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.

Wednesday, March 11, 2015

The Evolving Role of Hospice and Palliative Medicine Leadership

As hospices and palliative care services evolve into accountable palliative care organizations with greater scope and influence over late-life care within their communities, a "new" physician executive role is emerging along the career path for HPM physicians. This role is broader than the traditional senior medical director or chief medical officer positions, and is progressing toward what we refer to as the "chief community palliative care officer".

These physician executive positions have proven to be instrumental in shaping late-life care practices by applying management competencies to:

-build and sustain relationships that evolve into community-wide palliative care networks

-disseminate throughout a community the use of metrics and evidence-based practices to hold practitioners to high standards of performance

-inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics

-envision and stimulate a change process that coalesces the community around new models of late-life care

Daunting challenges, to be sure.  As hospice executives and HPM physicians (and nurse practitioners) come to grips with  rules around eligibility and face-to-face recertification requirements, we would all do well to remain mindful of the strategic leadership objectives that will ultimately determine how successful we are in transforming late-life care in the US. We've seen the importance of HPM leadership in exemplar communities across America (some of which have featured in this blog) -  assembling the right mix of intellectual capital, at the right time (what we refer to as bellwether practices) becomes one of the must-have competencies of late-life care organizations.

Wednesday, February 18, 2015

Accountable Palliative Care Organizations - Best Hope to Improve Late-Life Care?


The days of open access for hospice, regrettably, have yet, with few exceptions, to come to fruition. The hospice industry in the US has been taken over by single-purpose organizations who are adept at "enrollment management" - that is, identifying both low-cost patients who would be financially attractive (and encouraging these patients to enroll on the hospice benefit) AND high-cost patients who would be financial drains (and discouraging those patients from enrolling). And it is difficult to fault these organizations, as their managers are merely responding to the financial incentives built into the hospice benefit by Medicare and other payers.
 

 We are faced with the paradox that introduction of the hospice benefit has improved access to better end-of-life care, yet at the same time has come to define end-of-life care, and by extension, palliative care. It's similar to how 28 days of inpatient care came to define alcohol and drug rehab treatment merely because that's what the payers would cover.
 

How can we see further improvement in end-of-life care? By reorganizing how end-of life care is provided, so that "accountable palliative care organizations", of which hospices are an integral but not the whole piece, are the center of late-life care within health systems and communities.
 
Some of you have asked about the characteristics of APCOs. First, they are virtual enterprises, that is to say, unincorporated structures, that are 'sponsored" by a community-based health care organization, most often either a hospital (health system) or hospice.
 

Simply, the key elements of an APCO are:

  • A Chief Palliative Care Officer (full-time physician credentialed in hospice and palliative medicine) accountable for palliative care services across all settings,
  • Integrating tools that encourage dissemination of knowledge and promote collaboration across settings and disciplines (for example, APCOs have found Physician Orders for Life-Sustaining Treatment (POLST) www.polst.org to be just such an integrating tool),
  • Multiple sources of revenue (hospice, home health, physician services) that offer opportunities for cross-subsidization of individual patient care and economies of scale on the expense side.

How one constructs an APCO depends on many factors, mostly related to the amount of "palliative intellectual capital" already in place at the sponsoring organization.

Tuesday, February 17, 2015

Hospice and Palliative Care - Are We Giving a Mixed Message?


Is there a difference between Hospice and Palliative Care?
Some say this is merely a matter of semantics, so why bother? I'd like to offer my thoughts, as someone who has been involved with "hospice" since the mid-80s.

The reason why this is an important issue is quite simply because it matters to the public. It matters because use of the terms together suggests to some that they are synonymous, and to others that they are distinct. I submit they are neither the same nor distinct.

In its earlier days, hospice described a concept of care. Over the past quarter-century (once hospice became covered by Medicare as a benefit), it has come to describe (define?) an organized and highly prescribed system through which end-of-life services are provided. The practitioners of these services have taken on, perhaps out of convenience, the name of hospice into their titles.It's analogous to surgeons describing themselves as Operating Room and Surgical Medicine physicians, or ER docs referring to their specialty as Hospital and Emergency Medicine. I'm sure you could think of other analogies.

Those receiving palliative care do so in many settings (home, hospital, SNF, outpatient office, assisted living, hospice inpatient unit) while utilizing various health benefits/coverages (of course the hospice benefit but also home health benefit, physician services, i.e Medicare part B )to pay for these palliative services. In other words, palliative care is provided by a host of professionals to patients during "late-life". Some, but certainly not all of these patients use the hospice benefit (provided by Medicare and most private health insurance plans) to cover the cost of palliative care.

A recent study commissioned by the Center to Advance Palliative Care found that much of the public did not understand or was not familiar with the term palliative care. But it's not only the public who is confused. The specialty's own practitioners are confused, and are unintentionally adding to the general misunderstanding. On the website of a prominent Midwest medical center, a reader comes across this comment,“Palliative care and hospice are different,” explained the medical director of the palliative care service.  “Hospice is restricted to people who have a prognosis of less than six months to live. However, palliative care does not have that restriction because it does more than just help people at the end of their life.” What does a patient, or family member do with such information? For that matter, what does a prospective referring source (a discharge planner, or family physician) do with that information?

The question we in the field should be asking is how we can best increase access to palliative care. If some of that palliative care is provided by a licensed hospice, reimbursed by the hospice benefit, fine. If some of the care is provided by a hospital, or a SNF, reimbursed by the physician services benefit, all to the good. If some of the palliative care is provided by a home health agency, reimbursed under a home health benefit, all the better. What matters is that a patient (and family) receive timely access to palliative care and its practitioners.

More on this subject in future posts. in the meantime, I invite your feedback.

Monday, January 12, 2015

Valuable Experiences of a Hospice and Palliative Medicine (HPM) Fellowship


When asked by HPM fellows what experiences one should seek to strengthen skill set, I'll recommend the following (a currently practicing HPM physician would also do well to gain these experiences):

-Actively participating in any end-of-life care coalitions in the community, and if one doesn't exist, assemble several HPM practitioners in the community to start a coalition. Coalitions working to change the model of  late-life care in the community are a common element in those regions known for their exemplar practices in late-life care.

-Engaging in initiatives aimed at reducing late-life care clinical variation within the community. These often take the form of  interdisciplinary work groups standardizing protocols or tools, either within a palliative care organization or the community at-large.

- Joining with other clinicians in institutional or community-wide intiatives to ensure safe transitions across settings and reduce hospital readmissions. There is a strong palliative care component in prevailing readmission  reduction programs, among those the commonly used Interact (Interventions to Reduce Acute CareTransfers) tool.


The skills and competencies gained from these experiences will hold an HPM physician in good stead in securing the most attractive professional opportunities emerging in the HPM sector (see this previous post  for more on the emerging role of HPM physicians).

I'm curious to hear from current and recent fellows about what experiences you've found most valuable.