Tracking HPM Physician Performance - Physician Value Index

At a recent regional symposium  for  hospice executives and chief medical officers, following a presentation on the building blocks of a high-performing medical staff,  I was asked  how I would assess if the performance of a hospice medical staff is "high-performing". Of course, there is no single answer, but we (DAI Palliative Care Group)  have developed a tool that has successfully been used to benchmark performance.

Many factors weigh in upon the performance of HPM physicians within a hospice setting. Some factors can be quantified, many cannot not. So, based upon years-long study of hospice physician practices, our research group developed  a metric we refer to as the HPM Physician Value Index , or HPM-PVI. As with other indices, such as an economic index used to track changes in the economy, the HPM-PVI is a single number calculated from an array of figures. In other words, it is a statistical composite that measures changes from one period to another, and can be used to help answer a question often posed by hospice executives - "how can I  determine if I'm getting a reasonable return for the investment (physician compensation) in the medical staff"?

The HPM-PVI has served as a useful metric because it assigns a value to one of a hospice physician's principal activities - oversight of an interdisciplinary team. I invite your feedback and participation in our ongoing efforts to spread the use of this HPM physician value index.

Hospice and 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. A recent post described the current structure of the hospice industry. 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.

Improving Late-Life Care - Do We Know Exemplary Performance?

We're starting to learn more about late-life care, thanks in large measure to the Dartmouth Atlas Project.


For example, in a recent report  Trends and Variation in End-of-Life Care for Medicare Beneficiaries
with Severe Chronic Illness (read here),  we learned more about the final 30 days of life of a patient with cancer. More than half (54.7%) were hospitalized during that period. 5.6% received life-sustaining procedures. Half of the final month was spent in hospice (11 days) and an acute-care hospital bed (4 days). Interesting, but without context. Likely, the past 10 years has seen considerable improvement in these measures. How much more improvement should we expect? Can hospitalizations be cut in half? If so, what might be the most effective methods? A transitional care document , like POLST? A provider reimbursement structure where collaboration, rather than procedures, is more highly valued? A community palliative care officer who's accountable  for late-life care across settings within a specific community or region? Any of these, or all of them?

And how much better can the health care system do to encourage earlier referral to palliative services, so that greater than 11 days out of the final 30 can be spent under hospice care?  As always, your ideas and opinions are invited.

What Do Hospice and Palliative Medicine (HPM) Physicians Look For in a New Opportunity

I'm often asked what has made us (DAI Palliative Care Group) successful  in recruiting palliative medicine physicians. There are, of course, a number of reasons. Experience is one. Our experience "informs" our recruitng efforts. We've made a study out of understanding what physicians look for. We've come to appreciate "What's Important in a Practice Opportunity to Palliative Medicine Physicians".

 

We 've learned from our experiences in HPM physician recruiting that most prospects evaluate practice opportunities through four filters. Let's refer to these filters as:

 

• Rewards (monetary) 
• Community/environment (supportive culture of teamwork and recognition of contribution by HPM physicians) 
• Workload schedule (manageable workload and sustainable schedule) 
• Autonomy/control (ability to impact key factors that affect job performance).

Of course, each physician will place his or her own value upon each of these criteria in career decision-making.  The key to recruiting physicians (particularly in a market  where demand far exceeds supply) is to create a practice opportunity that recognizes and addresses all four filters in a balanced way.

Future posts will offer more detail into each of these filters and recommendations on how to create the "balanced" HPM practice opportunity.

 

 

 

Recruiting in Markets Where Demand Exceeds Supply

From time to time, clients inquire how they might best recruit a talented palliative care specialist. I've found success by utilizing recruitment approaches that have produced results in other markets where demand for talent exceeds its supply. In such markets, the scales are tipped in favor of the professional, in this case, the palliative medicine specialist.

How to best restore a balance? By understanding how specialists in short supply make career decisions, and then using methods that can best reach those "passive" candidates. The most commonly used method - job board postings - are most effective in reaching "actively-looking" candidates, usually in markets where supply exceeds demand. Such postings will typically not work in reaching "passive" candidates, since these individuals know well that, because of their relative scarcity, securing a new position is relatively easy.

Candidates in short supply need to be "approached and asked" and then "sparked and nurtured". This process is very demanding of time on the part of the hiring company /manager, and so frequently the "inside" recruitment team will be strengthened on an adhoc basis by bringing on a recruitment specialist with insider knowledge of the particular market.

When to Add a Hospice and Palliative Medicine (HPM) Physician to your Practice

Most hospice and palliative medicine (HPM) programs and practices are experiencing growing demand for their physician services. These growing pains, obviously, can put a strain on current staff and the practice's infrastructure. A physician practice that is stretched beyond capacity because of an unfilled position cannot carry the patient and on-call load of a larger group for an extended period of time. The overtaxed and overwhelmed physicians are prime candidates to leave the practice, seeking opportunities where they can find better control over their workload. In other words, unfilled positions beget unfilled positions. That is why turnover is often referred to as the "silent killer" of a practice.


One of the most challenging tasks for a HPM medical director or practice manager is determining how many physicians are needed to staff the program. Since most HPM practices do not generate revenue greater than their compensation, knowing when to add a full-time physician is not an easy decision to make. But it is important to consider the costs and lost revenue associated with an unfilled position as well as the salary it takes to fill it. Take a hospital inpatient palliative care consult service, for example. A 2008 study by the National Palliative Care Research Center found that savings from palliative care consults for hospital inpatients ranged from $1,500 to $5,000 per admission. A palliative medicine physician who performs 40 such consults per month will produce savings of at least $60,000 per month for the hospital. Or take a hospice program with a palliative care consultation service and a physician making home visits to palliative care patients. One-third of those patients can be expected to transition to the hospice benefit, generating, on average, $1,500 in hospice revenue per patient. An HPM physician visiting 30 patients per month on the palliative service will produce $15,000 in patient service revenue for the associated hospice.

While these guidelines are handy in building a case, alone they do not make a clear case for when a physician should be added. Nor will the conceptual approach, projecting the work for a time period (e.g., 5,000 home visits/year) and dividing that projection by the amount of work performed by one FTE HPM physician (e.g., 920 home visits/year). Careful consideration of several other factors will also enhance the decision-making process: use of non-physician providers, such as nurse practitioners; variation in workload (need to staff higher than the average to address spikes in service demand); expectations around nonclinical commitments that may include administration, teaching and research; and the need for off-hours coverage, vacations and the like. The right timing in adding a physician to a HPM practice will likely accelerate success. Mistiming will stymie program (and practice) growth. In future posts we will look more closely into effective ways to attract the right candidates to your practice.