Palliative care program at Porter Medical Center in Middlebury closes

Dr. Diana Barnard, one of the doctors who operated the Partners in Palliative and Home Care program at Porter Medical Center, will move on to another position when the hospital shutters the program at the end of the month. VTD/Alan Panebaker

Dr. Diana Barnard thought the palliative care program at Porter Medical Center in Middlebury was the best idea she ever had.
Partners in Palliative and Home Care, which Barnard pitched to the hospital along with Dr. William Porter in 2009, gave patients with serious illnesses more say in their treatment and provided care in a home environment. After two and a half years, the program will close at the end of this month.

The palliative care program allowed doctors and nurses to meet with patients in their homes and carefully craft a plan for the patient’s goals for dealing with illness or terminal disease. The program was designed to provide holistic care for patients with serious conditions, Barnard said.

Palliative care gives patients relief from the symptoms, pain and stress of a serious illness. Unlike hospice care, which is only covered by Medicare for patients who have been given a prognosis of six months to live, palliative care professionals provide care even if a patient doesn’t have a terminal diagnosis.

“I’ve never felt so strongly that what I’m doing is so right, and it mystifies me that it can’t keep going,” Barnard said.

Palliative care presented an alternative for patients with life-threatening, chronic conditions who are not able to express their wishes in intense hospital environments.

“People feel overwhelmed and intimidated in an office setting,” Barnard said.

The program was popular, but Barnard and Porter were emotionally drained by the long hours involved in making home visits for treatment of seriously ill patients. Both doctors were hired as three-quarter time employees, but they worked many more hours than they were paid for. Dr. Porter resigned from his post last summer, according to the Addison County Independent.

Private insurance companies, Medicare and Medicaid didn’t fully reimburse costs for the program. While home visits were covered, Barnard said, coordination and travel weren’t. In a medical system that is based on “fee for service” or payment for medical providers based on individual tests and procedures, she said it is difficult to reward doctors and hospitals for the benefits of a happy patient who opted to deal with a condition at home rather than undergo further hospital visits.

“The value that it brings to people cannot be judged in a fee-for-service model,” Barnard said.

After Dr. Porter resigned from his post, the hospital could not find another physician, and eventually Barnard and the hospital could not agree on how to continue the program. Barnard hopes to continue her work in palliative care elsewhere in Vermont.

James Daily, president of Porter Medical Services, said the hospital was concerned about the costs going forward, especially since many of the expenses would not be covered by Medicare—the federal program that insures people who are 65 or older, or disabled.

“All the payers should reward services that are going to keep people comfortable and help them avoid expensive care that won’t extend their lives in a meaningful way,” he said.

Daily said despite the inadequacy of the Medicaid and Medicare reimbursement system, “there’s clearly a need for it.” He said he hoped to work with community partners like Addison County Home Health and Hospice to continue to provide palliative care services.

Healthcare providers at Porter Medical Center are not the only ones mourning the closure of Partners in Palliative and Home Care.

Dr. Allan Ramsay, former medical director of Fletcher Allen Health Care’s Palliative Care Service, said the loss of the program at Porter will be unfortunate for the community and the state.

“The focus is on quality,” Ramsay said. “It’s about controlling symptoms and allowing them (patients) to set goals.”

Over time, Ramsay said, a good palliative care program will reduce costs for hospitals. The idea, he said, is to improve the quality of life for people with serious illnesses who generate the most costs for hospitals and the system in general. A good palliative care system can shorten hospital stays, reduce unwanted diagnostic services and reduce admission rates, Ramsay said. The important part is listening to what a patient really wants and setting goals accordingly.

The purpose of a palliative care program is not, as critics argue, to ration care, Ramsay said. The objective is to give patients more control over their treatment.

In the short term, the costs of care coordination and counseling for patients that are not reimbursed by insurance companies and federal programs may exceed revenues for hospitals, he said. This is the conflict between quality-based care and the fee-for-service model. Larger hospitals like Fletcher Allen Health Care, Ramsay said, are more able to absorb the costs of such programs while smaller facilities may struggle.

Ramsay is a member of the Green Mountain Care Board, the five-member panel tasked with reforming Vermont’s health care system. He said he hopes to make palliative care a focus of health care reform. For now, he said, the Fletcher Allen Rural Palliative Care Network will continue to work with physicians at rural hospitals to help them provide comprehensive palliative care for their patients.

As for Dr. Barnard, Ramsay said, “she was ahead of her time, and she provided a great service.”