Future Growth Prospects for HPM Physicians - Where Will They Be?

When I describe to health care colleagues outside the hospice and palliative care field the nature of my work (developing medical staffs of palliative medicine physicians) the usual response is something along the lines of : That must be a high-growth field". At first, it was easy to agree. I'm unsure now.


Why?


One, industry data suggests that hospice utilization may be approaching its zenith. In the ten states with highest hospice penetration (% of deaths served by hospice), utilization has dropped in recent years in seven of the ten.


Two, while the number of people availing themselves of the hospice benefit has grown annually by 2.3% from 2001-2008, the number of hospices has grown nearly 5% annually, or a rate more than twice that of the growth of patients using the hospice benefit (2010 MedPac Report). If one believes that small equals proficiency, then surely this is the golden era of hospice care. 50 % of hospices ADMIT fewer than two patients per week.


Three, hospital-based palliative care programs, another significant employer of HPM physicians,
may be experiencing growth in terms of new programs, but hospital-based programs are finding "same-store" growth slowing.


There's no disputing that hospices of today's median size are not as likely as hospices with an average daily census of 100 or more to deploy the services and expertise of a full-time HPM physician. Industry observers have been asserting for the past decade (and perhaps longer) that hospices will be consolidating. Meanwhile, there are few signs that such consolidation is indeed occurring. In fact, the biggest transaction in 2010 has been the acquisition of a national for-profit hospice chain by a HOME HEALTH giant. Who's to say if such a transaction will lead to hospices combining their operations with like-minded organizations, thus spurring the oft-cited predictions of consolidation.


Are home health-hospice combinations a positive development? Certainly could be, depending upon where one sits. And how will HPM physicians fare under such combinations? I'm curious to learn your thoughts.

Leadership Competencies in Exemplar Late-life Communities

What competencies are common among the leaders in exemplar palliative care communities, I'm asked from time to time. At the risk of oversimplifying, I'll suggest three

These community leaders, whether professional managers, physicians, or nurses, are particularly skilled at envisioning, energizing, and stimulating a change process that coalesces communities, patients, and professionals around new models of late-life care. These leaders have an uncanny ability to align their own priorities with those of the organization and the needs and values of the community. Call this a transformation competency.

These leaders display the ability to use metrics and evidence-based techniques to hold stakeholders to high standards of performance, using force of personality rather than the power of one's position. These leaders also understand the formal and informal decision-making structures around late-life care. In other words, they are adept at execution, translating vision and strategy into optimal organizational AND community performance.

And, these leaders are competent at building and sustaining relationships that evolve into networks, and take a personal interest in coaching and mentoring others. Put another way, these leaders possess exceptional people skills.

What competencies have I overlooked? I'd like to hear from this blog's readers.

Palliative Care Grand Rounds- June 2010

Have a look here for this month's round-up of the highlights from the palliative care blogosphere, hosted by Julie Rosen at the blog Bedside Manners.

Exemplar Late-Life Communities Five Years Later - The Role of the HPM Physician

In previous posts, we've featured interviews with physicians currently practicing Hospice and Palliative Medicine (HPM) in exemplar late-life communities, as identified by DAI Palliative Care Group in its study of end-of-life care data from the Dartmouth Medical Atlas. We're also followers of the Institute for Healthcare Improvement (IHI), and have followed closely IHI's identification of regions where high-value (low cost, high-quality) medical care is provided. One of our present studies is taking a closer look at the role of the HPM physician today in those communities identified both as exemplar late-life regions AND high-value medical care regions.

For more background on this issue, have a look at earlier posts for the regions of Grand Rapids,
Asheville, and Grand Junction. And for a look at exemplar late-life care hospitals, read here. More will follow in future posts. And, of course, your comments are invited.

What's the Right Amount of Practice Subsidy?

Why does a particular Hospice and Palliative Medicine (HPM) practice require more support than another? This is one of the most common questions I am asked. While there is no data to indicate what a "typical" subsidy may be, it is helpful to understand why the amounts vary so widely from one practice to another.

First, there isn't a uniform definition of subsidy. Some refer to subsidy as the difference between a practitioner's guaranteed salary (some will include benefits as well in this figure) and the amount of professional fee revenue generated. Others will carve out non-clinical time (such as administrative activities) from the subsidy calculation, and will treat that portion of practitioner compensation as an administrative expense. It's not unusual to see this difference in definition amount to $50,000 annually per practitioner.

Some other common reasons for the wide variance in subsidies:

Documentation, Coding, Billing, and Collecting

This is an area in which many, if not most, practices have room for improvement. One simple way to estimate how your practice is doing in these processes is to think about how you're performing on the following tasks:

Do all HPM practitioners understand the documentation requirements for each CPT code, and is their performance in selecting CPT codes audited regularly (we suggest at least yearly)?
Does the practice have a reliable method of charge capture that minimizes problems like lost charges?
Is there an established "chain of custody" of this information, from the HPM practitioner to the biller?
Is there a periodic review or audit of the biller's performance?
Does the practice monitor metrics, such as days in accounts receivable, collection rate. An audit could be as simple as reviewing ten billed encounters within the past three months for each practitioner, and identifying the status of each bill (e.g., paid, written off, or perhaps the bill has vanished or never made it into the billing system).

Payor Mix
The payor mix for most HPM practices is primarily Medicare, but in those areas with heavier penetration of Medicare Advantage plans, the contracted (negotiated) payment from the Medicare Advantage plan may be significantly different from the standard Medicare reimbursement.

Practitioner Productivity
Some hospices and hospitals have systems of care that interfere with HPM practitioner productivity. These could be such things as a poorly organized medical record, an IT system that requires logging into multiple programs to retrieve data on a single patient, or practitioners being expected to do clerical work. Every practice should think carefully about the systems and activities that might be getting in the way of efficiency.


The "right" amount of subsidy is a judgment call, and so will vary from practice to practice. A solid understanding of the factors behind the wide variances in subsidies, and an evaluation of those factors specific to your practice, will be valuable in determining your "right" amount.

Palliative Care Grand Rounds - May 2010

Have a look here for the May issue of Palliative Care Grand Rounds, hosted this month by Thaddeus Pope at his blog Medical Futility.