The Future of Palliative Care: A Podcast with Diane Meier

Eric: Welcome to the GeriPal Podcast! This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, there’s somebody else in our studio office.

Alex: We have a guest host today, Grant Smith, who’s a palliative care fellow here at UCSF, and will be at Stanford next year. Welcome to the GeriPal Podcast, Grant.

Grant: Thank you so much for having me.

Eric: And I see someone very very special.

Alex: Someone very special. A dear friend.

Eric: In our virtual studio audience.

Alex: International leader of palliative care. We have Diane Meier, who is CEO of the Center to Advance Palliative Care, among many other prestigious titles. Welcome to the GeriPal Podcast, Diane.

Diane: I am thrilled to be here.

Eric: Well, we are very honored to have you. We’re going to be talking about the future of palliative care, some of your work that you do with CAPC. But before we go into the meat of this, we always start off with a song request. Do you have a song for Alex to sing?

Diane: Yeah, I’d love to hear some Tracy Chapman. How about Tell It Like It Is?

Alex: Tell It Like It Is. That’s what you do. (singing).

Eric: That was-

Alex: Eric thought I was done after the dramatic pause.

Eric: I don’t know, the first question for Diane, what keeps her awake at night? I think that’s the question.

Diane: What keeps me awake at night. That’s a great first question. I’m a Baby Boomer, so there’s 10,000 of us turning 65 every single day. I don’t see the focused mind that our policymakers need to get the healthcare system ready for the impact that we’re going to have on our society and our healthcare system.

Eric: That was a very get ready kind of geriatrics response right there about this, the aging population. I just thought that was interesting.

Diane: You know, I’m a geriatrician, as well as a palliative care doc, and there’s very very little distinction in my mind between the specialties. There’s some non overlap, but mostly there’s overlap.

Alex: Yeah. Diane, you recently published a paper in Health Affairs, arguing that we should have a national plan to … What is it called? National-

Eric: A strategy.

Alex: … a national strategy to address palliative care in the United States. Now, for our listeners who may not know what a national plan is … what is a national plan?

Diane: Ha! That’s a great question. A national plan brings together the various entities in organized medicine and policy to come to agreement on how the healthcare system should be designed to improve some outcomes.

Diane: There was a national strategy for HIV, for example. There was a national strategy for smoking some years ago. These are usually initiated by Health and Human Services in government, and then involve bringing in and linking to other government entities like Housing, Drug Enforcement Administration, the FDA, as well as private-sector organizations such as the American Geriatric Society. Or the Academy for Palliative Medicine, and brings those key stakeholders together that have influence, power, and audiences that have a stake in what this policy might be, and try to come to some agreement. Ideally, this is associated with some financial investment from the government.

Alex: So this is a combination of government investigation, effort, policymakers, money, as well as specialty professional societies, interest groups, and what other entities are involved?

Diane: Well, it would depend on the cause. In the instance of this paper, which is about developing a national strategy for palliative care, you would need to include, for example, those who deliver care in community settings, like hospices and certified home health agencies. And clinicians in practice. And areas that represent rural clinical settings as well as urban, as well as the underserved.

Diane: The process is the product, to the extent that you get all of these entities participating and hammering out something that they can all get behind. That, then, makes it possible to act on it. But not till that happens.

Eric: And we have blueprints for how to do this, right? You mentioned there’s one on HIV, and there’s other countries that have done this before? Around palliative care, particularly?

Diane: Yeah. There are a number of countries, most of which have a national health insurance plan, like Australia or New Zealand or Scotland. Many in the former British Empire, and Canada, has a national strategy for palliative care where they do precisely that.

Diane: They bring together these entities, they hammer it out over some period of time … usually with government support. Then they put out the strategy, which then is typically adopted. And policy evolves from it.

Diane: It’s a way of thinking about the needs of the whole society, and the diverse needs of different populations in different settings, different age groups, different diagnoses, rural, urban, hospital, not hospital.

Diane: A lot of these national strategies have heavily focused on education and training, as well as essentially mandating that healthcare organizations provide palliative care. Which, in this country, we have nothing like that.

Grant: Diane, I think in your paper, you had mentioned that there might be some unique challenges that the U.S. faces, compared to some of those other countries. I’m wondering if you could talk a little bit more about those.

Diane: Well, the most obvious barrier is the profit motive, that increasingly drives the healthcare system in the United States, including both Medicaid and Medicare, which are increasingly administered by for-profit health insurance companies. Medicare Advantage and Medicaid Managed Care.

Diane: When you are reporting to shareholders, your primary obligation is to make a profit, so there’s a shareholder return. And to get to a point where that company can be sold, ideally, so that big profit can be made by the initial investors. That tends to be somewhat in conflict with developing policy and strategy that serves the greater good.

Diane: For example, it’s great that Medicare Advantage plans are contracting with various entities to deliver home-based palliative care. But if you’re not in Medicare Advantage yet, and you’re in fee-for-service Medicare, you’re just out of luck.

Diane: If your particular Medicare Advantage plan hasn’t decided to do such a contract, or invest, you’re out of luck. So you give up equity, consistency, standardization, and quality, when you depend on the marketplace to deliver access and quality. In my opinion…

Grant: A word that I really liked in your paper was “patchwork” versus, as you described, a national strategy that is aimed at a larger picture.

Diane: Well, since one of the key elements of quality is equity … that like patients in a like situation have access to a similar standardized, consistent quality of care … realistically, the only entity that can make that happen is government. And in particular, the federal government.

Alex: So why is now the time for a national strategy to address palliative care? Would it have been time 10, 15 years ago? Or would it be too late if we waited 10 years?

Diane: It’ll never be too late. It needs to happen. It took a while to get an evidence base out there, and it’s still not as strong as I would like it to be. But there’s a fair amount of evidence out there about both quality and costs associated with a range of models of palliative care: different settings, different patient populations.

Diane: We needed to have some evidence before we could say, “This should be standard of practice across the country.” That took a while. We still need more, I would argue. So that’s one thing.

Diane: Second thing is the consensus, really bipartisan consensus that fee-for-service is the enemy. That fee-for-service is what’s driving not only a lot of waste and unnecessary spending, but harm to many patients. Because when the incentive is if you do more, you get paid more, surprise surprise, people do more. And are actually encouraged to do so by their employers.

Diane: There’s been across both administrations … the Obama administration and the Trump administration … increased attention and spokespeople and leadership talking about the importance of value-based care; that is, care that is focused on improving the quality of care, and in so doing, reducing unnecessary spending.

Diane: To have a principle like that cross very polarized political parties, and polarized leadership, is an opportunity. That’s why I think that this is the time. Because there is much more widespread recognition that we’re not only wasting a huge amount of taxpayer money, we are hurting people in the process. The only question is how to get there, really, that there’s differences, political differences, in how to get there. But there doesn’t seem to be disagreement that we need to get there.

Eric: A strategy would serve as a guide, right? There’s no teeth, no enforcement, right? It just tells us what we can do. Is that right? Am I understanding this correctly?

Diane: No. The purpose of a strategy is to build an accountability. Right now, for example, hospitals are not accountable for the delivery of palliative care. The fact that 86% of hospitals with more than 50 beds have a palliative care program, is not because the Joint Commission and the other accrediting bodies require it. It’s because somebody convinced them that the value impact was high enough.

Diane: That said, among that 84% of hospitals that are already doing this, there is enormous variation in what they are doing. For example, in a paper in Health Affairs a while ago, we found that fewer than 40% of hospital palliative care programs are staffed in a way that meets standards from the National Consensus Project. They’ll say they have a palliative care program with a .5 FTE RN on Thursday. Right?

Eric: Right.

Diane: You and I would agree it’s going to be really hard to deliver high-quality, effective care to all the patients in that organization that need it with that kind of staffing. But there’s nothing to stop that hospital from saying, “Oh yes, we do palliative care.”

Eric: Yeah, I actually just heard of one a ways back that was staffed by a pharmacist. I think pharmacists are great to have on palliative care teams. It’s hard to be a team of one. It seems like that’s not the optimal staffing-

Alex: That one pharmacist, no. No.

Diane: Probably not. Although if I had to choose one person, it might be a pharmacist. But the patients we take care of are the sickest and most complicated patients in our society. It’s pretty obvious that no single discipline has the training or the capacity to be responsive to that diversity of needs in these patients.

Alex: Now, I want to go back to something you just mentioned about the need for the research base. As a clinician researcher of course it’s like, oh, the ears perk up.

Eric: Yes.

Alex: When you think about, and you talk about the other areas where we’ve had national strategies to address smoking, to address HIV and AIDS, there was clear evidence around the harms of that behavior … smoking. And that disease, HIV and AIDS. Are there other examples where we have A), a strategy to address a field like palliative medicine. You don’t hear about a national strategy to address cardiology, for example.

Alex: Then B), are we there on the same level in terms of evidence as smoking and HIV/AIDS? I think I heard you say, “We have room to improve, but we’ve come quite a ways”?

Diane: Yeah, I think that’s right. But I also think that many of the successful national strategies in this and other countries were accomplished with way less evidence than we have right now.

Diane: The HIV national strategy involved investing in research. It was a crisis. Tens of thousands of young people were dying. We didn’t have any evidence about what worked at that point. But there was a commitment to get the evidence, and to invest a lot, and to invest quickly.

Diane: I think there’s plenty of evidence that people with serious and complex illness A) suffer a lot, and B), often get care that is not matched to what they actually need.

Diane: I don’t think that the problem requires more admiring. There’s a lot of research out there that admires the problem, and points to how bad things are. I think we should move past the admiring the problem research and only do research that’s going to influence policy, or help us develop interventions that make things better.

Eric: In that regard, like thinking in the future, what areas do you think are our biggest areas for research in palliative care? You talked a little bit about some of the barriers to accessibility, including outpatient or SNF-based palliative care; SNF, very few.

Alex: Home based.

Eric: Home based. In your mind, what do you think are the key areas that we need to focus on as far as research?

Diane: Well, for example, if you look at the National Consensus Project for Quality Palliative Care, some of what’s in there is evidence-based; most of it is not.

Diane: A RAND analysis, systematic review of those recommendations which was published either in JPM or JPSM a few months ago, found very little high-quality evidence in support of what we say is high-quality palliative care in the National Consensus Project.

Diane: I think we really need to study those assertions. For example, the fact that we say a high-quality palliative care program should include a chaplain, is based on no evidence. It’s based on clinical judgment on the part of those of us in the field. And it’s sacrilegious, pun intended, to suggest that perhaps that isn’t a necessity. But no one’s ever studied it. This has real cost and resource implications.

Eric: Yeah, it just reminds me of all the big trials that we have in outpatient palliative care. Many of them, I will say, include usually like two members: a physician and a nurse. Maybe a social worker.

Alex: But not a chaplain.

Eric: But not a chaplain, not a pharmacist, not that interprofessional team that they’re talking about in our quality guidelines.

Alex: You’re thinking primarily like Jennifer Temel and MGH [crosstalk 00:17:40]-

Eric: Jennifer Temel, those types of studies, followup studies by them. Yeah. I’m trying to think of one study that really included an entire big team. I think there was a heart failure study that came out. That included a bigger team. I think that’s one of our big challenges, is that we talk about this. But we haven’t really researched what are the key players involved?

Diane: And, given the understandable attention to money. And the not wanting to make the perfect the enemy of the good. We want the most affordable models that have the highest impact.

Diane: For example, if I was designing a home-based palliative care program, and doing a study … I think Sean Morrison’s actually doing this study now … it would start with a base of community health workers visiting people in the home. Who are then in large numbers, and who are then supervised by an RN social work team, who are in turn supervised by an NP or a PA, who can prescribe, who are in turn supervised by one physician.

Diane: You’ve got the most expensive, most highly trained member of the team present, available, reachable for problems that cannot be addressed by helping people fill their mediseps, and making sure they refill their meds, and making sure they have transportation.

Diane: But as the literature repeatedly shows, most medical problems are actually related to social determinants of health, and need to be addressed by addressing gaps in access to food, transportation, housing, literacy, family violence, history of trauma.

Diane: Many of those things don’t require a doctor. They don’t require a nurse practitioner. Yet, because we have fee-for-service model, and a payment system that is driven by doing things so that you can bill, we don’t put the money where the issue is. We put the money where you can bill.

Alex: Many of our listeners will know that the Center to Advance Palliative Care is abbreviated CAPC. How does CAPC fit into this idea that we should have a national strategy for palliative care? Also, do we have a birthday to celebrate?

Diane: We do.

Eric: An anniversary!

Alex: Anniversary.

Diane: I was afraid to say it because what it says about me, and where I am in my life. But CAPC is 20 years old this year.

Alex: Woo-hoo!

Eric: Holy smokes.

Diane: Yeah, like out of adolescence, ready to move out of its parents’ basement. Pull out into the world.

Eric: 1999.

Diane: 1999. 1999 is when the Robert Wood Johnson Foundation approached me and my then-chairperson, Christine Cassel, and asked us to start a national program office of the Robert Wood Johnson Foundation that would help hospitals across the country establish palliative care teams like we had established literally 18 months before, at Sinai. Being very naïve, we said “yes.” So here we are.

Alex: That’s amazing, what CAPC’s done. How much, primarily by huge amount of effort on your part, supported by a tremendous team.

Eric: We’ll have two links to articles. One article also from Health Affairs talking about the Palliative Care Leadership Centers. For those who don’t know what those are, do you want to briefly describe that, Diane?

Diane: Yeah. Again, I can’t take credit for this idea; this was Rosemary Gibson’s idea, from the Robert Wood Johnson Foundation. They were throwing tons of money at us, at CAPC. And they wanted to spread it out and enlarge the center of gravity for leadership in the field. It was a brilliant idea.

Diane: So we did a competitive application for people around the country who wanted to teach others, who were willing to give it away … what they had learned … how to establish hospital palliative care programs.

Diane: To my delight and surprise, there were many … 50 or 60 applicants who were evaluated based on several criteria. One was educational track record. Was this a team that did a lot of teaching and was committed to teaching? Because this was a teaching job that they were getting.

Diane: Was this a team that was measuring what they were doing? And modifying what they were doing based on data? Was this a team that had identified a financial model that was sustainable? Because lack of financing means no program.

Diane: So having identified people who met those and other criteria, we ended up … I don’t know, I don’t remember, with about eight centers that met those criteria in very different parts of the country. Very different hospitals. One of which is UCSF.

Eric: How many total sites did you train from those places?

Diane: Oh, something like 13 or 1400

Eric: Wow.

Diane: But it’s about 80% of the total hospital palliative care programs in the United States, were trained by one of the Palliative Care Leadership Centers.

Diane: I think this says something about our field, because of the incredible generosity and commitment of the people at these Leadership Centers, to give away everything they had learned to their competitors, essentially. To help their colleagues do exactly what they had done successfully. It was really moving to see how effective that was.

Grant: Diane, as end of June approaches, many palliative care fellows are about to finish up their fellowship and enter the workforce. I think we’re all excited for the next step. I think we all feel very blessed to stand on giants’ shoulders at this time.

Grant: I’m just curious if you have any advice or words of wisdom for those of us who really want to push this field forward, to think about the next thing, to help promote this national strategy. What would you recommend to us who are about to get started in our careers?

Diane: That’s such a great question. I think the first thing is don’t get tricked into going right out of fellowship and being told to lead a program. The number of young people right out of fellowship that I’ve encountered who, the minute I start asking them how things are going, start to cry. Because they’re so overwhelmed. So burned out, so overextended, and don’t have the mentoring or the support to learn how to negotiate what can get done and what can’t. Is you don’t lead a program right out of fellowship.

Diane: If you are leading a program right out of fellowship, find yourself some mentors at other programs who are willing to hold your hand through that. That’s number one.

Diane: Number two, I think it’s important to put your time in a program to develop clinical skills and expertise, to develop educational skills and expertise. But also if you’re going to be a junior faculty somewhere, to start joining committees.

Diane: Start acting like a leader. See how decisions get made. Develop relationships with the chief medical officer, the chief nursing officer, the chief quality officer. Be part of the solution. Don’t be marginalized and siloed. That is how you learn to be a leader: by watching other leaders. That is how you start to have influence, by being at the table.

Diane: What I did … and I wish I had done it earlier than I did it … in 2009, I did a Health and Aging policy fellowship, and went to Washington. Because I didn’t really understand how health policy was made, and it was a transformational year.

Diane: I learned things that I got no exposure to in undergraduate or graduate medical education. That are critical. If you want to change how healthcare is delivered, you have to know about policy. Right?

Grant: Yeah.

Diane: Bizarrely, we don’t learn about that in school. You have to go get it. You have to go get what you didn’t get in your training.

Grant: Thank you so much for that advice. Maybe one followup question too. I was definitely reading your paper, starting to recognize that pushing on policymakers and thinking more about policy is going to be really important for the next phase. It’s great to hear your experience of how you got involved in that.

Grant: Are there other things that you would advise people who are interested in getting more involved in policymaking around palliative care issues? Where to get started?

Diane: Yeah. First of all, states are in some ways more influential than the federal government on policy, advancing access to all kinds of care. In your state, or in your community, there are ways to get involved. That’s either at the city level, if you’re in a big city, or at the state level.

Diane: There are many states have palliative care committees. There are state hospice and palliative care organizations that do all the advocacy at the state level for our field. Again, something none of us learned during our training.

Diane: Being part of those state-based organizations gives you a voice and a whole coalition behind you that gives you experience with trying to influence how legislators in fact, as well as the executive branch, make decisions. Be at the table or be on the menu.

Alex: Right.

Grant: Love that.

Eric: Me too.

Alex: I wanted to ask you; this national strategy. Is this the issue? Is this something palliative care should rally around? This should be our top priority? We should be calling our congresspeople, our senators, trying to get this to happen. Is this the top of the list?

Diane: I think it’s a timing issue. I’m not sure whether the timing is right, although I’m not sure how I would know if the timing was right. But there are now two coalitions that are working at both federal and state levels in our field.

Diane: One is the Patient Quality of Life Coalition, which was stood up and is largely funded by the American Cancer Society, which is an incredible gift to our field. And has about 50 different national organizations in it, of which all of the major palliative care organizations are part. Like NHPCO and the Academy, CAPC and others. But cancer-specific organizations, the Alzheimer’s Association, the American Heart Association are also members in helping us.

Diane: When you’ve got a coalition with that kind of membership, it has influence on The Hill, and on the executive branch. Working inside a coalition, you don’t get to decide what the policy priorities are. There’s a process. It’s a process of compromise and conversation. Right now, the policy priority is PCHETA, the Palliative Care and Hospice Education and Training Act, and people do not want to be distracted from that.

Alex: Right.

Diane: It came close, and now we’re trying to get it over the hump. The other coalition is the National Hospice and Palliative Care Coalition, which represents the hospice and palliative care organizations, and currently has 10 members plus other organizations wanting to join. That’s also a powerful entity.

Diane: Right now, for example, that coalition is meeting with CMMI, the Center for Medicare and Medicaid Innovation, to have influence on this new advanced alternative payment model that CMMI just released. The primary care’s first alternative payment model has a serious illness program within it that will enable hospice and palliative care clinicians to deliver palliative care on a risk-bearing model. That is, there’ll be a per member/per month fee, plus some additional support. This will be a demo in about half the states. Supposed to start this summer.

Diane: Just last week, members of the coalition were in force, meeting with CMMI about our concerns and suggestions for making that demo usable by the field.

Eric: Taking a big step back … If you had to go forward 10 years from now, or 15 years from now, what do you imagine palliative care will look like in 10 or 15 years?

Diane: Everything depends on the political situation.

Eric: In your perfect world. Everything goes right.

Diane: If everything goes right? In my perfect world, you will not be able to call yourself a hospital if you don’t have a palliative care program that meets certain quality standards. The same will be true in nursing homes.

Diane: Certified home health agencies will have a lot of their rules lifted, like having to be home-bound, and having to have time-limited services. They will be able to partner with people delivering palliative care for people who are chronically ill and not hospice eligible.

Eric: Who do you think would be delivering that? Let’s say in the skilled nursing facilities. Given that there are workforce shortages from physicians and NPs. How does that actually … again, perfect world, everything goes well, 10, 15 years from now? Who’s actually delivering that palliative care at these skilled nursing facilities, let’s say?

Diane: Yeah. There’s no way there will ever be enough palliative care specialists across disciplines to meet the need in this society. As I was mentioning, 10 of us turning 65 every day. We have to train the workforce. I wish that that was an easy thing to do, or something that a policy flip would take care of.

Diane: Right now, the LCME and the ACGME do not mandate palliative care training at the undergraduate or graduate level. Still. What we’ll have to do is develop mid-career professional training standards that are …

Diane: For example, we all have to learn to wash our hands. Every year, we have to demonstrate with some kind of test that we know how to wash our hands. And we know about infection control. Because there’s a law in your state that requires it. That is the sort of thing that’s going to be necessary.

Diane: Health plans are starting to do this, like Medicare Advantage plans. They are starting to incentivize palliative care training as a condition, for example, for being in network, or as a condition, for example, for being eligible for bonuses. There’s certain things that commercial health plans can do that the government needs to also start doing.

Diane: ACOs, if they ever get to the point where they’re taking downside risk … which isn’t happening very much in this country … they will have a very strong incentive to mandate broad-based clinician training.

Alex: Sorry, what does “downside risk” mean?

Diane: Downside risk means that you get a certain amount of money to take care of a patient or a population. If you spend more than that amount of money, that’s your problem. You have to pay it; it’s your money out of pocket. You’re not going to get reimbursed for it. Right now we have just the opposite. No matter what you do, no matter how unnecessary or harmful, you get paid for it.

Diane: This is the flip of that, where every clinician is on a budget, every health system is on a budget. Similar to Kaiser, similar to the VA. There’s an incentive to do what helps, and not what is harmful.

Eric: Switching track a little bit, CAPC. 20th anniversary, 1999. This year, you revamped your entire web site. Lots of educational stuff on it. You’ve got to be pretty excited right now, where CAPC is.

Diane: Yeah. I’m really excited about it. There’s six different things we’re trying to do, six different levers to try to advance access to quality palliative care. One is training all clinicians.

Diane: Eric, you contributed to an incredible curriculum on how to relieve suffering for people living with dementia and their families and caregivers. It’s a beautiful thing, in my opinion. Again, something that isn’t taught the way it should be in undergraduate and graduate medical education, even though every clinician is taking care of people with dementia.

Diane: There’s no room for hopelessness and helplessness in that disease. There’s so much that can be done to make it better. And it needs to be taught.

Eric: There’s tons of other great modules on CAPC. They are ready to go, that people can, came from a fellows or resident or med student or nurse practitioner perspective.

Diane: Yeah.

Eric: Just, I’m always surprised when I talk to people about it, many people don’t know the wealth of resources. And many people don’t even know that they’re CAPC members, because it’s an institutional thing. I can probably go around at UCSF here and ask people, like Grant, did you know you’re a CAPC member? I won’t put Grant on the spot.

Grant: I’ve used the modules; I love them.

Eric: Oh, great.

Diane: Thank you, Grant. This is like paid political advertising here. Well, so we build this online CEU/CME/MOC-linked curriculum to try to make it as easy as possible for frontline clinicians to gain the knowledge and skills that their medical schools and nursing schools, post-graduate training failed them on. We’re nearing 300,000 course completions-

Eric: That’s great.

Diane: … by about 60,000 clinicians. But obviously, we have a long way to go, because I don’t know how many total doctors, nurses, social workers, PT/OT, et cetera, there are in the U.S. … But it’s way more than 60,000. We have a long way to go.

Eric: So everybody who’s listening to the podcast, check out the CAPC web site. Check out the modules. Share it with people, think about building a curriculum about that. But that’s one lever. Quickly, what are the other five that you were going to mention?

Diane: Training everybody is one lever. Advancing access to specialist-level palliative care through technical assistance and tools. How do you write a business plan? How do you figure out what kind of staffing ratios do you need? How do you develop a financing mechanism? How do you develop partnerships with community entities? This is again, all stuff we don’t get taught. Yet if you’re heading out there to lead anything, you need all of these skills.

Diane: What we’ve basically tried to do is create a mini-MBA for people who are leading in palliative care. One person said to me, “I actually did an executive MBA, and CAPC is better.”

Eric: And those resources are on your site, right?

Diane: They’re on the site, CAPC.org. Particularly, for younger people who are being thrust too early into leadership roles, this is the angel on your shoulder. So make use of it. That’s the second one.

Diane: The third one is public awareness, driving public awareness. We have a public-facing web site called GetPalliativeCare.org, which gets more than 130,000 unique visitors per month, because people come in from other disease-specific web sites, like the American Cancer Society or the American Alzheimer’s Association, because we have links with all those organizations.

Diane: There’s increasing public curiosity and interest. My belief is … not based on data, that if people start demanding this, that health systems will respond. And policymakers will respond. That’s the third.

Diane: The fourth is working on payment and policy. Allison Silvers in our shop is working with Medicare Advantage plans, with ACOs, with both the coalitions that I mentioned. With CMMI, in an effort to make it feasible to survive financially. Delivering palliative care.

Diane: The fifth is accountability. We talked about this. That it shouldn’t be possible to be a hospital or a nursing home and say you’re delivering high quality if you’re not delivering palliative care. Organizations should be accountable for that.

Diane: The last is standardization and quality. That’s through our registry, the National Palliative Care Registry, and mapping which attempts to measure how many palliative care programs there are out there, in what settings, and what exactly they are doing in terms of staffing, penetration to reach patients, to get some sense of where we are, and how we’re progressing as a field.

Eric: The last question for me, when we think down the future, what do you think the biggest threat is for our field?

Diane: Right now, I would say it’s burnout. The exhaustion level of the people in the field, the commitment to the relief of suffering of people in our field is remarkable and admirable. But suffering is infinite.

Diane: You can’t walk through the hospital without being able to identify 15 patients in five minutes that need you. None of us are staffed adequately, nor have the capacity to meet that need. And getting the field to figure out that it’s not just about saying “no,” it’s about figuring out other ways to meet those needs.

Diane: For example, through mid-career training. And screening. And expecting hospitals, for example, or oncologists, or the NPs who work with oncologists, to learn enough to deliver the basics of palliative care.

Diane: That’s our job, is to develop those programs and meet those programs and support that work. And not just be looking at our list and seeing the tiny fraction of people in need that we see. Burnout is my biggest concern in the field right now.

Eric: Great, I know we took up a lot of your time. I want to thank you very much for joining us on this podcast.

Grant: Thank you so much, Diane.

Eric: Thank you. It was awesome.

Diane: It was fun. Really fun. Like I said, when somebody finally wrote me and invited me, I thought you’d never ask. [laughter]

Eric: Well, how about before we end, Alex, can you give us some little bit more?

Alex: A little bit more.

Diane: Yeah, please.

Alex: (singing). I think I maxed out our …

Eric: You got a little feedback grunge there. Yeah, Alex turned it up to 11.

Alex: I love that song. Tracy Chapman. She’s a great performer. I think I saw her three times 20 years ago.

Eric: Oh, really?

Alex: I haven’t seen her … I don’t know if she’s still performing.

Diane: I don’t know … I haven’t seen her anywhere.

Alex: Yeah, I think she lives in San Francisco, or at least used to, when I was in med school 20 years ago. She played in the soccer team out. They played out here.

Eric: Yeah, did you play her?

Alex: No, I never played.

Eric: Well Diane, thank you for always telling it how it is. And thank you for sharing your viewpoints on our podcast. Thank you to all of our listeners for joining us.

Alex: Thanks everybody. Thanks, Diane. See you next week.

Diane: Bye.