Sunday, October 31, 2010

Evaluating Performance of Hospice and Palliative Medicine (HPM) Physicians

I'm often asked (usually by hospice executives) how the performance of palliative medicine physicians can best be evaluated. What they're really asking is: how can they tell  if the hospice's investment in its medical staff is paying off? While there is no single, or simple, answer, there are several proven ways.

 I find that most palliative care programs (including hospices) have only recently added to their medical staff (up to this point the majority of physicians practicing palliative medicine (HPM) have been in conventional, part-time hospice medical director positions), and so a strong need for an ongoing performance evaluation program has not been perceived.

But as palliative care organizations move toward a model  relying  on an expanded  role for physicians, performance management takes on greater importance.

To underscore this point, the Joint Commission recently introduced a standard named Ongoing Professional Practice Evaluation (OPPE). The intent of the standard is to encourage health care organizations to  look at data on performance for all practitioners with privileges on an ongoing basis rather than at the customary two year reappointment process, to allow the practitioners to take steps to improve performance on a more timely basis. While this standard applies specifically to hospitals, hospices and palliative care programs should take note.

In coming posts, I'll offer some ideas for physician performance management which we've seen work well, and may suggest a starting point for those grappling with the issue of evaluating and managing a palliative care  organization's investment in physician resources. And, I'd like to swap ideas with readers.

Saturday, October 23, 2010

Hospice Industry Data from NHPCO - A Look Back Five Years

As Dr. Christian Sinclair pointed out in a recent post on the  blog Pallimed, the 2010 edition of the NHPCO report  Facts and Figures:  Hospice Care in America was short of surprises when compared to data from last year's report.

So I looked back to a 2005 report to better understand how the hospice industry has changed (or not) over the past five years. Among my surprises were these:

-Impressive growth in the percentage of decedents receiving hospice care. Sure, I expected growth, but not at the rate we've seen.

-Short-stay patients (7 days or less) remained level at one-third of total deaths and discharges. Is this an intractable issue, in which case hospices should consider improving their capacity to provide exemplary care for short-stay patients, or does there remain optimism that  knowledge of more timely (earlier) referrals will spread quickly, thus reducing the percentage of short-stay patients.

-The size of hospices remained small - nearly 8 out of 10 have fewer than three admissions per week. Given the speculative talk about consolidation, I  expected that over the past five years there would have been considerably fewer hospices admitting less that 150 patients per year.

Got me to thinking. If I was considering hospice care for a family member, aware that there is a one-in-three chance that the episode of hospice care will be no longer than a week, I'd want to select a hospice that admits ten times the number of patients than the average-sized hospice. I figure that the additional volume would mean greater proficiency in short-stay care.

Does volume matter? No studies to prove either way.
What do your professional instincts tell you?

Thursday, October 14, 2010

Disruptive Innovation in Health Care - Has It Arrived At Last?

The authors of the 2000 Harvard Business Review article Will Disruptive Innovations Cure Health Care? suggested that organizational delivery models were in need of  modernization, or as they put it, "the health care industry is trying to preserve outmoded institutions". New organizations to "do the disrupting" need to be created, the authors went on. 

 What few could have predicted was the timing of the modernization. Organizational structures to deliver health care have largely remained static over the past decade, outside the ascendancy of  stand-alone ambulatory surgery centers. If Accountable Care Organizations (ACOs) do little else, they will be considered as successful because the spectre of their implementation has brought parties together who likely would have otherwise remained apart.

In future posts, we'll take a closer look at the role of one of those parties - palliative
medicine -  in a post-acute network.

Wednesday, October 13, 2010

Closing the Performance Gap in Palliative Care by Reducing Clinical Variation

The Dartmouth Medical Atlas gives us a compelling portrait of the variations in practice in late-life care. It also offers insights into the palliative performance improvement opportunities in communities.

How wide are the variations? Let’s take a look at Charlottesville, Virginia, an area of about 100,000 residents, with an academic medical center and a community hospital, a large not-for –profit hospice, and plenty of smaller hospices. According to the DAI Palliative Performance Profile (drawn from the Dartmouth Medical Atlas), Charlottesville earned a B grade for its late-life care practices. Respectable, for sure, but short of exemplary. What’s the difference between respectable performance and that of the top 10% performers? Consider the following: in Charlottesville, 32% of Medicare decedents died in a hospital. That’s better than the state average, yet 25% higher than residents of a community in the top 10%. In other words, a Charlottesville resident is 25% more likely than a resident of a high-performing community to die in a hospital than at home. That same Charlottesville resident is 40% more likely to have spent 7 days or more in a hospital during the last six months of life than someone in a top-performing community. Considerable room for improvement, I think you'd agree, and yet Charlottesville's performance is better than most communities across the nation.

Tightly integrated delivery systems have proven to be the most effective in reducing clinical variation. Because of their structure, these delivery systems are adept at disseminating evidence-based practices. It is time that hospice and palliative care leaders accelerate collaborative efforts to create networks with greater potential to reduce clinical variation in late-life care. What better opportunity for HPM specialists to take the lead?


Wednesday, October 6, 2010

Is Palliative Care A Disruptive Innovation in Health Care?

It's been a short (or is it long?) ten years since the September-October 2000 issue of Harvard Business Review published the article "Will Disruptive Innovations Cure Health Care?  In that piece, the authors (Clayton Christensen, Richard Bohmer, and John Kenagy) argued that powerful institutions fight simpler alternatives to expensive care because those alternatives threaten their livelihoods. If history is any guide, the authors posited, the health care system can be transformed only by creating new institutions that can capably deliver lower-cost, higher-quality, and more convenient care, rather than attempting a tortuous transformation of existing institutions (read that as acute-care hospitals) that were designed for other purposes. They went on to comment that our major health care institutions have together overshot the level of care actually needed or used by the vast majority of patients. Has much changed  during the intervening decade? And, it set me to wondering, is  palliative care  considered a disruptive innovation?

James Cleary, MD (palliative care chief at the University of Wisconsin Hospital and Clinics), referred to hospital-based palliative care as a disruptive innovation in a 2008 keynote address to an audience of hospice and palliative care professionals. And as one considers that disruptive innovations "sneak in from below",  start by meeting the needs of "less-demanding customers", and enable "less-expensive professionals to do progressively more sophisticated things in less expensive settings", the case sharpens  for palliative care as a disruptive innovation.

So why doesn't palliative care always feel like a disruptive innovation? Surely one reason
is that new organizations to do the disrupting have not sprung forth  the palliative care sector. That is likely to change soon, as  the formation of Accountable Care Organizations (ACOs),  encouraged by the health reform bill,  reconfigure the delivery models of health care over the next decade. And within the ACOs will emerge Advanced Palliative Care Organizations (APCOs), proven to be  successful models for improving delivery of chronic and late-life care because their characteristics encourage processes of care that are:

Timely - delivered to the right patient at the right time (early identification of patients)

Patient-centered - based on the goals and preferences of the patient and family, articulated in goals of care conversations

Beneficial and effective - demonstrably influencing important patient outcomes (place of death, intensive care utilization, transitions between settings and providers)

Accessible - available to all who are in need and who could benefit (multiple entry points into palliative care continuum, and absence of barriers related to reimbursement and prognosis).

I invite our readers to weigh in.  Is palliative care a disruptive innovation? And if so, what steps will best advance its influence within the larger health care system?