide up reimbursement for services—that makes a lot of sense.
How can health equity come into play regarding who is offered palliative care services, and, potentially, in what setting?
Andrew Esch: Yeah, this is a big area for CAPC right now. We just did a big research outreach across the country to palliative care programs, and that the data from that equity factfinding study is actually being presented today in a webinar at 2:30. So I think the most honest answer to this question is, I don't think we know for sure, and that's why we're studying it and looking into it, it's a priority for us. It's part of our mission. It's one of our strategic planning goals is to address the issues in health equity.
I don't think any of us go into medicine thinking that we're part of the problem. But I think those of us that have had our eyes open and have done this long enough, realize there are structural racism issues or implicit bias issues that come up for all of us, or are part of all of us. And I'm excited about the work moving forward because naming the problem is really the first step. And we've named it now. A lot of us have known it's been a problem for a long time, but now it's front and center and being addressed. And I think we'll get our answers as we go forward. So I wish I had a better answer to that question right now, but we're working on it, and the answers are coming. And that's—I actually love that. I love that the answers are coming. I think we're going in the right direction in palliative care.
Alana Hippensteele: Absolutely. And I think it's on track with fields that have been established for decades. Those fields are doing some similar work right now. So it's really exciting to get to kind of dive into that work as well.
What are your hopes for the future of palliative care services and health care organizations in the United States?
Andrew Esch: I would like palliative care to be available to every patient everywhere. It can do so much good. I think when you describe what palliative care is to people: An extra layer of support that can be provided along with all their other disease treatments and other specialists. I mean, when it's described to patients that way, they universally want it, and, overwhelmingly, the patient feedback we get is positive that we made such an impact on somebody's travel through the disease process.
So, my hope is that palliative care is available to everyone everywhere. My second hope for palliative care in the future is that we have an available and sustainable workforce. Workforce is a huge issue in medicine right now, and palliative care is not immune to that. So, we have workforce issues. And so we need qualified, if possible, board certified providers taking care of the people who need us most, the ones with serious illness that are trying to get through.
So addressing workforce shortage or workforce issues, making sure the services are available everywhere, and a financial mechanism beyond fee for service that allows for a more matched reimbursement for the services that are being given by palliative care would be the third. I probably should put the financing first, because without all that I'm not sure the other stuff happens. But patient-centric thinking is: We need to make sure they have access to it, that qualified people are providing it, and then the third thing is that it’s paid for.
Alana Hippensteele: I have one last follow up question regarding the kind of reimbursement system. Does that come from health systems that would kind of look to support palliative care within the organization, or is there involvement from insurance companies in that financial reimbursement?
Andrew Esch: Great question. It's a really diverse landscape of what is sort of behind the financing of palliative care programs. If I had to say the biggest piece of pie if I thought of it as a pie chart would be hospitals or health systems, deficit funding or supporting palliative care programs, to do the work, to fit them to fill the need in their community that they service. Community organizations can do this and support palliative care programs. I think big multidisciplinary medical groups sometimes have their own palliative care programs. There's just a lot of different mechanisms for finding that funding. Some of the big health insurance companies have their own palliative care, home-based palliative care efforts as well.
So yeah, there's no there's no one recipe for this. And actually, that's part of when I talk about teaching the tools and technical assistance, part of it is, map your community, find out where the gaps are, find out what the needs are, design your program to fit those needs, and then find community partners that recognize your worth and what you're trying to do, and build your support network both financially and collegially that way.