In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Brad Stuart, MD.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"This is advanced care: helping people live the best they can and stay out of the hospital."
Nearly four decades ago, as a third-year medical student in California, Brad Stuart, MD, didn't want to give more chemotherapy to a dying patient who had bone marrow cancer. Stuart argued against the care plan, pleading with his superiors: Please talk to the patient and his family to determine "what was in store for them."
His bosses rejected Stuart's suggestion, saying they should finish the research protocol and not discuss the patient's status or treatment with him. Just give him the chemo, they told Stuart. Two days later, the patient died, sooner and with less comfort, Stuart believed, than if he had not given the chemo.
" 'I killed him,' I said to myself. 'I am never going to forget this. There's got to be a better way,' " Stuart recalls.
The incident was a turning point in a new doctor's life. Over the next decades, Stuart turned to hospice and palliative care to treat very sick patients, people who didn't want more tests or more procedures, but just sought peace.
Until recently, Stuart was CMO at Sutter Care at Home, part of Sutter Health system's network in Fairfield, Calif. He left Sutter in October to start Advanced Care Innovation Strategies, an Alamo, Calif.–based firm that will consult for hospitals, health systems, and medical groups on advanced illness–related issues, and increase the quality of care for advanced chronic illness and reduce its cost by promoting the dignity, choice, and responsibility. Such programs are meant to partner with families and patients for better coordinating care for those who are very sick, have chronic conditions, or who are dying.
Under Stuart's leadership, Sutter has been demonstrating success in its palliative care program for years.
From 2009 to 2011, Sutter reported a 54% reduction in hospital admissions and readmissions, an 80% reduction in intensive care unit days, and a 26% reduction in hospital lengths of stay. There were reduced visits to physician offices and clinics, too, Stuart says.
Sutter received $13 million from the Centers for Medicare & Medicaid Services' Innovation Center under a three-year grant for advanced illness management for patients with late stage chronic illness. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions
"In our program we deal with patients who are as sick as they possibly can be," Stuart says. "They can't be sicker than this, yet we've reduced hospitalizations. We are enabling people to stay at home, where they can be comfortable and nonstressed. This is advanced care: helping people live the best they can and stay out of the hospital."
Through palliative and advanced care planning programs, patient care is often focused on pain, symptoms, and the stress of serious illness, or even spiritual assistance, if wanted. One of the major hallmarks of advanced care is that it is not seen as a failure when patients say they have grown tired of treatments and want comfort for their chronic illness as they see the end of life near.
As the U.S. population ages, with the probability of more chronically ill patients in hospitals, more physicians should get acquainted with advanced care, not only for quality reasons but also as an improved economic tool, Stuart says.
"In our way of thinking, we are reducing costs the right way," Stuart adds. "You are preventing readmissions, having incredible savings, and letting patients say what they want, and make sure they get that. I made the mistake for so many years just assuming my job was to diagnose and treat the patient."
Like many physicians, Stuart says that was part of his medical training. During his first two years at Stanford Medical School, he says it was thrilling, with Nobel Prize winners as teachers, and he studied internal medicine, clinical psychology, and neurology.
"It was very intoxicating, but then I went into the wards and immediately realized we were doing something very wrong," Stuart recalls. "We were literally treating people to death. I was horrified." He saw that many procedures were done on patients with devastating illness, yet they still died "pretty quickly."
At the beginning his career in palliative care, there were only a few hospital programs in the country, and some hospital officials maligned them as not being cost effective, Stuart says. Just being in such programs made him and others feel as if there were a lack of support as time passed and they pushed for greater support for advanced care. "Developing advanced care as a step beyond palliative care was like pushing a rock uphill," Stuart says. He kept at working for palliative care. "It just stubbornness."
Over time, palliative care programs have grown markedly, with the number of palliative care programs in U.S. hospitals showing "a rapidly rising trend," says the Center to Advance Palliative Care. According to its most recent data analysis in 2011, 1,568, or 63%, of U.S. hospitals with more than 50 beds have a palliative care program—an increase of 138.3% between 2000 to 2009, according to the Center to Advance Palliative Care's most recent survey.
Even though more hospitals are developing such programs, the need may be greater in the years ahead, considering the growth of the U.S. aging population, Stuart says.
By 2030, the number of people in this country over the age 85 is expected to double to 8.5 million.
"The pace of progress for palliative care was definitely glacial; it was worse than glacial," Stuart says of the beginning of the movement. "But we've hit one of those tipping points and things have really taken off in the past year or two, the most that I've seen in the 20 years. "I've never seen in my lifetime this much enthusiasm [and] supporting innovation for this."
Despite the advances in palliative care and related programs, the government has been slow in widespread reimbursements for such care, Stuart says.
"Right now the bottom line economically is for places like Sutter Health spending their own money and using grants to put teams to provide care, but the savings are going to the payers," he says. "We're saving Medicare a lot of money. The goal is to have much less hospital-based care and more home- and community-based. And then we can have care management reimbursed. The savings can be shared and the quality can be increased at the same time."
"We want to change the standard of care for advanced illness across the U.S., for the clinical and reimbursement structure, so this kind of care management is paid for, through any new mechanisms or bundled payments, or something else," he adds.
With the government's efforts to reduce readmissions and reduce costs, palliative and advanced life programs fit nicely into healthcare planning, Stuart says.
Stuart says he wants to spread the message about palliative care and advanced care planning. He is developing a strategies company around such programs and is a member of the board of the Coalition to Transform Advanced Care based in Washington, D.C.
"My personal aspiration is to develop a national initiative that can help change the game for this population," Stuart says of patients facing chronic and life threatening illnesses.
"I've gone from being a naïve medical student back in the day to having a platform to stand on, and some data to back it up," Stuart says of his mission. "It's taken 40 years, but I'm very grateful to the way it is turning out."
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
