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The future of palliative care - Issue #16

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"Networks in nature show how...the pattern of links at the local scale sets the options for stability
 

The future of palliative care

July 2 · Issue #16 · View online
In many respects, we've arrived. Yet what we know now won't get us to the next level. So I'm looking for signals from the future, & I'm curating them here.

“Networks in nature show how…the pattern of links at the local scale sets the options for stability and transformation.” Deborah Gordon

1. The unintended network effects of pre-authorization.
As more vertical consolidation occurs in healthcare–for example Humana is buying the division of Kindred involved in hospice–the legal system is starting to recognize the network effects of these relationships. A recent case in Massachusetts allows a family to sue Walgreens for failing to act in a case where patient with epilepsy died because paperwork from the physician was not available to the dispensing pharmacy–she never got her antiseizure meds, and died after a seizure. From CNN: ‘The pharmacy is not required by law or regulation to facilitate the pre-authorization, but “it is evident that they have some role in furthering the well-being of their patients, and are well suited to assist patients with certain issues regarding their medication” the court wrote.’ The question for the future is: what is the best way to strengthen these networks? Is it ownership? I’m not too sure about that.
Family can sue Walgreens over woman's death after insurance denial, court says - CNN
2. Network effects from opioid dispensing policies.
“Have you been unable to get your opioid prescription pain medication because your pharmacist was unwilling to fill it even though the pharmacy had it in stock?” From national online surveys: 12% answered yes in December 2016. 18 months later, in May 2018, 27% answered yes. Worrisome–suggests that access to opioids is now problematic for patients with cancer pain. Are their needs being swept away in the national concern over opioids? Is this a kind of network failure at the local level – e.g. pharmacists don’t feel certain about what they’re being asked to do, because they have little relationship to the prescribing team or patient, so they balk.
ACS-sponsored opioid access survey results
3. The network depends on the most local connection.
The lesson from biology about networks? Local interactions are responsible for regulating large-scale phenomena. And what happens in ant colonies scales up into human systems. What the preceding 2 stories illustrate is that the top-down policies weren’t the failure points–the most local connections were where the failure happened–with terrible consequences. We’re going to have to work on the networks of things–acute care, clinics, pharmacies, etc–and the connections between them to create care delivery that works across settings.
The most important connection in any network is the local | Aeon Essays
4. The vulnerability in systems related to local factors.
“Spending on post–acute care (PAC), or care provided after a stay in an acute care hospital, is the largest driver of variation in total per capita Medicare spending. To address this, Medicare has targeted PAC spending in payment reforms such as Model 3 of Medicare’s Bundled Payments for Care Improvement (BPCI) initiative, a voluntary bundled payment program.” The problem, reported in JAMA? The organizations couldn’t make this work. “Only 3.7% of PAC organizations ever participated in the risk-bearing phase of BPCI Model 3, and 43.2%of those participants discontinued participation by the second quarter of 2017.” Disappointingly, this report contains nothing about why–and given that orgs don’t like reporting failures, we’ll probably never find out. If you access to this article, look here.
Participation in a Voluntary Bundled Payment Program by Organizations Providing Care After an Acute Hospitalization | Health Care Economics, Insurance, Payment | JAMA | JAMA Network
5. Physician-assisted dying, now.
The 2017 report from California’s End of Life Options Act was just published, right at the same time as the proceedings from a workshop held at the National Academy. The California report, while it contains less detail than the Washington or Oregon reports, shows nothing surprising, although the patients are a tiny bit more diverse. The National Academies workshop was quite a diverse group, and by way of disclosure, I was a speaker. My main point, which you can watch here, is that there is a public majority consensus about this, and whatever one thinks about the practices, we now need to deal with them responsibly. My personal take is that we – our field – need to consider deeply what patients are hoping for with a medically assisted death, and compare that to the experiences they have now (some which are not so good). The reason: the use of euthanasia is steadily rising in Belgium, and the next discussion in Canada is going to be about medically assisted dying by advance directive
Physician-Assisted Death: Scanning the Landscape and Potential Approaches
6. What's the critical mass for social change?
Centola et al conducted an empirical experiment, published in Science, with online communities indicates that 25% of people committed to a new behavior is the tipping point–a bit higher than some prior estimates. (Note that for physician-assisted dying, we’re way past 25%). Of course, medical networks may be different, but this finding gives us some new ways to think about creating social change in the serious illness space – and it provides a more solid basis for the principle i’ve learned that you don’t have to start with the most recalcitrant person. In fact, you shouldn’t spend your time with them. Go for the 25% who are open to you and get them to commit. [If you need access for the Science paper, look here.]
How Many People Does It Take to Start a Revolution? - YouTube
This newsletter is made possible by the John A. Hartford Foundation. But the views, opinions, and recommendations are mine alone. Thanks this week to Bob Arnold, Katy Butler, and Amy Berman.
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