Good Death How palliative care innovation will disrupt hospitals, doctors and the way we die
Copyright © 2011 By Joel P. Engardio For information about or to support the documentary film version of “Good Death” please contact: Joel Engardio jengardio@hotmail.com 415-577-6251 www.joelengardio.com
Joel P. Engardio Harvard Business School BSSE Section 2 Professor Willy Shih April 25, 2011
1 Table of Contents I. A New Definition In Medical Care: The Palliative Way…………………………………2 II. Hypothesis: What A Palliative Disruption Will Look Like…………………………….5 III. Disruptive Innovation: Low‐End and New‐Market………………………………………7 a. Disruptive Versus Sustaining……………………………………………………........9 b. LowEnd and NewMarket…………………………………………………………...11 c. Moving UpMarket………………………………………………………………….......12 d. Business and Politics…………………………………………………………………...14 IV. Culture Model…………………………………………………………………………………………17 V. Organizational Capabilities: Resources, Processes and Priorities………………23 VI. Job‐Based Segmentation (The “Baby Boomer” Effect)……………………………….28 VII. Conclusion………………………………………………………………………………………………31
2 A New Definition In Medical Care: The Palliative Way
“As much as I believe in palliative care, the very existence of hospitals is an impediment to it. Hospitals exist to save people. Doctors all want to save somebody. But we live in a culture where we believe medicine can fix more than it can. Maybe we need to change the definition of ‘save.’ People don’t think of being saved as saving themselves from a horrible death in order to have a good one.” Dr. Allen Kachalia, Medical Director of Quality and Safety at Brigham and Women’s Hospital in Boston, when asked why hospitals are not eager to adopt and expand the palliative care philosophy in every department.1 “Yup, you’re on to us…We see ourselves as a Trojan horse of fundamental change. We want to integrate palliative care into the genome of medicine so it keeps replicating. Changing the DNA of hospitals needs to happen, and that’s a disruptive innovation if there ever was one.” – Dr. Diane Meier, director of the Palliative Care Institute at the Mount Sinai School of Medicine in New York, when asked if the palliative care philosophy is an innovation that could disrupt the traditional hospital over time.2 Everyone dies and many die badly. We spend the final weeks of life in a hospital receiving aggressive treatments that cost hundreds of thousands of dollars, have no cure and do little to prolong any quality of life. What is the palliative way? It is not about hastening death in a morphine haze, as commonly perceived. It is not just the last months of life one might spend in hospice care, having given up on all treatment. The palliative way is about the long journey of life in which patients are treated, cared for ‐‐ even cured of ‐‐ a variety of illnesses with the final stop being a natural “good death” when the body has run its course. The palliative way is a holistic approach to medicine where all needs of the patient are met in a synergy between health care providers. 1 Dr. Allen Kachalia interviewed by Joel Engardio March 25, 2011 2 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011
3 In a hospital, a patient might see a dozen different doctors, nurses and social workers who independently look at something specific – your heart, your lungs, your diet, your emotional state – without speaking to each other. A patient has to tell their story multiple times to a host of health care professionals who are only interested in one part of the story. The palliative philosophy creates an integrated medical team that puts everything – heart and lung functions, diet, and emotional health – into one matrix where all the dots are connected and addressed together from diagnosis to death. Dr. Atul Gawande, an associate professor at Harvard Medical School, said hospitals are good at over‐serving patients while failing to meet their actual needs: “Our medical system is excellent at trying to stave off death with $8000‐a‐ month chemotherapy, $3000‐a‐day intensive care, $5000‐an‐hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. The failure of our system of medical care for people facing the end of their life runs much deeper. To see this, you have to get close enough to grapple with the way decisions about care are actually made.”3 When it comes to death, surveys say the top priorities of patients – or jobs they want done ‐‐ are “avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others.”4 Dr. Gawande said palliative care matches these jobs, but hospitals don’t: “Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium…The end comes with no chance for you to have said goodbye or ‘It’s OK’ or ‘I’m sorry’ or ‘I love you.’”5
3 Gawande, Atul, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 4 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 5 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010
4 The tenets of palliative care – pain management, close communication, navigating difficult and complex treatment choices, emotional and spiritual support for patient and family6 – are all things hospitals do poorly or fail altogether. Studies show that the differences between hospital and palliative care are enough to have an impact on length and quality of life:7 “Palliative care is medical care focused on relief of physical and psychological distress and delivered at the same time as care that is meant to cure or prolong life. There is emerging evidence that palliative care not only improves quality of care and quality of life and reduces unnecessary hospital use, it also appears to prolong life, compared with usual care patients who do not receive simultaneous palliative care.” ‐‐ Dr. Diane Meier, director of the Palliative Care Institute at the Mount Sinai School of Medicine in New York. 8
6 Center to Advance Palliative Care, 2011 7 New England Journal of Medicine, “Early Palliative Care for Patients with Metastatic Non‐Small‐Cell Lung
Cancer,” August 19, 2010 8 Nelson, Roxanne, Medscape Oncology, April 20, 2010
5 Hypothesis: What A Palliative Disruption Will Look Like “Disruptive companies are those whose initial products are simpler and more affordable than the established players’ offerings. They secure their foothold in the low end of the market and then move to higher‐performance, higher‐margin products, market tier by market tier.”9 Palliative care is disruptive because instead of offering a complicated and expensive intensive care unit (I.C.U.) for terminally ill patients, it provides an easier and cheaper alternative that does the same job: a space for death to occur. Whether under I.C.U. or palliative care, a terminally ill patient will eventually die. But the palliative way costs less and provides a higher quality of life – even longer life, according to a recent New England Journal of Medicine study.10 When comparing patients with the same terminal illnesses, research shows that choosing palliative care versus the hospital I.C.U. can add real time to one’s life: “those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.”11 End‐of‐life care is considered a low‐end activity for hospitals, which gives palliative care an opportunity to satisfy the next part of disruptive theory: moving up‐market. Palliative care providers don’t see themselves as just an end‐of‐life service. They aim to treat patients over the course of many years, from the moment of diagnosis until death. Stand‐alone palliative care centers will move up‐market to treat people with chronic illnesses that can be managed using the palliative philosophy of holistic medicine. As the disruptive theory plays out, hospitals will 9 Christensen, Alton, Rising, Waldeck, “The New M&A Playbook,” Harvard Business Review, March 2011 10 New England Journal of Medicine, “Early Palliative Care for Patients with Metastatic Non‐Small‐Cell Lung
Cancer,” August 19, 2010 11 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010
6 gladly shed end‐of‐life care and other low‐end activities like chronic illnesses that don’t have a surgical cure. Hospitals will then focus on more complex and higher value activities like the I.C.U. and organ transplants. Meanwhile, stand‐alone palliative centers will keep expanding its philosophy into larger areas of health care. Over‐served and new‐market patients will go to palliative centers instead of hospitals, seeking cheaper and simpler care that produces as‐good or better results. These patients will prefer the new palliative philosophy – or technology ‐‐ because it best meets the jobs they need done. The palliative centers will look like hospitals and treat a variety of illnesses. But they will operate under a completely new culture model. They will use different processes and priorities that are conducive to the palliative philosophy of medical care. As the palliative care disruption moves up‐market, hospitals will shrink to the point where they are only a place for emergency trauma, I.C.U. and the most intricate of surgeries. Stark differences in culture will prevent hospitals from successfully adopting and integrating palliative care into its established processes. While the disruption has already started, it won’t happen overnight. The full effect might not be felt for decades, as was the case for other disrupted industries. This paper will examine hospitals and palliative care using the lenses of Harvard Business School theories: Low‐End and New‐Market Disruption, Culture Model, Organizational Capabilities (Resources, Processes, Priorities), and Job‐Based Segmentation. The following pages look at each theory more in‐depth.
7 Disruptive Innovation: LowEnd and NewMarket “When I started in [palliative care], people said it would go away if it was successful because hospitals would integrate the philosophy into medical care. But the opposite has happened. Hospitals have difficulty seeing the positive impact palliative care has across the board. They only see it as a cost‐center and do not see it as profitable. So they shed it.” Diane Stringer, CEO of Hospice of North Shore & Greater Boston, when asked why the major Bostonbased hospital chain Partners Healthcare sold its hospice program to her.12 There is a classic story of an industry so large, so established and so irreplaceable that its disruption seemed unthinkable. Yet the disruption happened, slowly ‐‐ almost unnoticeably at first ‐‐ over the course of 30 years. Where are steel mills now? As the story goes,13 mini‐mills began making concrete reinforcing bar (rebar) with a new technology that allowed them to compete with large steel mills. The big mills, however, didn’t care about the low‐end rebar market and dismissed the new technology. For the big mills, making rebar was a distraction from focusing on high‐ end products like sheet steel that provided much more profit. So they gladly shed rebar to the mini‐mills. In time, the mini‐mills perfected the technology and took over the rebar market. Then they looked to the next rung in the ladder to take over: bars and rods. As with rebar, the big steel mills saw bars and rods as more of a nuisance than a profit‐maker. So they gladly shed bars and rods, too.
12 Diane Stringer interviewed by Joel Engardio April 4, 2011 13 Christensen, Clayton, “The Innovator’s Solution,” Harvard Business School Press, 2003, pp. 35‐39
8 Again, mini‐mills were able to dominate the market and move on to the next stop: structural steel. This cycle kept repeating for years. Late in the disruption, large steel mills tried adopting the new technology that made mini‐mills so competitive, but the RPP (resources, processes, priorities) and culture model of the big mills was so engrained that it got in the way of change. Eventually mini‐mills conquered sheet steel ‐‐ the most profitable product of all ‐‐ and put large mills out of business. The disruption took three decades, but was hard to stop once it was in motion. In this cautionary tale, hospice care is rebar, the palliative philosophy is the new technology and hospitals are the big steel mills. The mini‐mill is Diane Stringer, CEO of the Hospice of North Shore and Greater Boston. Hospice care is under the palliative umbrella, focusing on the very end of life. Hospitals consider hospice the lowest tier of medical care since it treats patients with less than six months to live. In December 2010, the Boston‐based hospital chain Partners Healthcare sold its hospice program to Stringer’s “mini‐mill.”14 Six months earlier, another major hospital chain shed its end‐of‐life hospice services to a palliative “mini‐mill.” When New York‐based Continuum Health Partners sold its hospice and palliative programs, the deal sparked the following headline: “Metropolitan Jewish Health System becomes New York’s biggest end‐of‐ life caregiver, taking over beds and staff in NYC as Continuum exits the field.”15
14 Press release: “Hospice of the North Shore Acquires Partners Hospice,” Dec. 13, 2010 15 Messina, Judy, “Largest NY nonprofit hospice business is formed,” Crain’s New York Business, June 1, 2010
9 Why are hospitals shedding the low‐end activity of hospice? Dr. Eyal Zimlichman is studying how to help hospitals more effectively manage their strategic future. He is with Sheba Medical Center in Israel and Harvard Medical School’s Executive Management Program. He said hospitals are mainly interested in the “heroic medicine” that best fits their culture and financial outlook: “Terminal illness is not interesting to hospitals. It’s non‐sophisticated treatment and low‐end. Hospitals are focused on high‐end, profit‐making treatments that generate lots of income ‐‐ like heart transplants. But you can’t heart‐transplant everyone. The profit to the hospital is low when you are no longer a candidate for anything heroic like a heart transplant. So it is easy for the hospital to shed everyone else.”16 By shedding the lower tiers of medical care to stand‐alone palliative centers, hospitals are open to disruption. In the beginning, hospitals don’t mind when palliative centers take over the first tier of terminal illness or even the second tier of chronic disease. But eventually, hospitals will be left with only a few highly specialized tiers like organ transplants at the top of the ladder. Disruptive Versus Sustaining There are two types of innovations: disruptive and sustaining. Hospitals shed palliative care because it is a disruptive innovation. If palliative care were a sustaining innovation, hospitals would do the opposite and expand it. Theory explains the difference between sustaining and disruptive innovations:
16 Dr. Eyal Zimlichman interviewed by Joel Engardio, March 10, 2011
10 “A sustaining innovation targets demanding, high‐end customers with better performance than what was previously available…Disruptive innovations, in contrast, don’t attempt to bring better products to established customers in existing markets. Rather, they disrupt and redefine that trajectory by introducing products and services that are not as good as currently available products. But disruptions offer other benefits – typically, they are simpler, more convenient, and less expensive products that appeal to new or less‐ demanding customers…Because the pace of technological process outstrips customers’ abilities to use it, the previously not‐good‐enough technology eventually improves enough to intersect with the needs of more demanding customers. When that happens, the disruptors are on a path that will ultimately crush the incumbents.”17 In other words, a sustaining innovation for a hospital would be a better performing MRI, surgical tool or I.C.U. life support machine. These target high‐end services that are high‐profit. But a better life support machine that prolongs life in an unconscious state does not fulfill the job a terminal patient needs done: quality of life while he is still able to enjoy it. The sustaining innovation over‐serves. That’s why palliative care is a disruptive innovation. While the I.C.U. offers longer life (usually by over‐serving in a vegetative state), the life span under palliative technology is not as long ‐‐ but good enough because it provides higher quality in a conscious state. And studies show that palliative technology is improving over time, even outperforming some I.C.U. treatments in life span.18 Palliative care offers other benefits such as being simpler and cheaper compared to a life support machine. It also attracts patients who don’t want overly aggressive treatment at the end of life.
17 Christensen, Clayton, “The Innovator’s Solution,” Harvard Business School Press, 2003, p. 34 18 New England Journal of Medicine, “Early Palliative Care for Patients with Metastatic Non‐Small‐Cell Lung
Cancer,” August 19, 2010
11 LowEnd and NewMarket As a disruptive innovation, palliative care fits two categories of disruptions: low‐end and new‐market. Palliative care is hybrid of both. A low‐end disruption pulls the least profitable customers from an established company. As a low‐end disruption, palliative care attracts the low‐profit patients hospitals like least: chronically or terminally ill patients who won’t benefit from high‐end and high‐profit surgical procedures. A new‐market disruption has a different measure of performance. While the existing I.C.U. market measures performance by the length of life, the new palliative market is measured by quality of life. The I.C.U. can keep a patient alive on a machine, but the palliative way provides more quality time. A new‐market disruption also targets new customers who weren’t previously consuming, and it draws customers out of the existing market who find the new product easier to use. As a new‐market disruption, palliative care offers treatment to patients who don’t go to hospitals because they can’t be cured by the hospital’s specialty: heroic efforts like an organ transplant. Palliative care can also take place at home, which is more convenient, accessible and affordable than the hospital. The low‐end and new‐market combination packs a one‐two punch: “Disruption has a paralyzing effect on industry leaders. With resource allocation processes designed and perfected to support sustaining innovations, they are constitutionally unable to respond. They are always motivated to go up‐market, and almost never motivated to defend the new or low‐end markets that the disruptors find attractive.”19
19 Christensen, Clayton, “The Innovator’s Solution,” Harvard Business School Press, 2003, p. 35
12 Ultimately, everyone becomes a terminal patient because everyone dies. If palliative care can deliver what every terminal patient wants ‐‐ more quality of life for a longer period of time – and do it better than the life support machine, then the palliative way will corner the market on end‐of‐life care. With that success, palliative care can take on the treatment of patients who aren’t so close to death. This cycle could continue until palliative care dominates health care to the point that hospitals only provide niche services like transplants, neural surgery and extreme trauma care. This could take many years, if not decades. But it is not considered out of the realm of possibility: “Hospitals could shrink enormously,” said Dr. Diane Meier, director of the Palliative Care Institute at New York’s Mount Sinai hospital, “becoming places only for high‐tech, specialized services.”20 Moving UpMarket Dr. Zimlichman of Sheba Medical Center and Harvard Medical School said palliative care is already looking up‐market to chronic illnesses like back pain, congestive heart failure and obstructive pulmonary disease. Hospitals make some money on these patients, but not a lot. Now, with health care reform, hospitals have less interest in low‐end patients because the system is moving toward paying hospitals for outcomes versus procedures. There will also be penalties for re‐admissions. Dr. Zimlichman said if a hospital can’t cure a chronically ill patient with an expensive and heroic treatment, then the patient is no longer worth the busy work it takes to manage their disease:
20 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011
13 “The U.S. system of healthcare is perfectly designed for what it gets: if the system reimburses providers by fee‐for‐service, don’t be surprised when half of the procedures are not warranted or justified. The system is engineered to earn money by shifting patients to extra tests. But under the changing rules of the healthcare market ‐‐ in which hospitals are paid for outcomes ‐‐ hospitals will shed more patients to palliative care. For example, no one wants the patient bed‐ridden with low back pain. He won’t bring lots of revenue if a big surgery won’t cure him. And surgeries on that kind of patient have a very low chance of a better outcome. So when you’re paid on outcome, there’s no point to deal with these patients anymore. Hospitals will shed them and palliative care will take them. Hospitals will improve their financials by focusing on things like the I.C.U., which they think they do best. If the I.C.U. is the only thing a patient needs and nothing can replace it, then hospitals can make a lot of money on it. Everything else they can shed.”21 After chronic back pain, Dr. Zimlichman said taking on congestive heart failure and pulmonary disease are the next logical steps for palliative care. Indeed, just two months after the New York‐based palliative care provider Metropolitan Jewish Health System (MJHS) acquired the Contiuum hospital chain’s palliative program, MJHS announced it was the first in the United States to earn certification for its home care heart failure disease management program.22 Diane Stringer, the CEO who bought the hospice program from another major hospital chain, understands exactly what MJHS is doing. She wants to do the same: “I saw opportunities in palliative care to move upstream. We can take the heart failure patients; the patients with chronic advanced diseases like cardiac, respiratory and dementia. They don’t need a hospital stay anymore. We are building a facility in Boston with chronic patients in mind, where they can get tuned up and go home. It’s a place for symptom management and discharge, not just a place to go for your last week of life.”23 Theory explains how hospitals won’t see the disruption coming:
21 Dr. Eyal Zimlichman interviewed by Joel Engardio, March 10, 2011 22 MJHS press release, August 2, 2010 23 Diane Stringer interviewed by Joel Engardio April 4, 2011
14 “Although investment analysts can see a company’s potential in the market tier where it’s currently positioned, they fail to foresee how a disrupter will move up‐market as its offerings improve. So they persistently underestimate the growth potential of disruptive companies.”24 Business and Politics Stringer said she was surprised that Partners Healthcare sold its hospice program to her. At first she wondered if they would drive her out of business: “I worried about Partners. If they ever did get their act together, they would be formidable in the marketplace.”25 Stringer knows that palliative care is a good business to be in: “Yes, we can make money. The margins are small, relative to something like a heart transplant. But we can make money on volume. We offer a service that just about everyone needs except for those who step off a curb and get hit by a bus.”26 The long‐range goal for Stringer is to keep disrupting hospitals: “Partners will possibly shed more, like acute chronic care. We want to manage everyone’s chronic illness so people have not just a good death, but also a good quality of life for years. Except for the very small group of people that need a heart transplant, palliative care should be the way all medicine is delivered. But it will happen only if incentives are appropriately aligned. This is the ‘blue‐sky’ goal.”27 What could darken the skies ahead? Politics can, said Dr. Meier, director of the palliative program at Mount Sinai hospital in New York. During the recent health care reform debate, much attention was paid to terms like “death panels” and “pulling the plug on grandma.” Doctors don’t have lengthy discussions with patients
24 Christensen, Alton, Rising, Waldeck, “The New M&A Playbook,” Harvard Business Review, March 2011 25 Diane Stringer interviewed by Joel Engardio April 4, 2011 26 Diane Stringer interviewed by Joel Engardio April 4, 2011
27 Diane Stringer interviewed by Joel Engardio April 4, 2011
15 about end‐of‐life wishes because doctors aren’t paid for those conversations. The attempt to compensate doctors for time spent talking to patients was turned into “death panels.” Dr. Meier remembers the debate all too well: “Remember, death panel politics almost derailed all of health care reform. Avoid politics at your peril. As an innovative disruption, palliative care is a profound disruption. There are so many stakeholders who will be badly hurt by fundamental change that they will fight it tooth and nail. Hospitals are major employers, they are unionized, and there are lots of lobbyists working to keep things the way they are. The art of the possible is very different from the vision, if starting from scratch. We have to ask ourselves: how do we make this a disruptive innovation that can actually happen? It involves the political and policy process. We have to ask: how do you move policy?”28 Still, Dr. Meier said she is convinced that the day will come when palliative centers like North Shore in Boston and MHJS in New York will be on the winning end of the health care business model. She said budget capitation would force hospitals to become dependent on places like North Shore and MHJS. Hospitals may want to shed chronically ill patients now, but will later seek to partner with organizations that know how to do palliative care well. Chronically ill patients won’t always be considered low‐end, as they will generate more earnings under capitation. Dr. Meier said a stand‐alone palliative center like North Shore would reap the business: “I believe capitation is coming for global budgets. Therefore it’s smart to invest in the delivery of services that are not well compensated now, but will be in the future. The more visionary hospice leaders are recognizing there will be a huge need to step up and manage the care of a much larger group of patients.”29
28 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011 29 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011
16 North Shore hospice CEO Stringer seems to understand what is coming: “Partners said we have the expertise. Now we are the provider of their end‐of‐life services, but they are not our only supplier.”30 Stringer is making plans to build a stand‐alone facility in Boston that will place more emphasis on treating patients with chronic illness than those who are actively dying. On a larger scale in Boston, she will replicate the 20‐bed stand‐alone facility she already has in Danvers, Massachusetts. The stand‐alone facilities look like small hospitals, but operate with an entirely different philosophy and culture. That’s why hospitals are not taking advantage of the palliative disruption and why palliative care works best when it is set apart from the traditional hospital: “I don’t know of a hospital that has built a robust, successful hospice program. It is so different from what hospitals do. It’s a cultural issue for hospitals – they can’t integrate. Hospitals just don’t get it. But to be fair, we also have larger societal and cultural issues that transcend hospitals when it comes to death and dying.”31 30 Diane Stringer interviewed by Joel Engardio April 4, 2011 31 Diane Stringer interviewed by Joel Engardio April 4, 2011
17 Culture Model “Physicians are trained to do all they can to prolong life. There’s a fundamental, almost philosophical, conflict in the way physicians are trained and the goals of hospice. A physician has to say, ‘This person’s illness is terminal and they will not recover.’ Most physicians find that difficult to do.” John Kimberly, Wharton School of Business management professor32 Dr. Allen Kachalia, Medical Director of Quality and Safety at Brigham and Women’s Hospital in Boston, said doctors are faced with a paradox: patients often arrive at a large hospital when they’ve exhausted all other options. They come to the hospital for extreme treatment in the hope to live longer, and doctors oblige: “We aim to honor the patient’s wishes, which means we keep going and going to avoid the sense of giving up even when we can’t do anything. That keeps us from focusing on palliative care. We know the patient is here because they have problems that can’t be fixed. That’s the tension we have to balance.”33 Dr. Kachalia said culture affects both patients and doctors. The entire society has difficulty dealing with the reality of death, even though it affects everyone. And doctors grow up in a death‐avoidance culture long before they ever become doctors: “We need to change the larger culture of our society first because that covers both patients and doctors. People need to see palliative care as an option they want. They need to see that palliative care is a way of treatment and it’s not about giving up. If that message can get out, then it won’t be hard to change the hospital culture if we can convince physicians this is what the patients want.”34 This sets up a classic which‐comes‐first scenario: do patients learn about palliative care from their doctors and demand it, or do doctors discover their patients want palliative care and offer it?
32 “The Business of Hospice Care,” Knowledge @ Wharton, May 31, 2006 33 Dr. Allen Kachalia interviewed by Joel Engardio March 25, 2011 34 Dr. Allen Kachalia interviewed by Joel Engardio March 25, 2011
18 Doctors in hospitals tend to avoid telling their patients about palliative and hospice programs, which means the service goes largely unused. “Despite the increasing availability of palliative care services in U.S. hospitals and the body of evidence showing the great distress to patients caused by symptoms of the illness, the burdens on family caregivers, and the overuse of costly, ineffective therapies during advanced chronic illness, the use of palliative care services by physicians for their patients remains low.” ‐‐ New England Journal of Medicine editorial35 Dr. Atul Gawande, an associate professor at Harvard Medical School, wrote about physician culture in the New Yorker article “Letting Go.” The perceptions doctors hold onto often get in the way of helping a terminal patient deal with the reality of a diagnosis. “Our views may be unrealistic,” Dr. Gawande said, citing studies that showed 63 percent of doctors overestimated survival time of their terminally ill patients.36 Dr. Gawande also said doctors are afraid to have frank discussions with terminal patients that deal with the realities of the diagnosis: “We often avoid voicing these sentiments. Studies find that although doctors usually tell patients when a cancer is not curable, most are reluctant to give a specific prognosis, even when pressed. More than 40 percent of oncologists report offering treatments that they believe are unlikely to work.”37 He wrote about a patient who had both lung and thyroid cancer. The lung cancer was inoperable and would kill the patient. But the thyroid cancer was fixable.
35 Kelley, Amy, MD and Meier, Diane, MD, “Palliative Care – A Shifting Paradigm,” New England Journal of
Medicine, August, 19, 2010 36 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 37 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010
19 Dr. Gawande wondered: Should he operate on the thyroid of a patient who was dying from lung cancer, sacrificing quality of life, or pursue the palliative way? “When you have a patient like Sara Monopli, the last thing you want to do is grapple with the truth. Given the extent of the [thyroid] surgery that would have been required, and the potential complications, the best course was to do nothing. But explaining my reasoning to Sara meant confronting the mortality of her lung cancer, something that I felt ill prepared to do…My solution was to avoid the subject altogether. I told Sara that the thyroid cancer was slow‐growing and treatable. The priority was her lung cancer, I said. Let’s not hold up treatment for that. We could monitor the thyroid cancer and plan surgery in a few months…I saw her every six weeks, and noted her physical decline from one visit to the next. I even raised with her the possibility that an experimental therapy could work against both her cancers, which was sheer fantasy. Discussing a fantasy was easier – less emotional, less explosive, less prone to misunderstanding – than discussing what was happening before my eyes.”38 A doctor’s identity of healer is threatened when he must tell a patient that a disease is terminal and pursuing aggressive treatment is not in the best action: “Your self image as a person who helps others get things done butts up against the reality that you are going to be saying no. If you’re no longer the hero, will people see you as the villain? Difficult conversations threaten our identity. Our anxiety results not just from having to face the other person, but from having to face ourselves. The conversation has the potential to disrupt our sense of who we are in the world.”39 Despite the culture barriers to palliative care, there has been a 125 percent increase in the number of U.S. hospitals with palliative programs in the past decade. Today, almost 60 percent of all U.S. hospitals (with more than 50 beds) have a palliative program. The rate is 80 percent in hospitals with more than 300 beds.40 But Dr. Diane Meier, director of the Palliative Care Institute at the Mount Sinai School of Medicine in New York, said these numbers don’t tell the whole story: 38 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 39 Stone, Patton, Heen, “Difficult Conversations” Penguin Books, 1999, pp. 15 and 112 40 Nelson, Roxanne, Medscape Oncology, April 20, 2010
20 “The majority of U.S. hospitals report a palliative team, but that does not mean needs are met. The fact a palliative program exists tells us nothing about its penetration.”41 Dr. Meier said a hospital palliative team should be seeing six percent of the hospital’s admissions. This is based on the criteria that about two percent of all hospital admissions result in death and three times that number have palliative needs. But Dr. Meier’s research shows the actual number of hospital patients who receive palliative care is only one percent, resulting in a five percent gap.42 Out of 235,000 Medicare patients who died from advanced cancer between 2003 and 2007, less than half were offered hospice care. And when they were given the option, it was often so close to the day of death that it didn’t matter. Nearly a third of the patients died in a hospital I.C.U., receiving aggressive treatments “at the expense of improving quality of life in the last weeks and months.”43 Yet hospice care is growing. In the past 25 years, Medicare reimbursement for hospice care has increased from $68 million to more than $10 billion – and is expected to reach $45 billion in the next 20 years.44
With so many palliative programs inside hospitals, why are so few patients
benefiting? And why are stand‐alone palliative and hospice centers thriving? The answer is culture. Hospitals don’t employ doctors that fully embrace the palliative philosophy and stand‐alone palliative centers do.
41 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011 42 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011 43 Dartmouth Atlas Project and Robert Wood Johnson Foundation, “Nearly One‐Third of Medicare Patients with
Advanced Cancer Die in Hospitals and ICUs; About Half Get Hospice Care,” November 16, 2010 44 “The Business of Hospice Care,” Knowledge @ Wharton, May 31, 2006
21 In hospitals with a sub‐group of palliative doctors dedicated to the palliative philosophy, the difficulties are pronounced: “There are big battles in hospitals to connect patients with needs to the service they’re not getting,” Dr. Meier said.45 The culture model theory explains the difficulty: “As sub‐groups within an organization develop their own strong, independent cultures, they experience problems communicating with other groups and become more inflexible in their own operation. Managers [should] view communication breakdowns as symptoms of a deeper root cause: real differences in how people perceive and understand the phenomena they encounter, because of their membership in different cultural units.”46 According to theory, a strong culture is desirable for consistency. It is how everyone in the organization can instinctively assume the best ways to do things. But while “culture is a powerful tool for consistently pursuing a particular set of goals, culture can constitute a disability at times when change is critical to addressing new competitive or technological challenges from unexpected directions. Attempts to change culture or process by directly attacking culture and process are unlikely to result in significant change.”47
Theory offers two options for changing engrained culture: (1) the “burning
platform” situation in which a sudden cultural shift that shocks the system comes with a “change or perish” choice, or (2) a gradual evolution. The measured shift involves creating separate teams to tackle problems in a way the entire organization needs to behave for its future survival. As the new group develops better processes,
45 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011 46 Christensen, Clayton, Harvard Business School Case, “What Is an Organization’s Culture?” August 2, 2006 47 Christensen, Clayton, Harvard Business School Case, “What Is an Organization’s Culture?” August 2, 2006
22 they are not sent back into the old organization. Instead, members from the old organization are slowly added to the new team and exposed to the new culture.48
Stand‐alone palliative centers are creating a new physician culture. Harvard
Medical School will start a one‐year program in 2011‐12 for mid‐career doctors who want to switch to palliative medicine. Dr. Meier and others at teaching schools purposefully train student doctors in the palliative way. These efforts are what Dr. Meier describes as a “Trojan horse” that will deliver palliative‐trained physicians: “The more integrated we are, the more it spreads.”49 While working in a stand‐alone palliative center would be easier, Dr. Meier said she chooses to stay in the hospital setting where changing the culture is a daunting task: “Because we are disruptive, everything we do is counter‐culture. We are constantly speaking a different language and swimming against the tide. It’s exhausting ‐‐ mentally, spiritually and professionally. But I need to be on the inside to have an influential national platform.”50
48 Christensen, Clayton, Harvard Business School Case, “What Is an Organization’s Culture?” August 2, 2006 49 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011 50 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011
23 Organizational Capabilities: Resources, Processes and Priorities “We have a palliative care presence, it’s not like we aren’t paying attention. Palliative care could be compatible with today’s hospital, but we don’t start it soon enough. And we need a better way to deliver it that helps people understand why palliative care is good for them.” Dr. Allen Kachalia, Medical Director of Quality and Safety at Brigham and Women’s Hospital in Boston51 Most large hospitals have a palliative care unit. There are ample resources for it. But the palliative units are under‐utilized because the hospital’s culture and processes do not consider palliative care a priority. According to theory: “Whereas resources and processes are often enablers that define what an organization can do, priorities embedded in the business model often represent constraints – they define what the organization cannot do.”52 Much like culture, process is difficult to change once it becomes so engrained in an organization that it happens instinctually. Theory says what was once considered a strength can become a liability: “When the capabilities have come to reside in its processes and business model and especially when they have become embedded in culture, change can be extraordinarily difficult...A process that becomes a capability in executing a certain task can be a disability in executing other tasks. In contrast to the flexibility of many resources, processes by their very nature are meant not to change.”53 If palliative care was a sustaining innovation – a higher‐end product like a better MRI machine, surgical instrument or life support system meant to serve higher‐profit patients with improved performance – the hospital would have an
51 Dr. Allen Kachalia interviewed by Joel Engardio March 25, 2011 52 Christensen, Clayton and Kaufman, Stephen, Harvard Business School Case, “Assessing Your Organization’s
Capabilities: Resources, Processes, and Priorities,” August 21, 2008 53 Christensen and Kaufman, HBS Case, “Assessing Your Organization’s Capabilities,” August 21, 2008
24 easy time adopting it. Since palliative care is a disruptive innovation – a lower‐end product that serves a new category of lower‐profit patients with less high‐tech demands – the hospital is having a difficult time: “The incumbent leaders in an industry almost always emerge victorious from sustaining‐technology battles, but lose battles of disruption. Established companies have the resources required to succeed at both sustaining and disruptive technologies. But their processes and the priorities that are embedded in their business models constitute disabilities in their efforts to succeed at disruptive innovation…Very often the cause of an innovation’s failure is that the wrong processes were used in managing its development and execution.”54 What are hospitals doing wrong? Dr. Diane Meier, director of the Palliative Care Institute at the Mount Sinai School of Medicine in New York, said the process problem goes all the way back to medical school and the residency programs that train future doctors: “We will never see change in the hospital without fundamental change in medical education. Medical school rewards people who are good at memorizing; it favors people with science‐only skills. That’s exactly the opposite of what is needed for patient care. Doctors need to understand science. But they also need to understand the patient, which I’d say is most important. So much of being a good doctor is relational and listening; you have to be able to tolerate ambiguity and uncertainty. Yet the people we are choosing to be doctors have the opposite temperament. They see patient care as a burden. They stare at their computer screens, because to look elsewhere means dealing with emotion and things that are sad.”55 Dr. Atul Gawande, associate professor at Harvard Medical School, wrote in the New Yorker that doctors tend to give patients what they want – more treatments, more medicine – regardless of outcome because it is easier than having to deal with the complexities of patient care that go beyond ordering another test: 54 Christensen and Kaufman, HBS Case, “Assessing Your Organization’s Capabilities,” August 21, 2008 55 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011
25 “In an era in which the relationship between patient and doctor is increasingly miscast in retail terms – ‘the customer is always right’ – doctors are especially hesitant to trample on a patient’s expectations. Hope is not a plan, but hope is our plan.”56 Doctors don’t usually value the processes that palliative care requires because it is seen a low‐end activity. But Susan Block, a palliative‐care specialist at Brigham and Women’s Hospital in Boston, said dealing successfully with patients in a palliative care setting requires the same attention to process as the most intricate of medical procedures: “A family meeting is a procedure, and it requires no less skill than performing an operation.”57 Dr. Gawande explained in his New Yorker article how Dr. Block taught him the importance of process when dealing with terminal patients: “There is no single way to take people with terminal illness through the process, but, according to Dr. Block, there are some rules. You sit down. You make time. You’re not determining whether they want treatment X versus Y. You’re trying to learn what’s most important to them under the circumstances – so that you can provide information and advice on the approach that gives them the best chance of achieving it. This requires much listening as talking. If you are talking more than half of the time, Dr. Block says, you’re talking too much.”58 The Mayo Clinic supports Dr. Meier and Dr. Block’s concerns that many physicians do not have the necessary listening skills for quality patient care. When Mayo Clinic doctors conducted a recent study that examined the perceived barriers, supports and changes needed in end‐of‐life care in the I.C.U., the research concluded that lack of communication was the biggest problem: 56 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 57 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 58 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010
26 “The change most needed to improve end‐of‐life care in the I.C.U. was found to be improved communication in general. Physicians were more than any other category considered to be the strongest barrier.”59 Dr. Meier agreed that doctors are the greatest barriers to palliative care in hospitals. The causality is medical education, in which doctors are taught to pursue aggressive treatment at all costs and only see body parts instead of whole people. Dr. Meier said this creates a fossilized culture in the hospital, which is an extension of medical school: “Physicians are the barriers. They were educated in a system that teaches them they can do anything and everything. They were also taught that medicine is disease‐specific. The whole person is not their job. An oncologist only cares about shrinking the tumor. But if the person around that tumor had a stroke, it’s not the oncologist’s problem. An oncologist only sees tumors and they can’t act on what they don’t see.” 60 The Mayo Clinic research found that “surgeons tended to view their role as preserving life at all costs.” The study also determined a need to “enhance physician education and the practice of end‐of‐life care, and improving teamwork between physicians of differing specialties.”61 To change the current process, all the various physician specialties and hospital departments must communicate and work together. According to theory, if the hospital is going to successfully adopt the palliative process it will require what’s called a “heavyweight team.” “Heavyweight teams are tools to create new processes, or new ways of working together…heavyweight teams allow members to interact differently than they habitually could across the boundaries of functional organizations. Members bring their functional expertise with them as they join the team. 59 Festic, Emir, MD, Acta Medica Academica, 2010:39, pp. 150‐158 60 Dr. Diane Meier interviewed by Joel Engardio March 30, 2011 61 Festic, Emir, MD, Acta Medica Academica, 2010:39, pp. 150‐158
27 But their mindset must never be to ‘represent’ the interests of their functional group during the team’s deliberations. Rather, it is to collectively figure out a better way to knit things together so that the overall project is successful.”62 The Mayo Clinic study echoes the theory: “Improved communication between healthcare teams and…cooperation between critical care providers and palliative medicine services is integral to optimal end‐of‐life‐care…Curative modalities and palliative care coexist upon a continuum and should be addressed simultaneously upon presentation.”63 But hospitals still have a long way to go. “Everyone agrees that palliative care is important,” said Dr. Kachalia of Brigham and Women’s hospital in Boston. “But it is still seen as a different kind of service than what we normally provide.”64 62 Christensen and Kaufman, HBS Case, “Assessing Your Organization’s Capabilities,” August 21, 2008 63 Festic, Emir, MD, Acta Medica Academica, 2010:39, pp. 150‐158 64 Dr. Allen Kachalia interviewed by Joel Engardio March 25, 2011
28 JobBased Segmentation (The “Baby Boomer” Effect) The first of 76 million American “baby boomers” hit retirement age in 2011 and will begin to reach their life expectancies in a decade. How this large and influential generation chooses to face illness and death will profoundly affect our health care system. “Baby boomers” have revolutionized the conventions and practices of society at every stage of their life when their circumstances required getting a job done. Death will be no different. Due to their sheer size, how “baby boomers” approach their final “job” will forever change the way we die. According to theory, understanding the meaning of jobs and circumstances is the key to knowing what really motivates people: “Predictable marketing requires an understanding of the circumstance in which customers buy or use things. Customers – people and companies – have ‘jobs’ that arise regularly and need to get done. When customers become aware of a job that they need to get done in their lives, they look around for a product or service that they can ‘hire’ to get the job done. This is how customers experience life…The jobs that customers are trying to get done or the outcomes that they are trying to achieve constitute a circumstance‐based categorization of markets. Companies that target their products at the circumstances in which customers find themselves, rather than at the customers themselves, are those that can launch predictably successful products. Put another way, the critical unit of analysis is the circumstance and not the customer.”65 What circumstance do “baby boomers” have and what job do they need done? “Baby boomers” have always sought better ways of doing things. Currently, they are focused on defying aging. But when they ultimately accept their mortality, past behavior suggests their final revolution will be to insist on a better way to die.
65 Christensen, Clayton, “The Innovator’s Solution,” Harvard Business School Press, 2003, p. 75
29 What does this mean for palliative care and the disruption of hospitals? The first rung on the disruption ladder will be conquered when millions of “baby boomer” patients see how well palliative care meets their end‐of‐life job to have a “good death.” According to surveys, the jobs that patients most want accomplished at death are “avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others.”66 But what does the hospital I.C.U. offer dying patients? “You lie on a ventilator, your every organ shutting down, your mind teetering on delirium…The end comes with no chance for you to have said goodbye or ‘It’s OK’ or ‘I’m sorry’ or ‘I love you.’”67 Harvard marketing professor Theodore Levitt famously told students: “People don’t want to buy a quarter‐inch drill. They want a quarter‐inch hole!”68 Yet marketers don’t heed Levitt’s advice. They keep making a drill with more bells and whistles, thinking the drill with the most features will be the one customers want. But the added features have nothing to do with the actual job the customers are trying to get done. End‐of‐life care in hospitals offers life support machines with more and better features. But those machines do nothing to help patients have the “good death” they desire. By contrast, palliative care accomplishes exactly what the patient wants and needs done:
66 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 67 Gawande, “Letting Go: What should medicine do when it can’t save your life?” New Yorker, August 2, 2010 68 Christensen, Clayton, Harvard Business School Case, “Integrating Around the Job to Be done,” August 11, 2010
30 “A jobs‐to‐be‐done lens can help innovators come to market with an initial product that is much closer to what customers ultimately will discover that they value. The way to get as close as possible to this target is to develop hypotheses by carefully observing what people seem to be trying to achieve for themselves, and then to ask them about it.”69 Once a critical mass of “baby boomers” discovers the benefits of the palliative philosophy, health care will never be the same. Millions will demand it not only for end‐of‐life care but also for treatment of illness in general: “Knowing what job a product gets hired to do (and knowing what jobs are our there that aren’t getting done very well) can give innovators a much clearer road map for improving their products to beat the true competition from the customer’s perspective – in every dimension of the job…Growth would come by taking share from products in other categories that customers sometimes employed, with limited satisfaction, to get their particular jobs done. And perhaps more important, the products would find new growth among ‘non‐consumers.’ Competing against non‐consumption often offers the biggest source of growth in a world of one‐size‐fits‐all products that do no jobs satisfactorily.”70 69 Christensen, Clayton, “The Innovator’s Solution,” Harvard Business School Press, 2003, p. 79 70 Christensen, Clayton, “The Innovator’s Solution,” Harvard Business School Press, 2003, p. 78
31 Conclusion The failure of hospitals to address end‐of‐life care with a palliative philosophy comes at the expense of what everyone wants – longer quality of life. Patients are being over‐served by hospitals that treat them with medical technology that does too much with little benefit. Patients are being under‐served by hospitals that don’t give them what they really want: quality of life. Hospitals and government Medicare are over‐spending for expensive and ineffectual treatments when the more effective palliative care costs much less. All of this makes palliative care ripe for disruption, both low‐end (end‐of‐life care that hospitals are least interested in) and new‐market (patients who want a different and better way to treat their illnesses than what they have access to). A recent New England Journal of Medicine editorial said, “We now have both the means and the knowledge to make palliative care an essential and routine component of evidence‐based, high‐quality care for the management of serious illness.”71 But hospitals aren’t providing fully integrated palliative care because the palliative way is counter to almost every aspect of the hospital – from its processes and priorities to its very culture. That means stand‐alone palliative centers will continue to climb the ladder of disruptive innovation, with the first rung being the “good death” everyone hopes to have.
71 Kelley and Meier, “Palliative Care – A Shifting Paradigm,” New England Journal of Medicine, August, 19, 2010