Role of Wrongful-Life Cases In Palliative Care


11SPAN-master768Earlier this week Paula Span wrote in the New York Times about the increasing number of lawsuits being filed on behalf of patients being kept alive. Counterintuitive? Not when you consider they were kept alive only to endure more pain and suffering – against their known wishes.

If you’ve ever read or heard about a court case involving whether, how, why or why not an individual’s advance directive was carried out as intended by the patient, then you are no doubt familiar with the myriad circumstances and events that can lead to great confusion at the time of death. It’s an area of healthcare painted with a thousand shades of grey.

Unfortunately, an advance directive often gets twisted and manipulated nine ways to Sunday in the hands of numerous stakeholders standing bedside, whilst the person in the bed is most often unable to advocate for their own interests. This is when doctors begin envying lawyers because lawyers don’t have to practice medicine.   

I have yet to meet the physician who wants to cause his or her patient harm. They even swear an oath not to. There are other areas of the Hippocratic Oath wherein its fulfillment brings into question – absent an informed directive – to just what lengths are necessary and appropriate to save the life of a dying soul in the knowledge that such actions may cause increased suffering.

Allowing for the presumption of innocence, however, doesn’t change the very real consequences suffered in those cases shared in the article. I suspect attributing the failures to a breakdown in communication is a safe bet in most of those cases since that is a phenomenon, which continues to plague our healthcare delivery system despite the investment of billions into information technology.

Of course, the broader discussion this story touches upon is addressing life and death in the context of quality of life – and who determines the subjective nature of “quality.” To that point, we have much to benefit from the continued awareness and education of the role palliative care can play in treating severe and terminal illnesses.

In this country we are culturally adamant about resisting and ignoring the realities of death. One needs look no further than the hysterical idiocy that surrounded death panels. Perhaps these cases will help advance the broader conversation we need to have on how we can best protect individual patient rights while providing them the best possible life while still on earth.

  ~ Sparky

Accelerate! ~ Or Be Eaten

Originally published in November 2012.

Sparky's Policy Pub

John Kotter makes his latest contribution to an already authoritative body of work on organizational change management in the article,

that form the backbone of a strategy network, which he suggests should work in parallel with an organization’s existing operations. The accelerators differ from the eight steps in their being nonlinear, more organizationally encompassing and ideally facilitated independent of the traditional organizational hierarchy.

), while the other is a network framework that is able to leverage the organization’s group genius in ways that facilitate rapid strategy deployment.

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What’s Your Performance Improvement Strategy?

If you are a post-acute/long-term care provider still sitting on the sidelines waiting for a clearer understanding of how Healthcare Reform is going to impact your organization’s future, well then all I can say is, “Good luck with that – let me know how it works out for you.”

In an article published this past weekend (Medicare Seeks to Curb Spending On Post-Hospital Care), Kaiser Health News’s Jordan Rau reported on the wide variability in Medicare spending on post-hospital care across the county – and the attention that it is getting from CMS. Attention that is quickly turning to targeting: as in even more deeper cuts in reimbursement.
Several of the examples included:

Medicare recipients in Connecticut are more than two-times more likely to be admitted to a nursing home than residents in Arizona.

Medicare spends an average of $8,800 on a patient’s home healthcare in Louisiana – while spending $3,800 in New Jersey.

The rate at which beneficiaries receive post-acute services covered by Medicare in Chicago is three times the rate in Phoenix.

And the aggregate economic impact of variability in per capita spending is substantial. As the growth in post-65 age cohorts continues to accelerate both the inherent cost contribution (demand) as well as cost-push inflation (a result of seeking to satisfy that demand with scarce resources) is increasing. As reported in the Kaiser article, Medicare spending on PA/LTC, “has grown at 5 percent a year or faster in 34 of the nation’s 50 most populous hospital markets in recent years.”

The article goes on to describe the perceived reasons behind the variability that has captured CMS’s attention:

Misaligned incentives: Hospitals have not historically been economically impacted by the consequences of post-hospital care delivery, while PA/LTC providers have been incentivized to drive utilization based upon maximizing reimbursement rather than the appropriateness of the setting.

Information asymmetry: Very often PA/LTC referrals are a function of personal relationships and familiarity between those responsible for discharge planning and those responsible for marketing available beds.

Provider ambiguity: The evolution and confusion that today characterizes post-acute care services and settings (and the impact technology is having on care settings – e.g., telemedicine) often impairs market competition.

Lack of care coordination: While post-discharge readmissions have captured the popular media’s attention because of the ACA payment penalty, it’s the underlying lack of care coordination between acute and PA/LTC providers that results in cost inefficiencies extending well beyond avoidable readmissions.

These concerns, taken together with other indicators of potential waste and inefficiency (please refer to the article cited), will drive tremendous pressure in the years ahead to lower Medicare post-hospitalization expenditures (thus the chainsaw metaphor). How PA/LTC providers address these pressures will mean the difference between staying in business – or not.

When thinking about performance improvement as a vehicle to address this challenge remember this: more than any other singular criteria, successful PA/LTC organizations that survive the next decade will have learned to trade on value. Value in healthcare is quite simply the patient’s satisfaction with the care delivery experience divided by the cost to provide that experience (with the notable understanding that a patient’s satisfaction is typically augmented by their families’ satisfaction). With or without the Affordable Care Act, that is where the industry is headed.

But what does it mean to, “trade on value?” To help Pub visitors begin thinking about that I have provided a few fundamental questions that you might want to ponder – or discuss with colleagues:

  1. What’s most in demand?
    If Medicare, Medicaid and private insurers were to evaporate tomorrow, what core service offerings that you provide would be the most likely to still generate revenue? What distinguishes those services from others?
  2. Where do we fit in the care continuum?
    Forget the fancy charts and graphics of think tanks and consultants showing you where you fit. Think about the patients you care for every day from the perspective of their overall care experience: where does your organization provide the greatest value to that patient’s recovery along the care continuum?
  3. Who wants to work with us?
    How do potential partners in your market determine their value? Based on that understanding, can you enhance their value? What are the risks that you would lower it? Can you effectively address those risks?

  4. How do we protect and enhance our core value?
    In healthcare, more than any other industry, the innate ability to produce value is primarily attributable to direct caregivers. What should you be doing today to ensure you protect that most valuable resource? And what should you be doing tomorrow to help those caregivers increase the value you provide to patients?


A Moment Please ?

image_thumb2Dear Colleagues:
This is a short reminder to those intellectual policy wonks out there who are interested in debating US Healthcare public policy that my firm, Artower Advisory Services, sponsors and underwrites the cost of a private Listserv discussion group. The group was created out of a remnant of what was once known as HEALTHRE – begun back in the mid-90s.

It is free to join, free to participate – and free to just lurk (read the posts of other contributors). Approval is required to help keep the list free of “junk,” but that is an automated process. Participants receive e-mails only from other registered participants that are discussing US healthcare public policy issues (i.e., no solicitation, no advertising, no spam). To sign up, simply click on the link below. You can unsubscribe just as easily if you determine it’s not for you.

Join the Debate!!
  ~ Sparky

Click here to sign up for the HC Policy Discussion Group

“Ambient Despair”

I started Sparky’s Policy Pub back in May because I believed it would be a productive and enjoyable means of sharing information, thoughts, opinions and insights on public policy issues likely to impact providers of affordable housing, aging services and post-acute/long-term care. 

Four months and 27 posts later, rather than write about the what, the how and the wherefore of healthcare policy, I want to pause and focus on the why.  The only significance of my chosen timing is the recent availability of an interview on Terry Gross’ Fresh Air: Advocate Fights ‘Ambient Despair’ In Assisted Living.   In this program she interviews Mr. Martin Bayne, a long time consumer advocate of long-term care – and current resident of an assisted living facility.

In the early 90s Martin started a web site called, Mr. Long-Term Care.  Back then while the world wide web was still in its infancy Martin was years ahead of his time in recognizing the tremendous value the Internet would offer in sourcing, aggregating and organizing content.  He embraced this vision by not only providing – but producing, through both written and audio interviews – what was widely recognized as the definitive online knowledgebase on all matters relating to long-term care in the United States.

I met Martin the way many did – through being first attracted to the tremendous resource that was Mr. Long-Term Care.  It became an indispensable means of quickly accessing statistics, research, opinion – anything that existed or was being developed to help better understand the market, operational and financial characteristics of the long-term care delivery system.

Fortunately for me, my relationship with Martin went beyond just accessing his web site.  In 1998 we cofounded the National Long-Term Care Policy Institute as a reflection of our shared passion for believing there was more needed to be done in terms of taking an honest, objective and candid look at what was working – and what was not working – in our delivery system.

To compare my passion to Martin’s beyond that, however, would be a disservice to him and his life’s work.  I wanted to see change – Martin has effected change.  Some years on now, I still look fondly on the time I spent working with him.  And while we each in our own way continue to fight the good fight, as you listen to Terri Gross’ interview, you will understand why my deference is not humility but personal pride in not only having had the opportunity to learn from Martin – but being able to still consider him a friend.


Click on Mic to listen to interview . . .


Welcome to the Policy Pub

Greetings, and welcome to Sparky’s Healthcare Reform Policy Pub!!

This is my first installment, while our team is still working feverishly to create initial content for the Artower Advisory Services Web site.

Eventually – and hopefully sooner rather than later – here you will find a timely, informative sharing of knowledge, information, opinion and debate on public policy issues impacting senior housing, aging services and post-acute/long-term care organizations.

If I am successful in achieving my overarching goal, this blog will become top of mind with industry thought leaders desiring to stay at the cutting edge of awareness, understanding and insight of how Healthcare Reform policy initiatives will impact the industry and their organizations.

I know that success will depend on how diligent I am on keeping content fresh, how well I can provoke meaningful participation from others – and whether Healthcare Reform continues to offer tremendous business challenges – and opportunities.  Well, I’m pretty confident Healthcare Reform isn’t going away, so I guess it’s mostly on me.  I welcome the challenge.

So please come on in, grab a spot and let’s have some fun learning from one another in ways that will ultimately help those organizations providing life-improving housing, services and care for seniors and disabled individuals in our society.

See ya inside!

  ~ Sparky

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