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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, should palliative care be 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... Continue reading
Posted Oct 21, 2010 at Tim Cousounis
Unarguably, HPM practices are not, and will not be, sought after because of their revenue-generating capacities, either from direct patient care services (home visits, hospital consults, inpatient hospice management) or ordering tests, performing procedures, or utilizing a hospital's facilities. To be sure, hospital palliative consults have proven to be effective cost avoidance services for hospitals. This effectiveness, however, is subject to the law of diminishing returns, in that the "savings" are front-loaded in the first few years following introduction of the palliative care service. Once the "new" standard of care is firmly in place, savings become more difficult to squeeze out of the palliative care service. Some counter that eliminating the palliative care service would return costs to the hospital. While that may be the case to some extent, I don't know of many health care CEOs and CFOs who would "recount" savings that had already been accounted for. The Dartmouth Medical Atlas has shown that there is enormous variation in late-life care, among and within communities. In fact, it is not unusual to find wide variation in practice from one IDT to another within a hospice provider. Reducing clinical variation, simply put, is not a quality improvement priority for... Continue reading
Posted Oct 14, 2010 at Tim Cousounis
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Mar 15, 2010
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 2007) 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... Continue reading
Posted Feb 27, 2010 at Tim Cousounis
The practice of palliative care, by physicians and advanced practice nurses, has gradually moved into the mainstream of American health care. While there is little debate over the need to improve late-life care, especially within acute and long-term care institutions, there continues considerable discussion over how to best improve it. Unlike most other medical specialties, palliative care is not reliant upon the effective formation of physical capital (diagnostic and therapeutic equipment using advanced technology) for its practice. To the contrary, it is totally reliant upon the effective formation of intellectual capital. Its effective formation is integral to the success of palliative medicine practices. You’re thinking that palliative care is the lengthened shadow of a practitioner’s knowledge of clinical best practices. And, you’d be on the right track, for the provision of palliative care is based upon one component of intellectual capital, the know-how, skills, and competencies of the practitioners. Whether a practice or program has sufficient number of practitioners to render this knowledge-based care, first-hand, throughout the community, is a critical decision whose studied deliberation can tip the scales in a program’s outcome. Two other components make up a program’s intellectual capital: Structural capital (or infrastructure) : those workflow processes... Continue reading
Posted Dec 11, 2009 at Tim Cousounis
George Bonanno's new book, The Other Side of Sadness: What the New Science of Bereavement Tells Us About Life After Loss, is being heralded as the definitive scientific statement on bereavement-related research. Unfortunately, the book fails to live up to this advance praise, especially in its treatment of grief counseling. Bonanno's view is that grief counseling "has…proved to be not only notoriously ineffective but sometimes even harmful" (p. 105). Later in the same paragraph he again raises the specter of harmful effects, this time citing a 2007 article by Lilienfeld in Perspectives on Psychological Science. But what evidence from the... Continue reading
Posted Dec 5, 2009 at Dale G. Larson, Ph.D.
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Dec 3, 2009
Christian: I agree with you that those additional descriptors would be valuable. In this post I was putting emphasis on data that can be published immediately with no incremental effort to the input data stream. Anything that is already in the reporting can be made public in version 1.0. Additional data feeds would require changes to the reporting mechanisms, and so may get pushback due to increased labor effort by the reporting bodies.
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President Obama held a town hall recently in Grand Junction, Colorado. To healthcare reformers, Grand Junction, CO., is one of the areas of innovation -- a place that provides high-quality healthcare at a fraction of the costs in most other communities. And, according to some experts, Grand Junction chalks up some impressive statistics. Only 12% of Medicare patients required readmission 30 days after a hospital visit, as opposed to the nationwide rate of 20%. Children on Medicaid in the HMO are four times as likely as other Colorado Medicaid children to receive all immunization treatment -- and adults on Medicaid were up to 10 times as likely to get comprehensive diabetes care. How does Grand Junction stack up for its palliative care practices? The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of lowest percentages of deaths occurring in a hospital (20.7%). And hospice enrollment nearly 30% greater than the national average. Is it mere coincidence? Continue reading
Posted Nov 5, 2009 at Tim Cousounis
I'm often asked (usually by hospice executives) how the performance of palliative medicine physicians can be best evaluated. What they're really asking is: how do I know if the hospice's investment in its medical staff is paying off? While there is no single, or simple, answer, there are 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 have been in part-time positions as hospice medical directors in the traditional sense), and so a strong need for an ongoing performance evaluation program has not been perceived. But as palliative care organizations move toward a model that relies more on an expanded (and some would say progressive) 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 that organizations are looking at data on performance for all practitioners with privileges on an ongoing basis rather than at the two year reappointment process, to allow them to take steps to improve performance on a more timely basis. While this standard applies... Continue reading
Posted Oct 9, 2009 at Tim Cousounis