0:02

Welcome to TCNt alks . The

0:04

goal of our podcast is to provide

0:07

concise and relevant information

0:09

for busy hospice and palliative

0:11

care leaders and staff . We

0:14

understand your busy schedules and believe

0:16

that brevity signals respect

0:19

. And now here's

0:21

our host , Chris .

0:23

Como . Hello and welcome

0:25

to TCNt alks . I am super excited

0:27

. Today, our guest is Dr Ira Byock

0:29

. It almost feels like he doesn't need

0:31

an introduction to our many listeners , but he's

0:34

a leading in palliative care physician , an author

0:36

, a public advocate for improving

0:38

care through the end of life . He's the founder of the Institute

0:41

for Human Caring of Providence

0:43

Health . He's the past president of the American Academy

0:45

of Hospice and Palliative Care Medicine , ahpm

0:48

, from 1996 to 2006

0:50

. Dr Byock directed the Promoting

0:52

Excellence in End of Life Care and National Grant

0:54

Project of the Robert Wood Johnson Foundation

0:57

. He's written several books . His books include

0:59

Dying Well , the Four Things that Matter

1:01

Most and the Best Care Possible

1:04

. Dr Bayak is so good to have you .

1:06

It's really nice to be here . Thanks very much for asking

1:08

me to come on the podcast .

1:10

You bet this has been something I've been looking forward to

1:12

for a while , but always , always want to give our guests the opportunity

1:15

just to connect with our audience personally . So what do you

1:17

think they need to know about you besides those

1:19

amazing kind of thumbnail of the bio I just read

1:21

?

1:24

Well , I still experience

1:26

myself as being first and foremost a clinician

1:28

, with a perspective of

1:31

a clinician . I started my medical

1:33

career as a rural family

1:35

doctor , kind of cradle-to-grave family

1:38

medicine , and even during my residency

1:40

it was pulled in two directions one toward hospice

1:43

and the other toward emergency

1:46

medicine . And I ended up doing both

1:48

for quite a few years and

1:51

kind of you know , initially

1:53

I mean , I did emergency

1:56

medicine to feed my hospice habit because

1:58

you couldn't make a living back in the late

2:00

1970s and early 1980s

2:03

doing hospice work . So it was a volunteer

2:05

effort and I was , you

2:08

know , I guess I've risen in

2:10

leadership just because I

2:12

was writing and trying to figure out

2:14

for myself the

2:16

ethics and clinical practice of caring

2:18

for people who were

2:21

facing the end of their lives and

2:23

have a predilection

2:25

for committee work apparently . So kind

2:27

of was part of fleshing

2:31

out what has become the

2:33

discipline of hospice and palliative medicine

2:35

throughout my career

2:37

. Frankly .

2:39

Well , before we jump in , I was giving

2:42

you kudos in the show prep , but I want to do it again

2:44

now . There are a few books

2:46

that I've quoted like hundreds

2:48

of times and I'm a pretty prolific reader

2:50

the amount of people I've paid forward

2:53

, the four things that matter most . You know

2:55

quite often , growing up in hospice and palliative

2:57

care , people are in tough situations and you

3:00

want to say the right thing . And

3:02

the number of people I've just told hey

3:04

, before you love one past , I want to give

3:06

you this piece of wisdom . And the number of

3:08

people circle back later and said you

3:10

do not know what that meant and how we got

3:13

reconciliation , healing before my

3:15

loved one . One person even said I think

3:17

this will change the trajectory of the rest of

3:19

my life , and so I just want you to know

3:21

the impact that that had .

3:24

Thanks very much for saying that . It means a lot . I

3:27

didn't invent the four things that matter

3:29

most or the five things

3:31

with goodbye as the

3:33

fifth thing to say , but

3:36

I very deliberately have been kind of the Johnny

3:38

Apple seed of that little piece of practical wisdom

3:40

through my career , putting

3:43

it into almost every lecture I gave

3:45

for many , many years and then

3:47

writing that book as a way to pay it forward

3:50

myself . So it

3:52

means a lot whenever I hear from people

3:54

that it has impacted their lives .

3:56

Well , many people say right , as an Arthur

3:58

, I don't know where I began and where

4:01

the multiple people that I read and the wisdom

4:03

that I harvested , but I love

4:05

your analogy of the Johnny Apple seed . Well

4:07

, let's jump in . So you actually

4:09

wrote a great piece . I'll even

4:11

say even a good provocative piece , titled

4:13

Provocative in a Good Way for a Conversation

4:15

we Need to have . The hospice industry

4:18

needs major reforms and it should start

4:20

with apologies . What led you to write this

4:22

?

4:25

Oh boy , frustration

4:27

. I think

4:30

hospice as a national

4:32

field , as an industry

4:34

that we've become , is

4:36

in danger , is in

4:38

really trouble and

4:41

there is a way out of it , but

4:44

we have to acknowledge that

4:46

there's a problem

4:48

and then get busy fixing

4:50

it . What I see

4:53

, and have seen for a number of years

4:55

in the national associations

4:58

which I've been privileged often to be behind

5:01

closed doors in leadership meetings

5:03

with , is a

5:05

failure to acknowledge the responsibility

5:08

that we have had and the fact

5:10

that a real crisis in American

5:12

hospice care has happened during our watch

5:14

, and to own that

5:17

in a way that we can then

5:19

put forward strong recommendations

5:22

and actions on our own in

5:24

a way that you know solves

5:27

this crisis , which , again , is

5:29

solvable , but only if

5:31

we actually acknowledge that

5:33

it exists and are willing to

5:36

take the hard actions to climb

5:39

out of this morass .

5:41

Well , I think you , I agree

5:43

we're in a crisis , we're in a crossroads

5:46

, and so you're a great physician

5:48

. So when we just start with , what's your assessment of

5:51

this situation ? So it feels like you've kind of

5:53

you're a little bit on the periphery , so let's just be

5:55

a little bit more explicit . What is our assessment of the

5:57

current state of the hospice and about care movement ?

6:01

It's interesting that you call it a movement . That's

6:03

so interesting .

6:05

I can tell you the history of that . It started

6:07

as a social movement right , yes .

6:10

Led largely by nurses . Thank you very

6:12

much . We started

6:14

I mean I got into this field

6:16

back in 1978 , 79 , and

6:18

we were meeting in school

6:21

basements and , you know

6:23

, church meeting rooms after hours and

6:25

trying to figure out how we can put together

6:27

a little community effort or

6:29

an effort within our health system

6:31

, always volunteer to just care well for the health of the community

6:34

, to just care well for people who were dying

6:36

badly , often suffering

6:39

as they die needlessly , often dying

6:41

alone with a television on in their , in

6:43

their , you know , hospital room . And

6:46

we grew up into an industry right

6:48

through our success . My

6:52

assessment now is that hospice

6:55

quality of hospice care

6:57

across the country is highly

6:59

variable , whereas

7:02

, thank God , still some

7:04

fabulous hospice programs that are

7:06

doing remarkable work , that

7:08

are well staffed , that are responsive

7:10

to people's needs , that easily

7:14

exceed any of the conditions of participation

7:17

and will score well on quality

7:19

parameters . And

7:22

there are quite a few , quite

7:25

a few hospice programs in

7:27

the country that I would try to protect

7:30

anybody who was looking

7:32

for a program from that

7:35

highly vulnerable people are

7:37

made even more vulnerable and at

7:39

risk by being cared for

7:41

in programs that do

7:43

not meet even basic conditions

7:47

of participation , that are under

7:49

staffed in their nursing staff . So

7:51

case loads are untenably high

7:53

that do not have

7:55

enough physicians to care

7:57

well for seriously ill and dying patients

8:00

, and we can talk more about that , because it's

8:02

where I probably have most standing to

8:05

have expressed feelings

8:07

and beliefs about hospice

8:09

physician roles . As

8:13

a as somebody who practiced for years

8:15

both hospice medicine and also

8:17

emergency medicine , it

8:20

worries me a lot . I literally

8:22

lose sleep over knowing

8:25

how many hospice programs now

8:27

cannot effectively respond

8:29

to symptomatic emergencies

8:32

in the homes of hospice patients . And

8:35

I had I've been a hospice

8:37

medical director for a decade

8:40

. I was I was the director

8:42

of a large palliative care program

8:44

at Dartmouth for nearly a decade

8:47

and very much focused

8:49

on what do we do in emergencies ? Can

8:52

we ? Can we provide

8:55

the same response

8:57

in emergencies that somebody would get in

8:59

an ambulance or in an emergency department

9:02

? And we got very

9:04

close to being able to answer that . Yes , but

9:07

now with other

9:10

you know trends impacting this

9:12

, including the opioid crisis we

9:14

have retreated as a field . We have retreated

9:17

far from that , and I

9:19

worry about and it's not

9:21

an abstract worry , chris I

9:23

know multiple cases

9:25

of patients who have suffered

9:28

needlessly , of families who have

9:30

felt utterly betrayed and abandoned

9:32

when a when a symptomatic

9:34

emergency has happened in their home . So

9:37

that's , that's where we're

9:39

at in the country , and and you

9:41

know , and so quality

9:43

is variable . Some of it's very good , but

9:46

when you look at things like emergency responses

9:48

to emergencies in the home , boy , it's

9:51

. It's unusual these days for me

9:53

to be able to appoint to a hospice program

9:55

that reliably does that well

9:57

.

9:58

Gotcha , I had Dr Tino on

10:00

earlier this year and you

10:02

could refuse to answer this . But do you

10:04

have venture a guess ? Of what percentage do

10:06

you think that , of those programs that are probably giving you a chance

10:08

to answer this , that are probably giving us the bad

10:10

name ? Because , unfortunately , right articles like

10:12

the pro-public articles

10:15

it then tended to paint everybody

10:17

in that light .

10:19

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10:21

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10:23

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10:30

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10:55

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10:56

Well . So I didn't read that in

10:58

that way . I don't think it paints

11:00

everybody in that light , but

11:02

it does . When the associations

11:04

then deny that the ProPublica

11:07

article has any worth at

11:11

all , but I don't know and I'm

11:13

not sure I could hazard a guess . I will

11:15

tell you that when I last looked at

11:17

the data carefully , 53%

11:19

of American hospice programs provided

11:21

no continuous home care or

11:24

GIP care , which

11:26

, by the way , as our listeners know

11:28

, are conditions of participation . So what

11:30

exactly happens in

11:32

that situation when a patient

11:34

is starting to seize and

11:37

is having one seizure an

11:39

hour and then two seizures an hour and they're kind

11:41

of what we call kindling and they're

11:44

going into gradually into status epilepticus

11:46

? Or what happens when a patient

11:48

has just had a bowel infarction

11:51

at home and is having crescendo pain

11:53

and really the oral

11:55

morphine isn't

11:57

working or the sublingual morphine ? What

12:00

happens in those situations ? So

12:05

I think it's a substantial number . I don't

12:07

think it's good . I don't think it's not like

12:09

there's one

12:11

or two bad apples in this barrel

12:13

. I think there's enough bad apples

12:16

that the barrel is starting to smell

12:18

like rotten fruit

12:20

.

12:21

Good deal . Well , I think you've done a good job kind of defining

12:24

the state , the assessment

12:26

. Can we move to prognosis now , like

12:28

, what's the prescription ? How do we set

12:31

back on the right course here to

12:34

fix this ?

12:35

Well , let me , I have to say so . You

12:37

asked me why I wrote that second article

12:39

. I've written two articles for STAT , one , december

12:42

14 . I just looked up the date today , december

12:44

14 , 2022

12:47

. And they titled it STAT , titled it

12:49

Hospice Needs Saving , and

12:53

that looks at the problems , not

12:55

of the pro public article which looked at pure

12:58

fraud in hospice . I

13:00

looked at the highly variable

13:02

quality of hospice care which

13:05

we have been watching for years

13:07

and been discussing behind closed

13:09

doors at the National Associations

13:11

for Years but haven't really acted

13:14

on . I believe that's my my

13:16

belief . I wrote the second

13:18

article which you asked about and

13:21

emphasize the importance of apologies

13:23

, because corrective

13:26

action the prescription

13:28

for corrective action , has to start

13:30

with owning the fact that

13:32

, while we were responsible and

13:35

we all knew this was happening

13:37

, we

13:39

let it happen and at this point

13:42

now the

13:44

associations are feeling very defensive

13:47

and they they are doing things like writing

13:50

Earl Blumenauer with 34

13:52

recommendations . Well , I

13:55

happen to know representative Blumenauer

13:57

. I've worked with him a few times . He's

14:00

a lovely man and a wonderful

14:02

representative , but he

14:04

chairs no important committees . He

14:07

, you know . I mean writing Earl

14:09

Blumenauer about recommendations

14:12

. I don't mean disrespect

14:14

, but it's a little bit like writing Santa

14:16

and asking for things to

14:18

change . So that's a little

14:20

bit weak , but

14:22

we have to to assert to the

14:24

, to American public or to Congress

14:27

or CMS that we are responsible

14:29

for our field and these are recommendations

14:32

. That has no power

14:34

from my perspective unless

14:36

you acknowledge that we've already

14:39

had this responsibility and these

14:42

problems have happened under our watch . So

14:44

I think that apologies , both

14:47

in the personal , which is where I started

14:49

with with somebody had asked me there's a

14:51

real story . Somebody asked me what have you learned

14:53

over the years from your clinical work ? Personally

14:56

, and I've learned a lot of things

14:58

, but the thing I answered which is really most

15:00

resonant for me is I've learned it's

15:02

important to apologize when I screw

15:05

up , because apologizing

15:08

says you know , this relationship

15:11

is more important than the shame

15:13

I currently feel about having screwed up again

15:15

. So I think the field really

15:17

needs to start with apologies to say

15:19

look , we now recognize

15:22

that this was happening all along

15:24

and we haven't responded to it sufficiently

15:29

. And now here's what we're

15:31

going to go . We're going to do , going forward

15:33

.

15:34

So let me get , let's unpack that , and I love that . You

15:36

said that I get pushed back in this . So

15:38

I grew up at four seasons . There are

15:41

a lot of great nonprofits , and

15:43

you said in the pre show you're not making

15:45

this thing a for profit , nonprofit thing . I'm

15:47

partial to nonprofits because that's where I grew

15:49

up . I had an amazing , I'd

15:52

almost say like an Arrabaya kind of protege

15:54

, because Janet always looked up to you . She was an amazing

15:56

physician , her own right , and so we

15:59

built a high quality program . And

16:02

so for me to look at that and

16:04

go well , I don't want to apologize

16:06

for we've built something that is so

16:08

different than the other folks . But I

16:10

could also convince myself to say you know what ? I

16:12

hear you , I apologize that

16:14

we've let that occur in our industry . Here's

16:17

where we're doubling down in our community

16:19

and I will use what spirit of influence

16:21

I've been given to affect the national

16:23

. But you also have my commitment as a

16:25

CEO . That's not what we

16:28

have here . In fact , we're going to double down on

16:30

the quality , something along those lines .

16:33

I don't think the local excellent

16:36

programs , either for-profit

16:38

or non-profit , should apologize for anything . But

16:41

I think NHPCO and

16:43

the American Academy of Hospice and Palliative

16:46

Medicine and I'm a founder , one of the founding members

16:48

among many , of both organizations

16:50

need to apologize

16:52

. Nhpco , I can tell

16:55

you because I've talked to Jay Mahoney over the

16:57

years , I've talked to Don Schumacher

16:59

, I've talked to Edo . The

17:03

board knows that this has been happening

17:05

. There are people now that are pissed at me

17:08

for having written about it in public

17:10

, but it's a little bit like

17:12

they're pissed because I've told

17:14

family secrets .

17:18

We're about moving things forward and

17:21

I'm a huge history buff . Quite often

17:23

it is the firebrand who

17:25

says the stuff that needs to be said . That moves

17:27

things forward . Let's go

17:29

to that prescription . How do we fix this

17:31

thing ? I actually wrote something

17:33

in the show prep to you and I'm like , well , maybe frame your

17:35

answer public policy level

17:38

and you totally push back on

17:40

that . I love that . What do we need to do ?

17:49

Let me say NHPCO , nhpci

17:53

, leading Age

17:55

and one other I can't remember . The fourth

17:57

organization wrote

17:59

34 recommendations to CMS

18:01

and Congress . They're excellent

18:03

. I encourage listeners to go

18:07

look at them . I think all

18:09

of them are excellent . If I have any gripe about

18:11

them at all , it's that almost all

18:13

of them could have been written a decade or more ago

18:15

and we didn't

18:18

. A lot of

18:20

them have been discussed in board

18:22

meetings , in advisory meetings and committee

18:24

meetings , but it took the ProPublica and New Yorker

18:26

article for us to finally

18:29

write those In

18:31

a public policy sphere . Obviously

18:33

, cms and their surveyors need to

18:35

do a better job . They need to survey more often

18:39

, but they also have to survey more adroitly

18:42

. Some of what they do is just stupid

18:44

and really ham-handed

18:46

and they're surveying for the wrong

18:49

things and they're conflating

18:51

really good care that

18:54

, for instance , not all of us have

18:56

had the experience of meeting somebody

18:58

with late-stage

19:01

dementia or severe

19:03

heart failure and because of the

19:05

excellent , meticulous care that

19:07

they receive through hospice , they end up living

19:10

far longer than they

19:12

were expected to In

19:14

a ham-handed surveyors can

19:16

look at that and say , well , this was fraud

19:19

, because they should never have been admitted to hospice

19:21

, which is absolutely absurd . It's injurious

19:24

. What other specialty in

19:26

the United States has to worry if

19:28

their patients live longer and do

19:30

better ? Right , it's absurd . I

19:33

also think , however , that

19:36

in calling

19:38

for them to do better the surveyors

19:41

in CMS to do better it falls on

19:43

us to give them guidance

19:46

. We , as

19:48

provider organizations

19:50

or associations representing provider

19:52

organizations , should lay out

19:54

clear parameters and

19:56

help them understand

19:58

how to separate excellent

20:01

care , which is causing long

20:03

lengths of stay , from really

20:05

cherry-picking business

20:08

practices that front-end

20:10

load people who are going to get long

20:12

lengths of stay . So

20:15

there's that . I

20:17

also think , by the way , that while

20:19

those 34 recommendations are excellent

20:21

, for those of us who read deeply

20:24

into industry newsletters , it

20:27

is so common to find that after

20:29

the public announcement

20:32

and press release of these

20:34

recommendations that are so progressive

20:36

and protecting of quality

20:40

, that there are memos that

20:42

go out to CMS from the association

20:45

saying don't do it yet . We're

20:47

not ready yet the protocols aren't

20:50

in place , the metrics aren't exactly right

20:52

. I

20:55

think that's Well

20:58

to say . It's disingenuous

21:00

is the nicest way I can put it , but

21:03

it really is a way

21:05

of trying

21:10

to wear a white hat in public and

21:13

undercutting the very good

21:15

work that we're trying

21:17

to do . These

21:20

are never going to be perfect

21:22

, but if we recognize

21:25

how serious our brand

21:27

is being damaged and

21:30

, more important than that , how

21:33

injurious

21:36

the deficiencies in hospice

21:39

care are to the most vulnerable

21:41

patients and their families

21:44

in our American healthcare system , we

21:48

would have a different slant on

21:50

the urgency of

21:52

our recommendations to CMS and Congress

21:55

and the urgency of policing

21:57

ourselves in

22:00

this regard , and that's what we'll , hopefully

22:02

we'll talk about in a little bit .

22:04

Yeah , that's actually where I was going to ask us to go next . So

22:06

let's say , you and I were starting our own

22:08

hospice today and okay , Dr Barak

22:10

, what are those things we want to hold ourselves accountable

22:12

to ? That we will take to the accrediting

22:15

body and say , hey , these

22:17

are the things we're no , we're doing

22:19

, we're holding ourselves accountable to . You

22:21

should maybe survey us based upon and

22:23

survey other people . What would those things be

22:26

?

22:29

Boy . So I would start with

22:31

basic staffing levels . You

22:33

know . Again , just

22:35

let me call attention for the listeners . I

22:39

was the lead author on a

22:41

article in May 2023

22:44

, journal of Palliative Medicine that

22:46

was co written or co affirmed

22:48

by 325 hospice

22:50

and palliative medicine physicians . That

22:53

is called core roles and responsibilities

22:55

of physicians in hospice care and

22:58

we put out some basic

23:00

parameters for

23:03

what hospice physicians should

23:05

do in their program and

23:08

what their employment

23:10

agreements should both require

23:13

them to do but at least allow them

23:15

to do , like making home visits

23:18

, being available for emergencies

23:20

, having

23:22

no more than 75 or , at the very

23:24

most , 100 patients that they're

23:26

responsible for on any given day

23:29

, being

23:32

active in staff development and team

23:34

development and continuous education

23:36

, either being

23:38

a board certified in hospice

23:41

and palliative medicine or then

23:44

, as a hospice medical director

23:46

certification and , if they are not

23:48

board certified or have

23:50

a HMD certification

23:53

, pursuing that as a condition of

23:55

employment . We

23:57

also said in that article that

24:00

our colleagues , our hospice

24:02

nurse colleagues , should have no

24:04

more than 14 patients on

24:06

their responsibility

24:11

, their caseload , on any given day . Now

24:14

there may be slight exceptions , for

24:16

you know , we all know , and that's

24:18

the pushback that comes back as well . You know why

24:20

it's very complicated because , you know

24:22

, some nurses just have a

24:25

single building with all of their patients and

24:27

all this , you know . Let me just say to that , yeah

24:30

, it's complicated , but it ain't that complicated

24:33

. We do a lot of things that are more complicated

24:35

than that , and having

24:37

organizations where the caseload

24:40

for hospice nurses is

24:42

routinely 18 to

24:44

20 or more patients

24:46

has , you know

24:48

, does not pass the SNF test

24:50

and so , anyhow

24:53

. So we're back to surveyors . I would ask

24:55

surveyors to look at what

24:57

we published 325

25:00

hospice and palliative medicine physicians

25:02

signed that . It's

25:05

a very actionable set

25:07

of recommendations . That

25:09

would be a place to start . I would ask surveyors

25:12

to also survey

25:14

for staff well-being

25:16

. This

25:19

is an area of data that I believe

25:21

we all those of us who are interested

25:23

in quality need to start looking at data

25:25

sources for staff well-being

25:28

. You know , in nursing homes we look

25:30

at and I think it's probably the

25:32

most potent nursing home

25:34

quality parameter is the

25:36

annual turnover rate of

25:38

nurses' aides in

25:41

long-term care . I think we need

25:43

similar parameters to balance

25:45

the current quality

25:49

data that we all look at in hospice

25:52

care , because so much of the current data

25:54

, frankly

25:56

, has turned out to be gameable and

25:59

we need another data source and I would say

26:01

staff well-being , consistent

26:04

with , you know , the quadruple aim of American

26:06

health care's quadruple aim

26:08

of quality . You

26:11

know staff well-being is an important one , so look

26:13

for measures of moral

26:16

distress but also staff distress . Surveyors

26:20

could privately interview a series

26:22

of nurses about how

26:24

late they chart at night , whether

26:26

they feel that their case load allows them to

26:28

give really

26:30

high quality care . I would urge

26:33

the surveyors to ask about what

26:35

happens in an emergency in a patient's

26:38

home and whether they have the

26:40

medications in the home that they need or

26:42

whether they have to go to the home , assess

26:44

the patient , find a physician

26:46

to prescribe a

26:48

medication , get that often

26:51

written medication prescription , find

26:53

a pharmacy that is open and has it

26:55

and then get back to the home . Right

26:58

, those are problems

27:01

that cause unnecessary

27:04

suffering of the

27:06

patients who depend on us on us

27:08

for reliably safe

27:11

and effective care .

27:12

This is good , so one of the ones that

27:15

I'm surprised . There are two things

27:17

that you didn't say , although I can see

27:19

at the lower level where these

27:21

things are leading indicators . So number one re-hospitalizations

27:24

. I have a friend who , to

27:27

say , he's part of a large payer , ended up managing

27:30

a large amount of lives , and she was sharing

27:32

with me her

27:34

perception she has formed about hospices

27:36

based upon the re-hospitalization rate . I

27:38

was appalled what she told me . Years

27:42

ago , dr John Morris and I did an interesting project

27:44

for a large healthcare system to take their

27:46

55 hospices down to four preferred

27:48

providers . It's like speed dating 55

27:50

hospices . It blew

27:53

me away when I started to see the

27:55

re-hospitalization rate , but

27:58

I could also see where that's kind of a lagging indicator

28:00

or some things that you just talked about .

28:02

But I think it's excellent . I

28:05

mean there's structure , function and outcome

28:07

right , the Donabidian model

28:10

of quality improvement . You

28:12

could start with structure . Surveyors

28:16

could ask do you provide GIP care or continuous

28:19

home care ? It's

28:21

a condition of participation . If

28:25

you don't , what happens with your patients

28:27

? Do you have a contract with another

28:29

provider to provide these services

28:31

? Or do

28:33

you discharge the patient

28:35

, which I have air quotes

28:37

up because we're not supposed

28:39

to ? The benefit is the patients

28:42

to revoke . But

28:46

it's often not the way it happens and

28:48

patients end up in emergency departments , end

28:51

up in acute care hospitals . If

28:53

they're lucky they get into an acute care hospital

28:55

that at least has an inpatient palliative care team

28:57

that can help them be cared for . But

28:59

these are things that are egregious and

29:02

they're not that hard for a surveyor to

29:04

determine . But

29:07

you were right , rehospitalizations

29:10

happen too frequently and they're often

29:12

linked to the lack of GIP

29:15

or continuous home care or just

29:17

really deficient responses

29:20

to emergencies . Yeah , absolutely .

29:22

And the other thing I was kind of surprised

29:24

is a pain measure . So there's a national

29:27

consultant you know I've got an ongoing debate and

29:29

he's like , have we really ? We haven't moved the

29:31

needle whatsoever in quality and he's probably

29:33

almost 40 years in hospice movement

29:35

now , and so I

29:38

could argue both sides of the equation . But what are

29:40

your thoughts about like being held accountable

29:42

to some type of measure around

29:45

pain and symptom control ? It

29:49

wouldn't be where I would focus attention , frankly

29:51

, Tell me more , because with your background I

29:53

find that fascinating .

29:56

I just think there's way too many variables

29:58

that can impact that

30:01

and

30:03

whether it's you know , whether

30:07

it's the patient's pain or the perception

30:09

of pain by the family . You

30:13

know , in

30:15

an inpatient palliative care program

30:17

we look at

30:20

using the patient's baseline

30:23

as the mark and

30:25

then the delta from the baseline

30:27

and that's useful

30:30

clinically . But I think as

30:32

an aggregate quality measure

30:34

I would not be . I don't think

30:36

it's a strong quality measure . I think there's

30:38

too many variables and it's too

30:41

easy to misinterpret

30:43

.

30:43

And do you think maybe game at the end of the

30:46

?

30:46

day and I was trying to avoid that

30:48

.

30:49

Well , we want to be honest on this . I just about

30:51

really respect your response on that . Well

30:54

, dr Bayak , final thoughts and you and I are

30:56

going to go into Extend at Play because there are a couple of great

30:58

lead-ins . I want to ask some questions just

31:01

for our tele-ass members . But what are your final thoughts

31:03

?

31:05

Well , I'm going to come back to the associations . This

31:08

is a problem we can solve . This

31:11

is not about for-profit versus

31:13

non-profit . I think the for-profits particularly

31:17

after they went through the

31:19

wholly-owned , family-owned

31:21

for-profits which I used to speak

31:23

in favor of , because

31:25

they were usually owned by zealots who

31:28

were utterly committed to quality and

31:30

really did

31:32

this out of a passion as they

31:34

went through IPOs and became publicly

31:36

traded within two years

31:38

I saw multiple previously

31:41

excellent for-profits deteriorate

31:43

and it was shown in caseloads

31:46

and the level of involvement of physicians

31:48

in staff stress and

31:51

it just kind of spiraled down . Now

31:53

we have the private equity that are pushing

31:55

it even harder and I

31:58

could go further into this , but we can maybe

32:00

talk about that in our

32:02

extended portion . But

32:07

it's not about for-profit versus

32:09

non-profit . I want the for-profits

32:12

to succeed . I really

32:14

and truly do , because they're

32:16

not going away . I want them to succeed

32:19

, but they must succeed

32:21

through providing reliably

32:24

excellent care . They

32:27

must provide , at a minimum

32:29

, safe and effective hospice

32:31

care and they should really be

32:33

competing in the marketplace against

32:35

their for-profit competitors and

32:38

their non-profit competitors by

32:42

customer delight and

32:44

by staff delight . And

32:46

frankly , we now know there's a

32:48

margin to do that . A

32:51

well-run hospice program

32:53

can reliably provide

32:56

6% to 8%

32:58

or maybe even 10% profit

33:00

margin on

33:04

against expenses , but reliably

33:07

providing 18% to

33:09

20% or 22%

33:11

comes at the expense of

33:14

staffing , of responses

33:16

to emergencies , of number

33:18

of visits and , frankly , of

33:20

unmet need by the patients

33:22

and families these programs serve . Again

33:26

, it's untenable . I'm one who does

33:28

not believe it . If hospice

33:31

CEOs of local

33:33

programs or regional programs

33:35

are proudly

33:37

presenting to

33:39

their boards or overseers 18

33:42

to 22% profits , they

33:45

should know that I'm one who thinks

33:47

they're earning their

33:49

place in hell .

33:52

That's well said . One last thing I wanted you to say

33:54

. We also have the ears of lots of hospice

33:56

and power care staff people by the bedside

33:59

. What would you say to them ?

34:02

Well , you're doing God's work . This

34:04

is the best clinical work that I've

34:07

ever done . I mentioned I was

34:09

a rural family doc . For a short period of time

34:11

I practiced emergency medicine

34:13

for nearly a decade and a half . I've

34:16

practiced hospice and palliative medicine

34:18

for the largest part of my career , something

34:21

like three and a half decades . I'm now no longer

34:24

seeing patients , but

34:26

that's what I have done and

34:28

even recently have overseen and

34:31

resource large

34:34

amount of palliative care programs

34:36

through the Providence Health System . I

34:39

don't know of any more

34:41

vital and frankly

34:44

satisfying clinical work

34:46

than being at the bedside

34:48

of a hospice

34:50

patient and supporting their family . The

34:54

fact that it is always a crisis in patients

34:56

and family's lives makes

34:59

our work ever more important because

35:01

, as most of what I have written tries

35:03

to my own contribution

35:06

, I hope , to the hospice

35:08

literature has been to show

35:10

that in the midst of this crisis , we

35:12

can hold a space

35:14

for people to be confident

35:17

that their symptoms will

35:19

be managed , that they will not be too heavy

35:21

a burden on their family and have

35:24

allowed them to grow

35:26

inwardly and together toward

35:29

a sense of well-being through

35:32

the very end of life . That's

35:34

the highest clinical goal that we can

35:36

have for these patients and the people

35:38

we serve . I

35:41

believe that hospice clinicians

35:44

are holding

35:46

up not only the highest

35:48

work of healthcare but , frankly

35:50

, are examples to

35:52

our culture of the inherent value

35:55

of human life and

35:58

the full continuum of human caring

36:00

. Wow .

36:01

Well , thank you , I'm

36:03

so glad to ask you that question . One of our team members

36:06

CEO is one of our tele-ass

36:08

members sent me a book . It's a lady that

36:10

retired to the community . It's actually called Angel

36:12

, second Class . Of course it's a take-off and it's

36:14

a wonderful life . It's nothing

36:16

but hospice stories from an amazing hospice

36:18

nurse . I was

36:20

sitting there with tears going down my cheeks

36:23

and all the stuff

36:25

, the challenges . How do you navigate value-based

36:27

care ? I feel like we've kind of lost

36:29

that focus on . This

36:32

is really what we're here to do . So thank you for taking

36:34

us back to that . Thank you for your body of work

36:36

, dr Bayak , and we're going to end

36:38

with a quote which is actually from Dr Bayak

36:40

himself . In this situation

36:42

, whether the solution to the problem

36:44

or the problem itself , thanks for

36:47

listening to TCNt alks , thanks

36:49

for having me Chris .