Jan was a delightful old man from Russia—and his health was declining due to his heart.
Through data extraction and analysis, his healthcare delivery organization had identified him as a “high risk,” and a “potential high utilizer.”
They put him on the list for their palliative care physician, a semi-retired internist who did house calls.
The physician called Jan, made an appointment and went to his home.
The man and the physician quickly struck up a rapport, sharing their memories and their hopes and dreams for the future.
That’s when the physician told Jan he had no future, he needed to get on hospice so he could enjoy the last months of his life pain-free. The change in tone was abrupt and brutal—and the man was shaken and scared. In the space of a 60-second conversation, he fell from optimism to depression.
It was, he said, the worst moment of his life.
Now, I bow to no one in my advocacy for hospice services.
About how hospice can decrease the ridiculous burden of high-intensity services delivered at the end of life. About how hospice dramatically improves the quality of living for the terminally ill. About how hospice services can make your value-based care systems viable.
But
Trolling for terminally ill patients using questionable data analysis in the hopes of saving a few bucks—that is not what we as clinicians and administrators are supposed to be all about.
Having a previously unknown doc call on a patient out of the blue, pass sentence and then blithely walk away is not recognizable as medical care in any sense of the term. And, as a clinician or administrator, if you find yourself trying to justify such an encounter, I challenge you to share that opinion with a trusted advisor or loved one.
See if it stands up.
You can do better.
To my alarm, the clinicians I speak with describe the above encounters with increasing frequency. “Mr. Smith has a high “cost risk index”, send Dr. Jones from palliative in to see if Mr. Smith understands how sick he is and how close he is to the end.”
Sounds reasonable, unless you’re Mr. Smith.
The result? Frantic phone calls from Mr. Smith’s family to whomever they identify as his doctor.
“Are things really that bad?” “Why didn’t you tell us?” “How much longer does he have?”
If this is your strategy for controlling end of life costs, you’re doing it wrong.
All wrong.
This conversation should have been coming from the man’s personal clinician, and probably would have if that clinician hadn’t been bogged down with excessive patient numbers and onerous data entry tasks. The decision to enroll in hospice is a journey, one that needs to be taken with trust and empathy and kindness.
It’s not a layoff notice, it’s his life.
Hospice services are only identified with decreased costs and increased patient satisfaction if the patient has made the journey himself.
No one can push the pace.
If his personal clinician is not having an end of life conversation, it’s because she has too many patients and her workflow is designed to reinforce corporate rather than patient goals.
The clinician is being supported as a commodity, not a healer.
So Jan, the kind old man from Russia, went into a depression spiral that actually triggered costs he probably would not have otherwise incurred. He eventually wound up on hospice, but after passing his sentence, the palliative care physician never saw him again.
The organization’s reputation for “quality care” was not enhanced.
And Jan’s last few months were miserable.
I could rail against how your patients are human beings, not economic units. And that they are catching on as to who is treating them which way and why. I could point out that pretty soon market dominance and regulatory capture are not going to be enough to survive in the value-based world of healthcare to come.
But instead, I’ll remind us all of our mortality.
And that, at the end, all each of us desires is to approach death surrounded by kindness, gentleness, and peace.
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