I'm asked from time to time what makes for a better- performing hospice medical staff. I'm unsure that there is a straightforward answer. The strategy of hospices building medical staffs is a recent and uncommon practice. Uncommon because the median daily census (in 2007) of U.S. hospices was just over 50, and more than three-quarters of hospices admitted fewer than 500 patients annually. Hardly sufficient scale to employ a single full-time physician, let alone a medical staff of five or more. By one rule of thumb oft cited for physician staffing levels (1 FTE per 100 ADC), only 18% of the U.S. hospices would consider employing a full-time HPM physician.
Those who have closely followed other health care sectors, such as home health and infusion therapy, are quick to point out that consolidation swept rapidly through these sectors once reimbursement was tightened or reformed, and sub-scale agencies found that size did indeed matter. Will hospices follow a similar pattern? I wouldn't want to wager a hospice's existence against it. So the hospices of the future will likely be larger. And with size comes the need for a medical staff structure that enables access and quality. The structure may vary from hospice to hospice, but most will arrive at the right structure by careful and thoughtful building of the medical staff. Here follows, from our study, the eight building blocks.
- Create full-time "blended" practice opportunities that attract and retain HPM physicians.
- Develop bench strength to account for volume fluctuations, departures, back-up coverage
- Amass "intellectual capital" for an infrastructure that supports an effective and efficient medical staff.
- Deploy hybrid compensation models to align physician and hospice incentives, and reassess at least annually.
- Maintain relentless focus on capturing information on physician activity to provide timely and constructive feedback and aid performance management.
- Clearly articulate expectations among medical staff practitioners, medical leadership, and hospice management.
- Create virtual organizational structure to extend influence of medical staff into greater community to reduce fragmentation of late-life care.
- Foster an unswerving commitment to performance improvement to minimize inappropriate practice variation, reduce regulatory risk, and win the confidence of referring sources.
We'll examine, over the coming months, each of these building blocks with a little more precision. As always, your comments are invited.