Arrive Where We First Began, A Strategic Path Forward with Dr. Ira Byock

In this episode of TCNtalks, Chris Comeaux and Cordt Kassner reflect on the significance of hospice and palliative care, especially during the holiday season. They discuss the evolution of the field, the importance of fostering well-being for patients, and the transformative impact of hospice on healthcare. 

Dr. Ira Byock, a pioneer in the field, shares insights on the need to reframe the narrative around hospice, emphasizing its role in life completion and the importance of strategic planning for the future. The conversation highlights the overwhelming positive feedback received on Dr. Byock's strategic framework for hospice and palliative care, showcasing the ongoing relevance and necessity of these services in modern healthcare. 

In this conversation, Ira Byock discusses the importance of equity in palliative care, emphasizing the need for inclusivity and a rethinking of existing frameworks to better serve diverse populations. 

He addresses barriers to quality care, the role of health plans in ensuring quality, and the necessity of implementing clear standards for hospice and palliative care.  Byock also advocates for a compassionate approach to dying, celebrating life while acknowledging the challenges of mortality.

Guest:
Dr. Ira Byock, MD, FAAHPM

Host:
Chris Comeaux, President / CEO of TELEIOS

Co-Host:
Cordt Kassner, PhD, Publisher of Hospice & Palliative Care Today & CEO and Founder of Hospice Analytics

Teleios Collaborative Network / https://www.teleioscn.org/tcntalkspodcast

Chapters

• 2:18 Holiday Welcome And Setup
• 3:44 Family Updates And Personal Joy
• 6:20 Year-In-Review Frameworks
• 7:56 Future Council Insights
• 9:59 Introducing Dr. Ira Byock
• 11:01 Hospice As A Gift To Society
• 14:45 The Fourth Pillar: Fostering Well-Being
• 19:34 Stories Of Reconciliation And Meaning
• 22:28 Returning To Purpose And Big Dreams
• 27:19 The Strategic Path Forward: Four Components
• 34:17 Equity, Access, And Fixing The Bus
• 38:58 Beyond Profit Status: Competing On Quality
• 42:43 Health Plans Adopt Better Standards
• 46:40 From Measures To Actionable Data
• 51:18 Reframing The Brand Around Life Completion
• 55:06 Loving In Defiance Of Mortality
• 58:16 Closing Thanks And Holiday Wishes

Transcript

Dr. Ira Byock: 0:00

There have been serious regrets where a story that ends well reframes everything that has uh preceded it. Mother, who's struggling with bits of aphasion, having difficulty speaking, looks at her daughter and says, It stops here. And what she's talking about is the anger and the kind of neglect that has circled through their family because that mother had been uh either abused or raised by an unloving mother. And she said she looked at her grandson and said, stops here.

Cordt Kassner: 0:41

We've taken our eye off the ball, but I I think I want to frame that a little bit more optimistically, which is we have a solid foundation, and we need to come back to it and remember why we're doing what we're doing.

Dr. Ira Byock: 0:56

But I do see that this doesn't have to go badly, that we can still recover the bright potential of the field.

Chris Comeaux: 1:06

In reality, I interviewed a young lady that kind of contacted me from a PhD program, super young in her PhD, and kind of focused on death and dying, and I'm just sitting there going, that was not a thing when I came in 1995. And so, these dreams are coming to fruition. What's kidding me is, what are our dreams? Is it just to hold on to this thing?

Cordt Kassner: 1:28

First, you make the point that uh efforts must start with zero tolerance of fraudulent business and clinical practices that harm vulnerable patients. And I have uh mentioned your quote countless times. Collegiality stops at criminality.

Dr. Ira Byock: 1:45

Defeatism is self-fulfilling. If you if you think you're gonna lose, you're gonna lose. Healthiest response to dying that I know of is to live fully to face illness and caregiving and dying and grieving together as friends and families with love and to foster you know joy in the midst of sadness.

Jeff Haffner: 2:14

And now our host, Chris Comeaux.

Chris Comeaux: 2:18

Hello and welcome to TCNtalks. I'm excited today. I'm really excited. I know I'm all excited, always excited when I do these podcasts, but especially excited today. First off, happy holidays. Um, this is an incredible time for our listeners, just a special time of the year. Hopefully, have celebrated a beautiful Thanksgiving with your family and your friends. And now you're heading headlong into the holiday season of Hanukkah, Christmas, and New Year. It's kind of crazy. So, Cordt, welcome. It's our top news stories of the month, but a really different one we're gonna do this time. Thanks so much. It's great to be here, Chris.

Cordt Kassner: 2:49

Yeah, did you have good Thanksgiving with your family? It was fantastic. You know, uh, you might remember Dr. Dave Levy from the Air Force Academy presented uh or worked with you on a podcast, a couple of podcasts this year. Uh we are now officially related. My son married his daughter, and so uh we had a great time with with uh both of our families combined.

Chris Comeaux: 3:11

How about you? So yeah, actually, so we have our oldest son now married. So, I have a daughter-in-law who's a wonderful ER nurse, and so they all throw stuff at us and say, quit talking about healthcare. And um, I'm gonna have two daughter-in-laws between January and May of next year. So, all three of our boys will have been married. So, but we have now the future in-laws, and so our family is just growing exponentially. It's just a really sweet time. It's really cool. I feel like that great hair. I'm just feeling like, you know, I'm the wise father sitting around the table, just sitting back, marveling, and listening to the special conversations. Well, well, Cordt, you and I have um, this has really been a fun year as we've done these top news stories of the month and seeing how you and I've evolved this. And so I've had my framework I've used, probably even going back to Mark Cohen's days before you took over Hospice Impowered Care today, but I've really got mine dialed in based upon these eight challenges. And I love how this year you've been, I think since about summertime, have taken um Dr. Bayak's strategic framework and started organizing your articles. And so this has been fun this year to point out, hey, listeners, first off, Hospice Empowered Care Today is an amazing resource where Joy and Cordt are scouring thousands of articles to make sure you know what's coming. You always share here's court's articles and you actually then organize them based upon the framework. I then go into these eight challenge areas and say, as a C suite leader, this is what we hope you didn't miss. And this is kind of shows a foreshadowing for 2026. Cause as you've and I've got this dialed in, you have a wonderful lead behind which has the statistics. So, the data that shows this is what people have looked at this month. And then I take my little um document that organizes mine based upon those eight challenge areas. And literally in 10 minutes, someone could go, man, I'm not keeping up with the hospice powder care today. You first should. But if you don't, in 10 minutes, you could look at those articles or those documents and they could be fairly up to speed, not as much as if we're reading it on a day-to-day basis. Um, and so that's kind of how we've morphed this. And you had a really cool idea that next year we should maybe make the shows, we could keep you leaving the lead behind. Maybe we hit very quickly, like the stuff that we want to make sure that you and I have seen over the month that are big that we don't want folks to miss, but maybe theme the show around Dr. Byock's framework because it's so important to the future, which is going to get us where we're just going today, which is really meant to be a gift to hospice empowered care leaders and powered hospice empowered care staff. And so just a quick, you and I had a really cool thing we did last week. My categories have been these challenge, eight challenge areas. We had a future council meeting where all these future councils, we took those eight challenges and I think that was like a thousand man and woman hours working on those challenges and reported out over the course of a day. That meeting was incredible. I don't know what if you want to say anything about it, but it was a pretty incredible day.

Cordt Kassner: 6:06

You know, it was incredible. The breakouts for each of the work groups, uh, they did a fantastic job, and it really set the stage for strategic planning and thinking about the challenges and opportunities ahead for hospices and palliative care providers into the future. The one thing that really made me smile was when Andrea Hale, who was running, uh chairing the regulatory breakout group, started off and said, I'd like to start off by using Dr. Ira Byock's strategic framework for the discussion of the regulatory issues moving forward. And I, and the her whole presentation was hitting on first avoid waste, fraud, and abuse, then the four pillars, which we're going to jump into here in a minute. But I was so pleased because it caught me by surprise. Like I wasn't expecting that. And and I love when things are fresh and new and a little bit different.

Chris Comeaux: 7:01

So Dr. Byock is with us. So hopefully those that are watching already, like, who's that third person here? So he's in the room and we're talking all around him and about him. So I'll say one final thing. We really want today's show to be a gift. Hospice empowered care, leaders and staff. This work that you do is amazing. We walk on sacred ground. And I grew up reading Dr. Byock's book, Dying Well, the Four Things That Matter Most, Best Care Possible. Um, he's just one of these people that I held up as a an illuminary, someone who is shaping this ethos of what this field should be. Um, we were in the early stages of making it that, almost casting the vision of what it should be, um, the tools and the skills and the competencies to make it better. And so I also think there's a young generation. My my second son works in hospice now, and there's some of there's the nurse Hadley's, the nurse Julies that are on social media. And I fear a little bit they don't know Dr. Byock. So I want it today to be a bit of a gift to them. So, Cordt, would you do the honors of introducing him?

Cordt Kassner: 8:02

It would be my pleasure. Dr. Ira Byock's a nationally recognized palliative care physician, author, and advocate for improving the experience of serious illness and end-of-life care in the United States. A pioneer in the hospice and palliative care movement for more than four decades. He served as a clinician, researcher, and organizational leader committed to advancing whole person care. He's the founding director and chief medical officer of the Institute for Human Caring at Providence, where he led system-wide initiatives to integrate palliative principles across clinical settings. Previously, Dr. Byock served as president of the American Academy of Hospice and Palliative Medicine, directed palliative care programs at the Dartmouth Hitchcock Medical Center, and contributed foundational research and frameworks that have shaped the field. Widely known for the books that you mentioned, Chris, Dying Well, The Four Things That Matter Most, and the Best Care Possible, Dr. Byock brings a compassionate, humanistic voice to national conversations on quality, dignity, and meaning at the end of life. His work continues to inspire clinicians, leaders, and health systems to elevate care for patients and families facing serious illness. And I'll just mention on a personal note what, 15 plus years ago, uh I was CEO of the Colorado Hospice Organization, this the state organization in Colorado. And at that time, Ira and his wife Yvonne were at Dartmouth, and Yvonne was the state director for New Hampshire. And so I got to know Yvonne, who is absolutely an amazing individual and palliative care specialist in her own right. And it was through her that Ira, I think we met at a table at a conference one day during lunch somewhere. And it's just been a pleasure to get to know you and appreciate your passion for the field. Welcome.

Dr. Ira Byock: 10:03

Thank you very much. man, it's hard to listen to that. Um thank you. Uh I do want to correct, I am no longer uh with the Institute for Human Caring. I am still the founder. I'm on an advisory board, but I uh am officially jobless by choice, uh, which is, you know, a much better well, it's actually more accurate than saying retired, because I don't feel exactly retired, but I have the pleasure of not having a day job. And so uh uh Dr. Matt Gonzalez is the is the uh head of the Institute for Human Caring, which continues within the Providence Health System. Both of you, thanks very much for having me. This is gonna be fun. You have the floor, sir. Well, uh so okay. I'll start again with my introduction. I'm all all of that stuff. Um, but here we are in the holiday season, and I am very, very aware that um I am a father of two remarkable uh women, uh Leela Byock and Saya Doyle Byock. I am uh a grandfather of two remarkable young boys, uh Philo and Winslow. I am the husband of Yvonne Corbet, uh I'm you know brother to my sister Molly, and all of that is very much uh who I identify as. Uh and then I I do this work as um not just a profession, but as a passion, um and that all informs what I do. So, I'm I am here today with all of that identity uh within me. You said this was a gift to hospice, and I and I just want to say, you know, I my continued experience is that hospice is a gift to us all. Um not just those of us who work in this field, it it sure is a gift to us, but it is um it is a gift to our communities, it is a gift to the patients and families we serve, and it it really is a gift to um uh Western health care. Uh Western health care is so problem-based, it is so constricted by having to focus on the problems that bring you to doctors. We create problem lists, we soap our notes under every problem on the chart of a patient. And unfortunately, we have to justify what we do uh by determining that it's medically necessary. Um hospice uh does all of that and I think does it well. Um and it recenters human caring within the personal lives of the individual patients we serve, their families, uh not just their blood relatives, but those who they identify as part of their families, um, and rippling out to the communities that people live in. And that that's not a small thing. You know, um hospice, um I truly believe that hospice and which uh of course gave rise to palliative care, which is the larger um field within which now hospice is the specialty delivery model for people who acknowledge that they are dying, frankly, and mostly who are centered or want to be centered at home or out of an acute care setting. But hospice is really and truly one of the most dramatic developments of healthcare in the latter part of the 20th century. And it doesn't have the sizzle, you know, of genomics or uh transplantation or you know, all of the high-technical, remarkable stuff that frankly I love and that you know we rightly honor. But it genuinely transformed the way people who have advanced incurable illness um experience uh not only health care, but their lives. And that's not a small thing, but it doesn't get acknowledged uh hardly at all. And I for the listeners uh of TCNtalks and this podcast, I I think it's important just to pause and acknowledge that what we're involved in doing is truly a transformative development in human caring. And what we have uh tended to neglect, I guess, is that in trying to grow up and be like, you know, the internal medicine fields, the cardiologists and the oncologists and be respected in the halls of medicine, we tend to sort of have sheared off that um stuff that is built on the base of excellent uh medical care, the problem-based model and the you know diagnostics and therapeutics. Um and but we stop there. Um and this gets to the fourth, what you're calling the fourth pillar, the fourth component of that strategy that I I've elaborated, which is that what distinguishes uh hospice and palliative care from the very best of uh good medical care, you know, skillful communication, shared decision making, uh excellent symptom management, is that we deliberately foster well-being for the people we serve. I honestly think we don't see it or talk about it because there's not a billing code for it. And if not a billing code, it's not medically necessary. Well, you know, how do we how do we track it? But I'm not being, you know, this is not platitude. It is describing what the clinicians and the hospice teams do in caring for seriously ill people and their families. We do it so naturally that it doesn't seem like, well, well, that's just well, that's just what we do, right? We plan for the weddings and or we hold weddings at home for somebody who's not gonna survive to see the wedding that was planned three months from now uh in a garden somewhere. Well, that's not gonna happen. So we're gonna get married today, dad, and we're you know, we're we want you to be part of it. I've seen this so I mean I've seen this dozens of times, and and we just say, yeah, that wow, that was really cool. And then we move on. We help people attend, you know, a child's birth or first birthday or their confirmation or their bar mitzvah or their quinceniera or their school play, or we get them to zoom into the bar mitzvah, you know, that's happening a thousand miles away. Um we, you know, at least in the programs that I have been part of, um, we not only talk about the active problems that a patient has in at H weekly or bi-weekly IDT, but uh in my under m when I'm in the medical director of a of a program, we pause and say, are there opportunities here? Are is the patient comfortable enough now to talk about what might be left undone if um she isn't able to get to that event, or um might she want to see uh a uh a sister who I understand she hasn't been in touch with in years, or you know, if a guy has been previously married and it uh for 20 years but it ended in a bitter divorce, that would he want to reach out? Um and if so, could we help him? Could we maybe help him craft a letter? Could somebody, you know, either our social worker or maybe a trained volunteer sit with him and just uh listen, take some notes, and then maybe craft a letter for him with him, um co-creating it, so that he might send that letter to just be in touch with. Um as I I have to say, guys, as I'm talking about this, I I I could stop and tell a dozen stories, right? Because this isn't uh these aren't abstract. This is stuff that happens. What other discipline does this? I don't know of an oncology team as excellent as they are, and I'm I'm pro-oncologists, right? Um, who, in addition to making sure that the person has an advanced care plan, advanced directive, um uh is comfortable, is you know, needs are met. Um who else talks about life completion? Right? Who else takes the time to invest energies in um helping somebody celebrate uh life and relationships, um have a farewell party. Um you know uh I could keep going, but  we f this is a distinguishing feature of our field. And we really ought not forget that we do this too, uh, and that it has value um not just for the medical system, but for the persons, the families, and the communities that we are part of and that we serve. I was part of the field in the United States at its beginning, no question. And we were very concerned about, you know, being a mature, respected medical discipline. You know, um we may have visited about this before, but we sat around, literally sat around a campfire early on in uh Rocky Mountain National Park, uh at one of the lodges in Estes and talked about the future. And uh after days of you know, committee meetings and trying, you know, doing our work, we'd sit and have a beer and uh or a glass of wine and talk about, well, wouldn't it be cool if someday there were textbooks about you know hospice and care of people who are incurable? And wouldn't it be cool if there were courses in medical school? And oh my God, could you imagine someday there that there was a specialty? Oh man. You know, and this was this was dreaming big, right? Um I worry that in doing this, we positioned ourselves as a death and dying movement. And I think that's come back to uh haunt us or and we couldn't have known, uh no fault, but um I honestly think we were the completion of the well-being movement. Um that was also an active cultural theme in the late 20th century and now the first part of the 21st century. And I think, you know, how do we do this? We're gonna get to that probably in this in this conversation. Part of what we need to do is really work at uh with our public relations people who we still pay and to start repositioning ourselves as those who can help you complete life, uh a life well-lived or a life in which there have been serious regrets, uh, where uh a story that ends well reframes everything that has uh preceded it. You know, a story of a fractured relationship that ends well with reconciliation and offers of forgiveness and expressions of forgiveness and attestations of love and affection. All of that changes a person's story, the story of a relationship, it all becomes a prelude to a a better ending. And it frankly restories families. Uh you mentioned I've written books and uh, you know, I uh in in every one of those books, which are story-driven books, they're real stories, um, there's at least one story in which um oh, I'm thinking one from the four things that matter most, in which there was bitterness between uh uh an elderly now dying mother and her daughter. And in a very poignant um encounter with the daughter and uh and her now dying mother and the daughter's I think young son was with them. Mother who's struggling with bits of aphasion having difficulty speaking, looks at her daughter and says, It stops here. And what she's talking about is the anger and the n kind of n um neglect that has circled through their family because that uh mother had been uh either abused or raised by an unloving mother. And she said she looked at her grandson and says, it stops here. This is not simple stuff, and it's not it's not uh trivial, and I say we who are able to do this for families uh are a gift to modern health care and to our patients, families, and communities. Um let's not forget that as we deal with the serious problems that that we need to deal with.

Chris Comeaux: 24:49

Well, you know, I should have said this, but I did say it in the green room. I want to say it now. I I envision this show as us sitting around the Thanksgiving table with the hospice field. It would obviously be a very big table these days. Um and then hearing our uh Dr. Byock hold forth. There's so many poignant things in what you just said. The first thing I just want to call out and I want to hand it to Cordt, because we do want to use your this intro that you just did to me as a perfect segue in talking about your strategic framework. But something that occurred to me was actually one of my I know you're a person of faith, we're all different faith, you and I in court, but people of faith. Um, about that childlike faith, like returning to that childlike belief. I feel like you called us back to that mission, which you know, I didn't ask you directly to do that, but that's so awesome. One of my favorite quotes in the entire world is a T. S. Elliott quote that you arrive where you first began, but you know that place for the first time.

Cordt Kassner: 25:46

Lovely.

Chris Comeaux: 25:47

It feels like we need a dose of that right now in this beautiful feel that we have. Um, when I worked for Studer Group, Dr. Byock for a time, I was shouting all these student coaches in these acute care facilities, and many of these facilities were measuring 700, 800 things. And in the early days of Studergroup, what they were well known for is just calling people back to purpose. You may go, that's not brilliant, that's not technical AI or some really cool technology, but you just saw people come alive because they were calling them back to the purpose. I feel like that's what you're doing, and I think that's a perfect segue to this paper. So, Cordt, do you want to take it from there?

Cordt Kassner: 26:25

You know, I was kind of reflecting on uh on similar themes. Uh last month, Chris, you did a masterclass on back to basics, uh whether that's the football field and and uh repeating drills until you get it right. I and I kept thinking of that analogy. Uh Ira, you were talking about uh where hospice and palliative care began and how we need to return to those drills and be excited about you know life completion, not the death and dying movement, and uh how it is so incredibly important that we get this right. And I think in the perhaps in the growth of the field to you know multi-billion dollar uh kind of impact nationally, internationally. Um maybe I I was gonna say we we've taken our eye off the ball, but I think I want to frame that a little bit more optimistically, which is we have a solid foundation and we need to come back to it and remember why we're doing what we're doing.

Chris Comeaux: 27:44

I and maybe I was gonna say one more thing and take you could take a doctor by it just occurred to me to listen to Cordt, that story you just told by the bedside and how these potential redemptions occur at the end. Like you could almost redeem your story at the end that when we facilitate that, maybe that's what you're doing with this paper in some respects, that we have this opportunity to still redeem the story as a movement and as a field. Well, I thank you.

Dr. Ira Byock: 28:08

Yeah, I maybe so. Uh I mean I we're built on so much success and it and it is threatened, but you know, this field began to show that better care is possible when somebody is seriously ill and dying. We realized that we ha we're gonna have to show that in doing so, we didn't add costs to a bloated, uh, you know, unrealistically expensive uh health care system. Along the way, you know, scroll forward 30 plus years, we have now in the literature demonstrated not just that better care is possible, we have demonstrated that much better care is possible. And that it is utterly affordable, that it is actually diminishes costs uh when compared to uh care in its absence. That is a consistent finding. Both of those are consistent findings. So, we have succeeded brilliantly, frankly, uh and yet um and yet, frankly, uh the bright potential of the field continues to be threatened and frankly eroded. And that hurts my heart. Um and I wrote this um, you know, maybe to kind of be able to redeem the field, but but really I wrote it out of self-care, which is mostly why I wrote those books. If I didn't express myself and express what I was able to see and understand, uh I was gonna, you know, I was I was really gonna have to go on the couch and talk to somebody for a long period of time. And uh the writing uh may be more painful, frankly. Uh at least in my hands, but but um uh but I do see that this doesn't have to go badly, that we can still recover the bright potential of the field. Which is ex exists in a number of places, don't get me wrong. But if you as I scan across the country and I I'm just um you know public enough that people write me all the time and call me and ask for things. So, I get a I have a sense of what's going on in the country. I know we have work to do and there's reason to be concerned about the health of the of uh the field of hospice and palliative care.

Jeff Haffner: 30:39

Thank you to our TCNtalk sponsor, Dragonfly Health. Dragonfly Health is also the title sponsor for leadership immersion courses. Dragonfly Health is a leading care at home data technology and service platform. With a 20-year history Dragonfly Health uses advanced technology and robust analytics to manage durable medical equipment and pharmaceutical services as part of a single efficient solution for caregivers, patients and their families. The company serves millions of patients annually across all 50 states. Thank you Dragonfly Health, for all the great work that you do.

Chris Comeaux: 31:24

But one of the things you said that just struck me and it's so cool I think my family is at that same resort in Estes Park we'll have to maybe I'll check with that when we're done but I'm picturing you guys sitting around the fire and dreaming about those things that are now reality. I interviewed a young lady that contacted me from a PhD program super young in her PhD and kind of focus on death and dying and I'm just sitting there going, that was not a thing when I came in 1995. And so, these dreams are coming to fruition what's hitting me is what are our dreams? Is it just to hold on to this thing? You guys were dreaming big and are we dreaming too small right now for where the field goes which again I feel like is your part behind the strategic framework. So Cordt, do you want to take it from there and maybe start with your first question?

Cordt Kassner: 32:13

Sure. I and I'll set the stage for listeners just to cover the ground, right? Uh we're talking about IRA's paper, a strategic path forward for hospice and palliative care, a white paper on the potential future of the field. And to take this amazing work that you've done and sum it up quickly so that we can talk about the reaction and the development and the implementation of this I'll just highlight a couple of points. First you make the point that efforts must start with zero tolerance of fraudulent business and clinical practices that harm vulnerable patients. And I have uh mentioned your quote countless times collegiality stops at criminality and then you go on to describe four components of this strategic approach the first being publishing clear clinical and programmatic standards the second making meaningful data readily available the third driving quality based competition and fourth embracing the field's authentic brand of expert care that fosters well-being for patients and families and I think really my first question is in light of all of this what feedback have you received uh for  the paper positive or critical uh and has any of this made you rethink or refine parts of the strategy uh I'll close with this that I'm a a firm believer based on too many experiences of trying to do things with the right intent and doing them well that no good deed goes unpunished and sometimes the feedback that I have gotten for different ventures has just surprised me and I and it makes me take a step back and pause and reflect and kind of think about it maybe in a different way. What kind of feedback have you had for this?

Dr. Ira Byock: 34:17

Well the feedback has been overwhelmingly positive um uh I've gotten a lot of you know heartfelt thanks um from colleagues uh I should mention I I mean I looked early this morning um in preparation for our conversation and as of today there have been 10,202 downloads of the of the paper which is for our field pretty remarkable and it and it grows every day uh by you know somewhere between 10 and 30 new downloads um which is heartening I uh there's a sense that that this is still very active and being discussed thanks to things like TCNtalks did a Jerry Powell podcast that was very well received um so that that's really wonderful. I I took to heart the uh the letter to the editor by uh Karen Bullock and Kathy Johnson and uh and others uh about the need for emphasis on equity um and I've been sitting with that I reached back out to them uh immediately to say thank you for that and let's talk and let's be creative about how that would work and I haven't yet uh had any meetings with them but I'm interested in it. I do think just on the equity issue which I did acknowledge that I didn't uh I hadn't forgotten about but set aside in um white paper the strategic path forward paper that my thinking about it is you know everybody needs to get on the bus and we this bus should be uh a way to transport everybody to uh better care and healthy completion of their life within the context of family and community but the bus uh has serious problems it's leaking oil it's rattling it's the steering is out of alignment and things we could go off the road and so it's what I tried to do using that analogy is to fix the bus um so that it can contain all of us. And I and I uh I still think that for me that's where I can be of most value to caring for everyone um uh people of uh color, uh different people who speak different uh non-English languages, people who live in rural areas, um children who are often don't have access to this sort of high quality palliative and hospice care that we that um we think about all of that. Rethink is maybe not the right word court but I I think I would be eager to work with others or just to support others in doing it themselves in expanding uh this framework so that it can you know reach that Quintiple Aim I didn't know you were going to say this so actually maybe I'll go second.

Chris Comeaux: 37:30

First off, I do want to I loved Karen's question actually because it got me thinking and I have a suggestion maybe for you to keep processing maybe how to expand the framework. But on page 311 you did when you were laying out the symptoms of our field you that was the last point that you made about you know we're still woefully um not reaching many populations when you look at the statistics. So, you did call it out in your paper while it didn't get a whole subtext to that. So, here's my question to you Ira is that I picture I don't know if you guys had a framework when you're sitting around the fire. I mean maybe like holistic care and things like that. But if we have a framework going forward, I 100% think it's your strategic framework plus maybe two additional things the quintuple aim my read of what Dr. Berwick was after was original triple aim got added a fourth and now a fifth was grown up to the quintuple aim but basically better care um better service lower cost better work environment for employees and then health equity reaching everybody possible that you need to. If you took and then what I'm picturing is a Venn diagram almost like what Jim Collins did years ago what are you passionate about? What can you be the best of world at what drives your economic engine? So, your framework, the Quintuple Aim and then what I'm wondering is the third part of that little um Venn diagram is the four M's and we've done a lot of podcasts around that what matters most mentation mobility and medication those three together may be a really great like canvas that if we then paint and dream big like you guys did going forward. So, I don't know if you and I didn't prepare you that I was going to say that.

Dr. Ira Byock: 39:06

So well I love it. I do love it and I I wish we had a whiteboard here and we could start you know mocking it up I think best with whiteboards and in rooms and you know we'll have to get you down to TCNHQ.

Chris Comeaux: 39:23

We just got two whiteboards here in our headquarters so you need to come down to the Asheville North Carolina area and we'll get you on the whiteboard and Cordt will have to come visit and we'll do that.

Dr. Ira Byock: 39:31

I would enjoy that really but yeah, I love I love the idea. I I don't think this is done. I'm I man I hope the field is still young enough to keep evolving um we should be dreaming big, and we should be thinking about you know the future and how I mean there's so much wonderful advances in in healthcare that we need to somehow absorb and incorporate. People are living longer for things that we thought they were dying of and that's a good thing. My God it's a fabulous thing. So, you know what do we do about that?

Cordt Kassner: 40:06

And how do we you know how do we I you know we mentioned uh the the challenges of uh demographics and language and age and all all of that um we we need to think about you know how do we care well for people with dementia which I know is a a strong interest of all of ours but uh Chris you you've done some remarkable uh podcasts on this and I have my own thoughts about that but you uh this needs us uh the f you know the um when people think about dementia and advances in dementia they think about new drugs that are gonna you know unwrap our uh neurons and I hope please do right but in the meantime uh what does well-being look like uh in an individual affected with dementia uh in a family who's living with somebody who's uh affected with dementia though who else can address those questions better than uh we and our colleagues the piece that I really appreciate about your framework is the simplicity and the broadness of it the inclusivity of it and by that what I'm what I'm really thinking about here is that there are many frameworks you've outlined one Chris and Teleios have outlined another with you know eight to ten points of things to be looking for in the future DOIG has outlined a waste fraud and abuse framework of what how they're going to approach hospice and what that looks like there are frameworks for health care for the United States for world single payer systems there's pediatrics and Chris you know it started rolling off some of the some of the subgroups pediatrics minorities prison medical aid and dye use of marijuana and end of life care I mean there's like this shotgun approach of all of these different things and of course where my thinking started with this and I didn't include in my list what were the equity issues the diversity issues the minority populations and and how research is demonstrated over and over substandard care uh for particular groups of people that that we need to kind of write that chip and as I look at your four principles this is not an either or it's like it's like well Ira's right and the OIG's wrong it's and like well how do we take those equity principles how do we take pediatrics and rural and waste fraud and abuse and incorporate it into and that's what I love about your framework is that it is broad enough to have a place for all of those subissions if you will that that fall under well-being at the end of life while being simple enough that somebody like me can understand it. And for that I really appreciate that because I read a lot of frameworks and things that that I just kind of look at and go, wow I feel like I should understand this, but I just don't is the bottom line and that was not my experience in reading your paper and talking with people around the country with it. I have also had similar positive feedback that you know this is a really helpful construct to think about hospice and palliative care for the next five 10 20 years. And I think from a maturity perspective we we kind of need that we need that that kind of framework to think about where we've come from where we're at today where we're going tomorrow and and you've outlined that I'd like to ask you I think can I can I respond?

Dr. Ira Byock: 44:27

I think straightforward is not easy. It is straightforward it's simple because it's pretty uh I tried to be fundamental in in in constructing this so it it's n I mean it's not fancy or complex but that doesn't mean it's easy to implement. And I think uh let me just amplify what I said about the barriers and then I'll let you continue. Sorry Court the barriers are um you know people think oh I I've been told uh Ira this is painfully ambitious that's a quote um or Ira you know you don't understand uh the c corporations have all the power you're not gonna or Ira um we're never gonna get there I mean this is very nice but you know and so the barriers are firstly a sense of defeatism I hear that from colleagues uh not uncommonly and I would just point out that defeatism is self-fulfilling if you if you think you're gonna lose you're gonna lose I promise you there is uh I hear that I've said I hear fed back to me that Ira you have to stop beating on the for-profit corporations and I just like wait a minute I think I'm the only one who keeps saying we have to stop framing this as for-profit versus nonprofit. I think that's absolutely the misframing of this that's causing us to be paralyzed. I keep saying that and it keeps coming back to me as if I've said something that I haven't said. I it should not matter this framework that I've put forward makes it irrelevant who owns the program and what their tax status is. What's relevant is is the care demonstrably good enough so that I can refer patients confidently so that a so that the care is good enough for somebody's to take care of somebody's mother or father or spouse or child. We have to stop beating up on the four profits as if they're the problem and that the non-for-profits are the are the solution. I don't I honestly do not believe that's the case. And can we just get behind get beyond that and start focusing on quality and start redirecting component three competition to be based on quality and therefore if you can succeed by consistently demonstrating better outcomes, better staff experience, quadruple aim, um you know better economics, then we're gonna refer patients to you. We're gonna contract with you for uh our health plans book of business. We're, you know, let let's do that. And while the corporations indeed have much more power than the three of us, we still have the ability to shift competition progressively toward quality and away from the sort of quiet deal making that is uh obscure and that uh frankly does not serve uh patients and families that's well said I was gonna make a comment if you wanted to still ask your question in a second court that uh we did a podcast uh our on with uh Laura Katz Olson she wrote a book called Ethically Challenged and she really called out a lot of the private equity stuff and my ending to that whole show was you know private equity does some good in this country but here's the point I don't care what business you're in and how it's funded if you're not about creating a better product for a customer like usually I'll I do training all the time and I'll ask people give me an example of your worst just most frustrating customer service experience.

Chris Comeaux: 48:25

Invariably it's some type of internet typically because they have monopoly and there's not good quality and there's not good service. And so that profiteering that's occurred is people that are trying to treat a hospice as a vending machine, a cash vending machine to feed some economic model, that's created a lot of ills. Tax status aside, if if a nonprofit was all about maximizing the dollar and lost sight of the mission what where we started this conversation, that's not good. And so I love that you're I even owned up in our podcast together because I get a lot of criticism you're always down on the far profits probably more than you, Dr. Byock, because I work with a lot of nonprofits, that's what TCN is about but I own I owned it on the air with you is that hey I I totally agree with what you're saying because if we agree to this framework and we're all working for the betterment of towards those quadruple quantum aims and using your framework, the patients and families are going to win. Tech status aside, good competition you're not rigging the game, you're not doing some of the unethical stuff the criminality ends a collegiality so again I wanted to kind of own I get a lot of criticism in that and I kind of backed it up and I heard what I heard you say the first time is hey there's so much need and it's gonna be worse with the baby boomers. Nonprofits can't step in and fill all that void although I'd like to say hey give us a shot um but the for-profits that are doing it right that ecosystem together based upon your framework if we do that patients and families will win.

Dr. Ira Byock: 49:59

You know I just want to tell you one surprisingly positive thing that's happened uh and that is um I couldn't have anticipated this uh I've had two different large health plans contact me and ask me to consult with them uh around the framework and around the um their need to assess hospice programs that want to be in their network uh and have confidence that in bringing hospices into their network they are well serving their members and this is remarkable um uh one of them is a very large health plan that serves Medi-Cal patients they're both in California which is awash with fraud and abuse I mean California has what 2,500 of the of the nation's 6800 programs? It's crazy, right? Um it's just absolutely it's the Wild West. Despite their moratorium and despite everything that the Attorney General is trying to do they are they don't have the the resources to control this. So uh but the health plans have a lot of suasion and they and they have the ability um to set their own uh frankly proprietary filters for who they for which programs they include in network. And so I'm working with two of them to tighten up those um criteria for bringing people for bringing programs in network in a way that um is well motivated trying to make sure that we are safeguarding the health plans members uh and providing uh the best care we possibly can with metrics backing up uh metrics on quality and uh health resource use. I didn't anticipate that, and I think that gives me a real sense of uh hope that maybe this will have some legs.

Cordt Kassner: 52:04

I think so I think that's a great kind of thumbs up it gives that opportunity to implement that it's not just theory but like how do we actually do this which is really where I want to head with, I have lots of questions. I I keep thinking of the Thanksgiving table and hey everybody come out to Colorado and let's just sit around for about a week and and figure this out that would be so much fun. Where my question is going then I'll explain why I'm asking it is what's your first step Ira where does this begin and I I'm asking that in the context of thinking about publishing clear clinical programmatic programmatic standards like which organizations are supposed to do that how do we do that is this an update is this a full redesign making data available what data uh existing measures new measures how do you measure well-being what does that look like driving quality based competition you know the cultural and organizational changes needed to be made based on quality versus profits or market share as you kind of wrapped up the fourth principle around the brand the authentic brand around well-being for patients and their families uh so many questions on how to how to actually do that and so I'm um I I'll go back to my original question which is where's that starting place for you?

Dr. Ira Byock: 53:40

Well I think we've started um I think uh for me this has been a journey that didn't start with the publication it started probably three years before uh with uh ruminations and and uh and then uh two years probably I say a year and a half but it's probably two years of trying to write this stuff and trying to figure it out for myself in a way that seems simple as you said or straightforward I would say um I think we've started uh I think um when I look at who could do this uh I frankly look at the coalition um uh that uh coalition for uh compassionate excuse me for hospice and palliative care that Jennifer Hauser uh directs and particularly the professional associations within that coalition I would I would look at the Academy of Hospice Palliative Medicine um the uh Hospice and Palliative Nurses Association um the social work uh network uh hospice palliative care network the Chaplaincy network um I would put CAPSE in the in that line of professional um I would love to say that NPHI and the Alliance should be part of that um but I have to say that neither of those two groups have been willing to engage with me at least in uh in talking about uh this um and I and I wish they would. I think it's that perception somehow that that I'm trying to pit nonprofits against for-profits or something, I which is not the case at all. It's completely wrong. But I would start there. I think a state association could do this. I would love to see I mean um I would love to see the Coalition for Compassionate Care in California uh elaborate draft standards um uh and then begin to implement those in terms of publishing and pushing them out to their members and to the you know the discharge planners, the um physician groups, the hospitals uh and the health plans in California as use these as filters when you're choosing hospice programs. We need to push out the uh the fact that hospitals can have preferred provider lists of hospice programs and then create draft standards for those preferred provider lists. It won't be it's gonna be iterative we'll never get there's not a one and done. Same for measures. Where would I look yes, we have to build on the measures that exist. I mean I look at you know um a Medicare compare and the hospice uh locator that you you that uh hospice analytics uh nicely uh publishes and maintains that's a place to start yeah I want other measures I want I want uh measures like uh you know uh frequency of visits by each of the disciplines the major disciplines at least the uh nurses I think doctors and the the the diminishing role of doctors is important so data on the it's structure process outcome uh how you know do you have doctors on staff? How many doctors per patient do you have on staff? How often do they see patients? And then I would add responses to emergencies. How do you respond to uh symptomatic crises when they occur, particularly in patients' homes um I want to see uh thinking about that uh quadruple aim I want to see on data sets uh staff uh satisfaction and and annual staff turnover rates by discipline uh I know in the in the questions that you had drafted and nicely sent to me there is you know well how do you gonna get these data? Well for one thing, you know w I notice by the way, I haven't talked about government virtually at all uh here. Because I I think one of the things that our um field tends to do or the associations tend to do is they they l they think all policy has to do with what you ask Congress or CMS to do. I think well there's so much more that we could do internally without even worrying about the government, but it would also resource the government to do its job better. But I think, you know, if you're gonna receive Medicare and Medicaid dollars, we have a right to ask for the transparency in data, including staff satisfaction and staff turnover data. You can't hold that data and take our money. So give us the data. We're not gonna we're just gonna be transparent about the data, right? And we're gonna that's part of shifting competition toward quality right I could go on and on and I know we should have Jamie Boudreau on who a guy who I love and who has been asking about well what's the feasibility of this well you know I think Jamie could do this in Louisiana frankly and uh um uh he just needs a little coaching I'm you know I grew up like Thibodeau boo Boudreau jokes are a thing like you got Comeaux and Boudreau.

Chris Comeaux: 58:50

I'm thinking that's a whole show right there. Um well I wanted to land the plane in this last question. I want to give you then the final word, Dr. Byock and so the embracing and promoting our authentic brand I love what you said in kind of the opening monologue about we have been successful. I don't think there's any way we could have anticipated that we would have been come synonymous with death and hospice and now people hear that word and it's one reason why our medium let us stay is so low. I I'll I usually say that everybody wants to go to heaven, nobody wants to die. It's that human, we want to survive and I I think that we're gonna have to use different words. That's actually a little bit of my theory about the four M's I think the four M's is a framework to talk about what we do without bringing up the H-word. I'm not trying to tap dance around that we are I love what you said that we foster well-being at the end of this journey. I I like that framing. So can you speak about that a little bit because there feels it feels like there's a lot of work that needs to be done here, especially with the baby boomers. Um you know there's all these cool commercials we just showed a Weathertech the other day at the training that Cordt and I were at with these future councils with these wonderful old ladies that are like in the convertible and they're just like living it up. And that's like that vision of what retirement is like. But the storm cloud is the serious advanced illness that comes. And we're part of the solution to help them do that final chapter well, kind of still living that ethos of like this, you know, the spirit of freedom that has defined the baby boomers throughout these different decades.

Dr. Ira Byock: 1:00:24

You know, I am a firm believer that that dying sucks. Right? And it but it's but it is a fact of human life. Um and the healthiest response to dying that I know of is to live fully to face illness and caregiving and dying and grieving together as friends and families with love and to foster joy in the midst of sadness. Embracing even the sadness, because it is, it sucks. And I, you know, I say this having three or four good friends who are, you know, I'm about to turn 75. I uh in my life there is a constant, constantly I have close friends and relatives who are seriously ill and likely to die within two not too many months. Embracing the sadness, but the healthy response is is loving in defiance of mortality and to uh honoring and celebrating life and relationships. As a Jewish guy, uh I uh the uh toast the most famous Jewish toast is to life right uh I sign all of my books to life because that's what this is about to honor and celebrate the miracle and gift of life. I think that hospice is the completion uh of the continuum of human caring uh and it is a I'm gonna end where we started but it is a gift to us all uh I want to say thank you to your listeners to thank you to the the field for all that you do day in and day out and and thanks guys for having me back.

Chris Comeaux: 1:02:29

This is awesome. Well, that's almost a perfect final word but any other final thoughts you want to leave us with Ira? I'm done happy holidays the happy holidays is beautiful. I would have thought you were 60 by the way so you're my hero in many ways even in how you're doing aging well and you're still at it. So Cordt any final thoughts from your side no well said yeah happy holidays to our listeners to our listeners we really do appreciate you this really was meant to be a gift, and I hope you will treat it as such. Pay it forward to your friends, your coworkers in this amazing field of hospice and palliative care. Hip the subscribe button we don't want you to miss uh any future podcasts and Cordt and I are going to use Dr. Byock's framework going forward into the top news stories of the month next year. We'll do the first one of the years where we do our predictions of things that are going to happen, kind of set the table and then we're gonna use that framework each month going forward next year. So, this really was a foreshadowing plus anytime we get to sit down with Dr. Byock is just truly a gift. Happy Holidays to your family Dr. Byock, Cordt to you and your family as well and to our listeners also and we want to I want to leave you with two quotes today. This is really cool. One of our CEOs that we work with in the network took a picture in front of their orientation manual manuals and she said I totally forgot this was in there. It was this quote when the human dimension of dying is nurtured for many the transition from life can become as profound intimate and precious as a miracle birth of course that's Dr. Ira Byock in dying well. And then this last one gratitude can transform common days into thanksgivings turn routine jobs into joy and change ordinary opportunities into blessings. That's by William Arthur Ford. Thanks for listening to TCNtalk