Abstract
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You may secretly enjoy being ignorant of the business and finance aspects of your work. “I just take care of patients” or “Thankfully I just get to do my research” are phrases I commonly hear that belie this perspective. Although the virtue of bundled payments to make all financial problems go away is tantalizing to those who “believe”, it is probably as realistic as the Disney thinking that someday my prince will come.
Dissemination of what we have discovered in palliative medicine is essential to improving patient and family care. Contemporary business models are a barrier to that dissemination. I think we need to expand our notion of palliative medicine research to include innovative business models. Journal of Palliative Medicine would be happy to publish descriptions of new models that are designed to sustain generalist and/or specialist palliative care programs. Although data are nice, well-defended hypotheses would be welcome at this early stage.
Researchers will need new kinds of collaborators to engage in this research. Begin with inquiry. How is the margin calculated? What are “the rules” for doing the calculations? Where do the rules come from? What evidence beyond “we always do it this way” underlies the rules that are used? What other ways might be used? What failures led to the current methods and rules? There are many—most linked to fraud or inadvertent bankruptcy. Who finds this stuff exciting?
The most eye-opening course during my study for a master's degree in leadership of health care organizations was the health care finance course. I learned that spreadsheets are not scientific documents; they represent literature. They are (1) written by an author who has a point of view, (2) for an audience, and (3) from a set of facts, assumptions, and conventions. The author has choices. The sources of the numbers are embarrassingly unreliable. It became crystal clear to me why the person who controls the spreadsheet controls the conversation about any programmatic development.
The collaborators you will need to investigate new business models are unlikely to be found in the finance and accounting departments of your organization. The staff are not recruited for their creativity and willingness to pursue hypothesis-driven research in the same way that research-track physicians are recruited for the department of medicine in an academic medical center. That doesn't mean they don't exist. There is research conducted in schools of business and economics. Palliative medicine research is fundamentally interdisciplinary. I think we need to expand our research teams to include these nontraditional disciplines. The rapid growth of hospital-based palliative care in the United States is directly tied to the financial innovation discovered and disseminated by the Center to Advance Palliative Care at the Mount Sinai School of Medicine that supports hospital-based palliative care when payment is bundled in diagnosis-related groups. 1
The work of Thomas et al. in this issue illustrates why this is needed. In their qualitative evaluation of communication content between oncologists and palliateurs in an embedded model of lung cancer care, they found differences. The differences justify the two different subspecialties seeing the same patient. Unintentionally, this supports further industrialization of health care where each component becomes more and more limited, similar to a station on an assembly line at a Toyota factory.
I think it is entirely reasonable to hypothesize that the business model guiding the workflows plays a role in the observed differences. The prevalent complaint that “I only have 10 minutes with the patient” is driven by a scheduling program that is derived from a business model for funds and workflow. Are there alternative models? Is there experimentation and comparison of models? I do not see it published.
At a recent conference, I encountered a community oncologist ruefully shaking his head about the construction of yet another branch of oncology, palliative oncology that was further distancing him from the practice he loved—the primary palliative care part of oncology. It made me think of the work of Jackson et al. 2 that defined type I and type II oncologists. 3 The type I oncologists find great meaning in their work when they do the palliative care themselves. The type II oncologists need someone else; they are not going to do it. I doubt these two “types” are limited to oncology. It follows there needs to be two different business models and practice patterns. But if the prevailing model is built in a monolithic “everyone gets 45 minutes for a new patient and 20 minutes for a return” and half that time is spent in the electronic medical record, there is no choice but to yield the palliative care to the person who can spend an additional hour for a new, and an additional hour for a return based on a different schedule and business model. Have you ever tried to challenge the business model underlying your practice? I can show you my scars if you haven't.
New business models need to discover ways to capture the financial value of avoiding the US$1 million it costs to replace the specialist physician who leaves practice because the work is no longer meaningful; the US$200,000 it costs to replace the specialist nurse who has lost the reward of direct patient care. This is in addition to the costs of unnecessary hospitalization and treatment or the opportunity costs of admissions that are “blocked” by patients still in beds. Prevailing conventions don't permit the “counting” of such costs in a standard business plan—but they are real. How much “leakage” to other systems is stemmed when palliative care is reliably delivered as part of standard care? Current conventions don't allow you to count the revenue you never had.
We face global shortages of physicians and other health care professionals across all of medicine, not just palliative medicine. Innovative models that reliably capture the revenue and costs of what palliative care does for other physicians and the system as a whole as well as for patients and families with innovative methods that supplement or replace the current rules are desperately needed. If we assume that innovative finance and IT people can do more than embezzle funds and hack computer systems, we are likely to find the collaborators we need.