Former CMS Chief Berwick: Hospice, Health Care Needs to Reorient Systems Around Patient Needs

Delivering quality health care requires a moral compass, according to Don Berwick, M.D., former administrator for the U.S. Centers for Medicare & Medicaid Services (CMS) and founding CEO of the Institute for Healthcare Improvement. This requires hospice providers to go beyond regulatory compliance when they think about quality, with equitable access as a key component, Berwick said in a keynote at the National Hospice & Palliative Organization (NHPCO) Leadership and Advocacy Conference.

To achieve that level of quality health care, providers must reorient themselves towards customized care that is tailored to the needs of the patients, families and the communities an organization serves. This includes making available a diverse set of service options that make it easier for seriously ill patients to access the right care at the right time, further upstream of hospice.

“The very best definition of quality that I know is meeting the need, and meeting the need you intend to meet,” said Berwick at the conference. “Businesses that fail to meet the needs of the customers that they have chosen, they decline — those businesses will die. Communities and governments that fail to meet the needs of their people cannot thrive. Nations that forget to meet the needs of their people are lost nations, and they can die, too. Exclusion poisons improvement.”

Health care cannot be designed around patient needs if a wide swath of the population is excluded, according to Berwick. Racial and socioeconomic disparities persist throughout the health care continuum and represent the largest barriers to equitable hospice and palliative care.

Black and Hispanic populations are less likely to receive a hospice referral than White patients, according to recent data from the U.S. Agency for Healthcare Research and Quality. The LGBTQ+ community is another group historically underserved by hospice. A 2018 AARP study reported that 60% of this population was reluctant to seek out those services due to a lack of sensitivity to their needs among health care providers.

Providers have renewed their focus on equitable care following the heightened civil unrest of 2020, both from a moral perspective and the financial reality that these communities represent untapped markets, as well as unmet needs. A majority of the hospice providers who participated in a 2020 study published in the BMJ Supportive & Palliative Care Journal indicated that racial and ethnic disparities were an impetus for establishing greater diversity initiatives within their organizations.

A growing number of hospices have launched or invested more resources into diversity initiatives, with many indicating that this would be a top priority in 2021, according to an Axxess report earlier this year.

“We need leaders who remember that making people feel excluded or unheard or afraid begins a vicious cycle of exclusion, deafness and fear in our nation, which we can no longer endure,” Berwick said at the conference. “The people are turning inward because they think that walls are going to make them safe. We cannot afford a human race that retreats to islands of self-interest in an interconnected world.”

In addition to equity, Berwick cited standardization in health care and the need to address social determinants of health as key aspects of embracing quality. Variation in health care processes and outcomes does not lead to reliable or equitable care, he said.

Non-medical needs related to social determinants of health have a significant impact on the trajectory of patients’ health care. Social determinants of health include factors such as health literacy, meals, transportation, housing, food insecurity and other non-medical considerations.

The needle is moving slowly on social determinants, but is expected to accelerate. In addition to initiatives from private providers and payers, CMS now allows Medicare Advantage plans to cover supplemental benefits that include services to address social determinants, as well as palliative care.

Hospice providers need to adapt a common sense and simplistic approach to their patient care models when it comes to improving quality, according to Dianne Hansen, CEO of Partners In Home Care, Inc., based in Montana. Such an approach would be strategic and transcend positive performance on metrics.

“[Quality] is really a model of simplicity. It’s rooted in strategy,” said Hansen, speaking at the NHPCO conference. “One of the things that we do in quality too often is chase metrics. You can create a strategic vision around quality.”

The patient-centered, interdisciplinary, goal-concordant nature of hospice and palliative care can serve as examples for other health care sectors. The principle of quality can infuse almost every aspect of a provider’s operations, from clinical workflows and hiring to business functions like mergers and acquisitions. Quality of care is a key factor for many companies seeking acquisition targets.

“An organization needs to include quality in their strategic plan and allocate resources to support fulfillment of that strategy,” Jennifer Kennedy, senior director of regulatory and quality at NHPCO, told Hospice News. 

While improving quality can come with costs, positive results can also make a provider more attractive to payers and referral partners. This can open new markets to hospices, help build market share and reduce costs, as well as boost patient and family outcomes and satisfaction, according to Sarah Simmons, director of quality and education for Maryland-based Calvert Hospice.

“There is no reason to believe that quality always has to mean expensive — in hospice or in any part of our health care system,” Simmons, told Hospice News. “Hospice agencies, as well as regulatory bodies and pay sources, should work toward eliminating wasteful and redundant processes that cost agency resources and do not consistently lead to improved patient outcomes.”