Tuesday, April 7, 2015

Five Year Snapshot of Hospice Industry - What Does It Say About the Spread of Palliative Care?

Hospices and hospitals are the two principal organizational models delivering palliative care. The Center to Advance Palliative Care (CAPC) has consistently documented, through its regular studies, the growth of hospital-sponsored palliative care services over the most recent five years. During the same period, little has changed among certified hospices.

A close look at NHPCO’s Annual Facts and Figures Reports from 2009 and 2014 tells a lot (note:2014 report, which captures data from 2013, is most recent Report published by NHPCO).
From 2009 to 2014,

  • ·        % of decedents enrolled on hospice benefit for 7 days or less remained steady at 35%
  • ·         median length-of-stay fell slightly to 18.5 days from 21.3
  • ·         % of hospices with fewer than 500 admissions per year rose slightly to 79% from 77%. 45% of hospices admit fewer than 3 patients per week
  • ·         median Average Daily Census (ADC) served by hospices increased notably, to 79.5/day, up from 60/day
  • ·         % of total hospice billed at General Inpatient (GIP) days  jumped to 4.8, up from 2.9.

So, short-stays persist, as do subscale hospices. I believe there is a correlation.  And I also believe that the subscale, and highly competitive, nature of the hospice organizational structure inhibits the spread of palliative care.

On the promising side, larger hospices are getting larger. I describe this development as promising because size does bring proficiency (read this previous post on my reasoning about minimum volume thresholds).

In a 2010 post on this blog (read here), a similar five-year snapshot was taken. Taken together, one could conclude that little has changed over the past 10 years in the hospice industry.

Your thoughts and comments are invited.

Monday, April 6, 2015

Palliative Care - Diffusing the Health Innovation

A graduate student in a Health Policy program asked me during a Q&A session at a national colloquium why I characterize end-of-life care in this country as three parts potential for two parts accomplishment. I've been asked similar questions before, but what gave me pause this time was the context of the query (the workshop was addressing the issue of access to hospice). The previous speaker had just presented a strong case statement on why access to hospice has been threatened by the "cap". And why the main reason for the decelerating growth of hospice was poor reimbursement.
I replied that the delivery system for late-life care is fragmented, and there is insufficient collaboration among providers within most communities. Thus, conditions are uninviting for the "spread of the science" (palliative medicine and nursing).

 The Center to Advance Palliative Care (CAPC) has effectively spread the science throughout the hospital sector, as it relates to hospital-based palliative care services. No small accomplishment, to be sure. But the other major palliative care providers (hospices) have been slow to scale, in part because hospices have taken competitive stances to protect their market share rather than the collaborative approach which studies have shown to be more conducive to the dissemination of best practices.  Communities known as providing high-value late-life care are characterized by several attributes - one of the most defining is a coalition (some might say network) of palliative care stakeholders (organizations and individuals) which come together to deliver care across settings and boundaries. The beginning of an Accountable Palliative Care Organization (APCO), some speculate.

The structure of the social system can facilitate or impede the diffusion of health care innovation, concluded Thoms Bodenheimmer, MD, in a September 2007 report for the California Health Care Foundation on how innovations in health care become the norm. Do the current social systems in our communities best position HPM leaders to 'spread the science"? As always, your comments are invited.

Thursday, April 2, 2015

Salary Compression Stalls Growth of Hospice and Palliative Medicine Specialty

Hospices and hospital-sponsored palliative care programs are experiencing increased demand for physician services in clinical and quasi-administrative capacities (read here for an analysis by the Center to Advance Palliative Care on the growth of palliative care programs). As these organizations build their medical staffs by employing additional HPM physicians, they're finding that creating and filling "leadership" opportunities are proving to be a formidable challenge. Why?

The features of a compensation program  that enable staff growth become liabilities when the principal objective of medical staff development turns to leadership building. Some compensation experts label it salary compression. Others refer to it as salary stagnation. Either way, it is the result of forces currently converging in the palliative medicine sector.

When there is a shortage of credentialed professionals, the imbalance between qualified people available to fill positions and the demand for physicians forces hospices, hospitals,  and other program sponsors to offer higher salaries to attract the limited number of qualified applicants. And when insufficient revenue sources limit funding for medical staff development, those limited funds are typically used to attract new staff members. While such a priority enables staff growth, compression at the "senior" medical director levels typically results. Salary differentials between the ranks have an increased potential for erosion. And so leadership opportunities look unattractive, and prospects (both inside and outside the organization) shun opportunities that in all other respects represent a professional advancement opportunity.

Some hospices, and a few hospital-based palliative programs, have implemented structural modifications to their HPM physician compensation program, with varying degrees of success. But success, nonetheless. It all begins with a reevaluation of the "value" placed upon HPM physician activities and responsibilities.

Wednesday, April 1, 2015

Use of Hospice Benefit has Slowed – What This Means for Palliative Care

A recent analysis of Medicare claims by Healthcare Market Resources found that enrollment onto the hospice benefit has plateaued (see blog post Hospice Utilization: Is Hospice Stuck in a Rut?). When one considers that the hospice benefit has been the principal source of reimbursement for palliative care, and that Medicare-certified hospices have been the principal delivery model for palliative care, these findings should raise concern among advocates of palliative care and those dedicated to improving its access.

What does the evidence suggest? States that historically have had among the highest utilization rates (such as Florida and Arizona) are now experiencing declines in utilization rates, suggesting that the utilization rate of those states may have reached the natural peak of hospice enrollment. Of course, low-utilization states have growth opportunities, as  states in the top quartile of hospice utilization rates use the hospice benefit 75% more often as states in the bottom quartile: 3.23% (on average) versus 1.85% (on average).  The key question to be asked: is growth in hospice benefit use in those lower quartile states sufficient to drive the spread of, and improve access to,  palliative care? I think not.

To be sure, efforts by organizations like Center to Advance Palliative Care (CAPC) have yielded impressive results, especially among hospitals and more recently through outpatient practices, in disseminating the science (and art) of palliative medicine. Yet, when the primary vehicle for reimbursing and delivering palliative care stalls, it may be time to look at newer vehicle models. Perhaps the time has arrived for Accountable PalliativeCare Organizations.

As always, your feedback and thoughts are invited. And more will follow on this subject.

Tuesday, March 31, 2015

Medical Staff Development Plan - Why It's Essential to a Hospice's Growth

Resourceful (and strategic) use of physicians in hospices and palliative care programs has proven to accelerate the success of creating Accountable Palliative Care Organizations (APCOs) in some of our nation's communities (we'll explore several of these success stories in future posts). And while building an APCO is a test of endurance, will, and collaboration, the process of developing an APCO is stalled more frequently by the slow, fitful, and fragmented process of acquiring the palliative medicine "intellectual capital" requisite to an APCO. A Medical Staff Development Plan (MSDP) will serve as a management guide for the alignment of the physician staffing plan with the Hospice strategic plan.

The MSDP will allow a hospice to:
  • identify the opportunities and risks of the current medical staff complement relative to the development of a community APCO ;
  • define a reasonable range of investment required to meet recruitment needs; and
  • demonstrate the strategic and proactive thinking of hospice/palliative service senior leadership to the community, its hospitals, and other key stakeholders.

The MSDP comprises five sections:

  1. Community Assessment of palliative care practices - identifies improvement opportunities and provides competitive intelligence about peer and neighboring programs,
  2. Three-Year Staffing Plan - translates community needs into physician staffing requirements and associated financial commitments, 
  3. Responsibility Chart and Professional Performance Profile–these tools enable leadership to systematically identify decisions and activities that must be accomplished and to pinpoint the functions (positions) that will take on roles relevant to those results, 
  4. Compensation Plan –recommends physician compensation models to produce desired physician behavior and translates administrative, supervisory and teaching (AS&T) activities for physicians into fair and reasonable compensation ranges, 
  5. Recruitment Plan - the articulation of "community hospice and palliative care" practice opportunities that attract talent and fill competency gaps.

Securing executive/Board support for building a HPM staff is easier when it's the result of a well-thought out, comprehensive and strategic plan that pegs recruitment to milestones.

Building Blocks of a High-Performing Hospice Medical Staff

I'm asked from time to time what makes for a better- performing hospice medical staff. I'm unsure that there is a straightforward answer. The strategy of hospices building medical staffs is a recent and uncommon practice. Uncommon because the median daily census (in 2010) of U.S. hospices was just over 50, and more than three-quarters of hospices admitted fewer than 500 patients annually. Hardly sufficient scale to employ a single full-time physician, let alone a medical staff of five or more. By one rule of thumb oft cited for physician staffing levels (1 FTE per 100 ADC), only 18% of the U.S. hospices would consider employing a full-time HPM physician.
Those who have closely followed other health care sectors, such as home health and infusion therapy, are quick to point out that consolidation swept rapidly through these sectors once reimbursement was tightened or reformed, and sub-scale agencies found that size did indeed matter. Will hospices follow a similar pattern? I wouldn't want to wager a hospice's existence against it. So the hospices of the future will likely be larger. And with size comes the need for a medical staff structure that enables access and quality.

The structure may vary from hospice to hospice, but most will arrive at the right structure by careful and thoughtful building of the medical staff. Here follows, from our study, the eight building blocks.

  • Create full-time “blended” practice opportunities that attract and retain HPM physicians
  • Develop bench strength to account for volume fluctuations, departures, back-up coverage
  • Amass “intellectual capital” for an infrastructure that supports an effective and efficient medical staff
  • Deploy hybrid compensation models to align physician and hospice incentives, and reassess at least annually
  • Maintain relentless focus on capturing information on physician activity to provide timely and constructive feedback and aid performance management
  • Clearly articulate expectations among medical staff practitioners, medical leadership, and hospice management
  • Create virtual organizational structure to extend influence of medical staff into greater community to reduce fragmentation of late-life care
  • Foster an unswerving commitment to performance improvement to minimize inappropriate practice variation, reduce regulatory risk, and win the confidence of referring sources.

We'll examine, over the coming months, each of these building blocks with a little more precision. As always, your comments are invited.