Abstract
These data illustrate the high prevalence of medical torture—what I would define as medical care that causes suffering without benefit. In studies like these, medical torture is obscured by terms like “intensity.” Americans are united in finding use of medical intensity without benefit, but at high cost, anathema. No one argues that there should be a better way to care for the seriously ill.
If a difference in hospital beds cannot account for the difference in medical torture (“intensity”), what does? I think the 70% use of hospice care in San Diego contrasted with the 25% use of hospice care in Los Angeles provides a clue. Dr. Kaplan does not dwell on this because he cannot explain it. The number of hospice agencies in each area is not particularly different; neither is the mix between for-profit and not-for-profit (charity) hospice programs.
I think there are three reasons why there is less futile medical torture in San Diego than in Los Angeles. First, a different kind of hospice care, sometimes called “open access,” that has more than 30% market share is available in San Diego. 2 In contrast, hospice care in Los Angeles can best be described as “conventional” and anything but open access in orientation. In San Diego open access behavior influences the expectations of referring physicians, hospitals, and the behavior of all 18 hospice programs serving the region, none of which has more than 10% market share and feels intensely pressured by the open access hospice program. Second, required education of medical students that includes direct patient care responsibilities in a hospice program during the clinical clerkship year has existed since 1994. Third, required rotations for all primary care residents in internal medicine and family medicine where they have meaningful responsibility for patient care in a hospice program has existed since 1998. Los Angeles has no such educational programs. The largest effect of this education of medical students and residents is their improved understanding of hospice care and their willingness to refer patients for hospice care. Because approximately half of all residents practice in the area where they train, this should influence the overall practice behavior of physicians with time. Because 95% of all health care spending is influenced directly by physician behavior, this is no small thing.
These reasons should not be dismissed as the expostulations of a biased editor. Rather, and perhaps because these outcomes align so closely with some of the national objectives of health care reform, they deserve note as the U.S. Center for Medicare and Medicaid Services embarks on its hospice demonstration program of open access. The costs of teaching medical students, residents and physician fellows by full-time palliative medicine physicians in the direct care of patients enrolled in hospice programs is not part of any reimbursement plan for hospice programs or palliative care in the country, nor is it part of the demonstration programs. Yet, this study provides strong support to suspect such an effect has a big payoff. The hospice industry should redouble its efforts to fight the culture of fear of CMS currently enveloping its hospice agencies. Rather, an emphasis on doing the “right thing” for patients and their families and teaching doctors and future doctors how to do the right thing will result in less medical torture and a solution to “bending the cost curve” of the nation's health care expenditures. If this does not happen, I fear the conditions for a fundamental change in the way care in the last few years of life will change in a way that will not favor the hospice industry as it is now structured.
The New York Times recently noted that Blockbuster Video, once a high-flying and high-profit company formed in 1985, filed for bankruptcy in 2010. The explanation is Blockbuster Video failed to notice that their core competency was in providing video entertainment, not in renting moves that require a visit to a store. 3 It is a classic business example of a company failing to recognize a change in the market and adhering to the business model on which it was founded. I so hope that the hospice industry in the United States will not make the same mistake. The core competency of the hospice industry is the provision of palliative care to patients and families so that medical torture is avoided. It is not a cost argument—it is a quality of care argument. The business management literature advocates that every company needs to be engaged in creative destruction guided by its core competencies if it is to survive as a business in the face of a changing market. The risk of mistaking process for competency is to end up like Blockbuster Video; once viable, now a relic superseded by companies like Netflix. The opportunities to provide palliative care by hospice agencies, and shape the practice behavior of the physicians who will care for us in the future are enormous; there is a lot of medical torture that doctors do not want to do, but do not know any better. The data are firm: it is time to act.