Showing posts with label lupu. Show all posts
Showing posts with label lupu. Show all posts
Friday, October 31, 2014
How many times has a friend, a relative or a colleague asked me to recommend a good hospice in Reno or Redding or Rockford and I was flummoxed. Even if I knew the medical director or the executive director from work on national committees and thought he or she was a great, what did I really know about the quality of service provided by their hospice? I often wished I could have access to the kind of data I typically review when consulting with a hospice - their length of stay, proportion of patients living in a nursing home, proportion of patients discharged alive, readiness to provide continuous care, robustness of the on-call service, etc.
Now, at least some of that information is available on-line through a website developed by the Washington Post. The key information in the new Consumer Guide to Hospice is taken from Medicare cost reports and "other sources." One can see the size of the hospice, age, ownership type, amount of continuous care or general inpatient care provided, and spending per day on therapy, doctors, and nursing. The database also reports a hospice's "profit" per day, a label I find highly misleading (more on that below).
Is this information helpful?
In a limited way, yes. I would advise people to look first at accreditation status. Only 40% of hospices are accredited, and I would always lean towards an accredited program when available. Although accreditation tends to focus more on structure and processes than on outcomes, a program that has been accredited has had objective outside reviewers who have given it a stamp of approval. That speaks to a program's willingness to open itself to review and, hopefully, improvement.
Next, focus on size and age of the hospice. As in almost every other part of medicine, practice is linked to higher quality. Experience - gained over time and gained over a number of cases, usually helps build both individual clinician expertise and organizational/team expertise. Very new and very small hospices are unlikely to have the breadth of experience and the depth of resources to assist with challenging or unusual circumstances. Unless I had a specific reason to know that a very small or very new hospice had a service or skill that was needed (such as a new pediatric service or a new hospice residence), I would stick with hospices with experience of at least 5 years (10 years is even better) and volume of at least 80 patients per day. Not always possible in a rural area - but rural areas may not offer a choice in any case.
Third, I'd look at the "live discharge" rate. The Post justifies this number saying that large number of people leaving a hospice may indicate they are unhappy with the care and services. Maybe. More likely it represents a hospice had a very (maybe overly) open admission policy, taking people too early and too "healthy" and then discharging them. I would actually select hospices that had live discharge rates in the 10% to 20% range. Too few live discharges likely means the hospice is too tight and guarded in who they accept, and not willing to bend flexibly to each patient and family's needs. But too high a discharge rate - let's say over about one third - makes me uncomfortable too. Stay in the middle on this indicator.
Fourth - I would advise NOT looking at the $ per day. The data likely comes from the Medicare Hospice Cost Reports, which have all kinds of issues in how data is reported, especially when hospices run their own inpatient units. The so called "profit" is especially misleading. I can't tell exactly how the Washington Post calculated the number - but if, as I guess, it is everything left over after "allowable" Medicare costs, it is in no way all "profit" for a hospice. Recall, hospices are required to provide bereavement services without Medicare reimbursement. Many hospices plow money left over after nursing and doctor and therapy costs into community bereavement services, extensive community education, bridge programs, or other community services. The "profit" number doesn't give any indication whether these dollars are truly "profit" being returned to shareholders, reserves begin saved for a rainy day, or carefully husbanded resources that fund additional community services. As interesting as it is, I'd ignore that information when choosing a hospice.
The Consumer Guide allows you to filter by ownership status at the very start of a query, which seems to imply that ownership status ought to be part of one's consideration. But I don't find ownership status to be a very useful indicator. It's true that a lot of Medpac's recent policy analysis has focused on differences between not-for-profit and for-profit providers, and that some concerning trends are associated with for-profit providers. But in my experience there are both good and not-so-good providers in both groups, and ownership status is not nearly as helpful in distinguishing between them as the other factors mentioned above.
Finally - I would advise supplementing the information in the Consumer Guide with careful telephone screening of any hospice being considered. I like the list of 16 questions to ask on the website of the American Hospice Foundation (disclosure: I was on the AHF board for many years.)
Many in our community have been upset at the way that the ongoing Washington Post series has emphasized problems in hospice care. I agree that those problems are not the rule - but we also can't ignore them. Giving consumers - and us, the supposed experts - the information to begin to sort out who is operating way outside of the norm - is a helpful step. I applaud the Washington Post for making this information accessible.
PS. Make sure your hospice checks - and corrects, if necessary - the information displayed about it. We have already heard from some organizations who noticed errant information for their site.
Friday, October 31, 2014
Saturday, November 20, 2010
For those of you wondering what to do with all of your free time now that the boards are over, I highly recommend immersing yourself for an hour or two in the maps, graphs, and tables of the Dartmouth Atlas’ first comprehensive report on end of life care for patients with advanced cancer. The premise of the Dartmouth Atlas is that the large local variations in health care services which Dartmouth has documented, are caused by supply (more surgeons=more surgeries; more hospital beds=more hospital days) and by local patterns and customs of care, NOT by evidence-based care delivered to achieve better outcomes. The Dartmouth Institute researchers assert that
“Our findings point to important opportunities to improve not only the quality of care (by ensuring that effective care is reliably delivered) but also to reduce the costs of care (by reducing avoidable hospitalizations and unnecessary specialist visits).”[1]
Saturday, November 20, 2010
Sunday, September 26, 2010
 |
| A Perfect Morning at Glacier National Park Photo by Flickr user: Trey Ratcliff |
This inaugural post in a new Pallimed series on health policy for palliative care groupies has taken longer to write than I expected. Why? I expected to start in the clichéd manner: by defining the term “health policy.” But I was stopped short when I could not find a definition for health policy. The websites, textbooks and articles that I consulted all take for granted that we know health policy when we see it. Many sources discuss topics covered under health policy (such as access, quality, financing, delivery systems, workforce), but none that I could find offered what I considered a useful, concise definition that set clear boundaries for the field.
Since it is impossible to prove the negative, and feeling very uncertain about the thoroughness of my research (maybe I had just missed some great definition out there that EVERYBODY but me knows about), I consulted with Dr. Gerard Anderson, my professor from doctoral student days in health policy and management at Johns Hopkins School of Public Health. Gerry confirmed in an email, “there is no uniformly agreed upon definition.” There you have it. So I am left to my own devices in trying to paint for you readers the major concerns, techniques, and boundaries of the field of health policy.
So what is health policy? For me, a key defining aspect of health policy is that it takes a 30,000 foot view of the health of a population and of the systemic factors (political systems, health financing, cultural norms) that contribute or detract from a population’s health. Contrast this to the clinical view, which put the needs and concerns of a particular individual (and possibly that individual’s family) first and foremost.
 |
| Rosa Passione Photo by Flick user Bruno C |
A second defining aspect of health policy is the “policy” part – the general rules (often expressed in laws and regulations at the governmental level) that are used to guide organizational and system behavior, particularly allocation of resources. Although we may be able to read the words of the laws and regulations, it can often be difficult to understand the policy goal and the policy assumptions that motivated them. In the words of Eugene Bardach (more on his policy analysis guide in the next post):
In real life, policy problems appear as a confusing welter of details: personalities, interest groups, rhetorical demands, budget figures, legal rules and interpretations, bureaucratic routines, citizen attitudes, and so on. ..You therefore need to learn to “see” the analytic concepts in the concrete manifestations of everyday life.[1]
To get a feel for the types of questions and the approaches to analysis that are typical of the health policy world, I suggest you explore these notable sites that track and digest health policy issues:
§ The Henry J. Kaiser Family Foundation (not associated with Kaiser Foundation of managed health care fame) is widely respected for its analysis and reporting on health policy issues. In particular, they are a source for cogent and succinct summaries explaining Medicare issues. Although they have a big focus on chronic care and on disparities between different subpopulations, Kaiser has yet to do much work on palliative care or hospice issues.
§ The Englelberg Center For Health Care Reform at the Brookings Institute does its own research as well as presenting analysis of others’ research.
§ While there are several journals that cover health policy in the US and internationally, Health Affairs is the preeminent source. They have covered palliative care and hospice sporadically in the past, but seem to be paying closer attention recently. The January 2010 issue carried several coordinated articles addressing policy issues about delivery, quality and financing of palliative care in the nursing home setting.
§ Finally, a personal favorite of mine is a website that serves as a portal to a host of information sources, US Health Policy Gateway. This is a good starting point when you are looking for information. It’s thin on the palliative care info, and hit or miss in some other areas, but its simple, straight-forward presentation makes it an excellent starting point.
My goal in this column and those to come is to give my palliative care clinical colleagues an introduction to health policy as it impacts palliative and hospice care. In the coming months I will cover analysis methods, data sources, issues, governmental and non-governmental players, all with a focus on their relevance to palliative and hospice care. I am planning to write about the standard format for a health policy analysis, large scale data sources that are used to understand palliative care, options for financing and promoting palliative care in the long-term care setting, and the mysterious “U-shaped curve” that Medpac proposes for hospice reimbursement reform. If you have other topics you would like me to cover, please leave a suggestion!
[1] A practical guide for policy analysis : the eightfold path to more effective problem solving. 3rd edition. Eugene Bardach. Washington, D.C. : CQ Press, c2009.
Sunday, September 26, 2010
To make an impact on health policy (and I assume that the reason you are reading this post is that you – eventually- want to influence the policies that affect you and your patients), one must deal with two different but related spheres that I will call the art and the science of policy-making. The art aspect is the political and organizational process for making, changing and implementing policy. It’s a messy process where emotions and alliances usually have more influence than information. The science portion is the rational, analytic approach practiced by the armies of policy analysts that populate think tanks and government policy offices. The science of health policy analysis – with its tools like adjusted quality of life scores and mortality risk adjustment – attempts to professionalize the otherwise very messy political process.
Of course, the two categories are not mutually exclusive. There is art to the science of policy analysis: how to organize information and arguments, what options to analyze. And there is science to the art: the entire field of “Political Science.” My own practice of the art has been instinctual and uninformed by formal study of political science. Therefore, I’m going to leave an explanation of the political process to others. In this post, I’m going to try to give you a feel for the science side: rational policy analysis methods.
One guide to policy analysis that I like very much is A Practical Guide for Policy Analysis: The Eightfold Path to More Effective Problem Solving by Eugene Bardach.[1] (Nowhere in the book did I see an explanation of the title’s allusion to Buddhism’s eightfold path, but I would be surprised if it were merely a coincidental reference.) Although this guide is not specific to health policy, its common sense approach and readable style makes it a quick and useful read.
Bardach’s 8 step method is:
§ Define the problem
§ Assemble some evidence
§ Construct the alternatives
§ Select the criteria
§ Project the outcomes
§ Confront the trade-offs
§ Decide!
§ Tell your story
These steps are common sense, but Bardach’s explanations of how to work with them is sophisticated, practical, and at least for me as a policy wonk, fun to read. He gives an array of pointers about how to conduct each of these steps in the most artful way. For instance, regarding defining the problem, he warns about the common mistake of defining a solution right into the problem statement:
Don’t say: “New schools are being built too slowly.” Simply assuming that “more schools” is the solution may inhibit you from thinking about ways to use existing facilities more efficiently. Try instead: “There are too many schoolchildren relative to the currently available classroom space.”
Some people despair that the rational, analytic, and evidence-based realm doesn’t exert much influence on the political process. In our own field, the classic example is the Medicare Hospice Benefit. Congress passed the enabling legislation in 1982 without bothering to wait for the results of the hospice demonstration project, which had been expressly designed to determine whether a hospice benefit was useful and how best to shape it. After the law was passed, Vince Mor and the other social scientists working on the evaluation of the hospice demonstration were able to feed preliminary information from the demonstration to the regulators as they shaped the details of the Medicare hospice regulations. [2] Should congress have waited? Would we have the hospice benefit (with its strengths and its flaws) that we have today if they had?
I am a realist about this. The political aspect of policy-making proceeds at its own pace, usually without slowing to wait for the results from years-long and careful demonstrations. (Does anyone REALLY know at this point whether medical homes or accountable care organizations work? They are in the health reform legislation anyway.)
I am a realist about this. The political aspect of policy-making proceeds at its own pace, usually without slowing to wait for the results from years-long and careful demonstrations. (Does anyone REALLY know at this point whether medical homes or accountable care organizations work? They are in the health reform legislation anyway.)
Even though rational analysis does not usually have the upper hand in how health policy is determined, I think it nevertheless plays an essential role. It is like the rudder of a sailboat. In calm seas with favorable winds, the rudder sets the course. However, in stormy seas, strong winds and waves may work against the course set by the rudder. Even so, it is far better to have the rudder’s steadying effect than to sail without it.
I conclude with Dr. Bardach’s sage words about the relevant contribution to be made through rational, insightful policy analysis:
Finally, just as policy analysis originates in politics, so it concludes in politics. Political life has two sides: channeling conflict and building community. Policy analysis serves both sides. It channels conflict by showing that some arguments, and their proponents, are in some sense superior to others and deserve to win out. But it helps to build community by marking off potential common ground as well. This common ground Is defined by the rules and conventions of rational discourse- - where opponents may employ analytical procedures to resolve disagreements, or where they may discover that at least some seemingly irreducible values conflicts can be recast as dry-as-dust technical disagreements over how much higher a probability Policy A has than Policy B for mitigating Problem P.
[1]Eugene Bardach. A practical guide for policy analysis: the eightfold path to more effective problem solving. 3rd ed. Washington, D.C. : CQ Press, 2009.
[2] A Short History of the Medicare Hospice Cap on Total Expenditures
Subscribe to:
Posts (Atom)
