Medical Specialty Code: Effective Oct. 1, the federal Centers for Medicare and
Medicaid Services (CMS) will implement a new medical specialty code for hospice
and palliative care. Physicians and other practitioners who bill Medicare file
a CMS-855i application to self-designate their primary and secondary medical
specialties, and HPM will now be available as an option. It does not require
board certification or completion of a fellowship, and it does not involve
additional payment for palliative care, at least not yet. But this new code
offers an opportunity for physicians with an interest in HPM to consider how
they wish to represent their practice to Medicare. Downloadable 855i form.
Commentary on President Obama's Grand Junction Town Hall: President Obama held a town hall last week in Grand Junction, Colorado. To healthcare reformers, Grand Junction is the land of innovation - a place that provides high-quality healthcare at a fraction of the regular price. According to some experts, Grand Junction chalks up some impressive statistics. Only 12% of Medicare patients required readmission 30 days after a hospital visit, as opposed to the nationwide rate of 20%. Children on Medicaid in the HMO are four times as likely as other Colorado Medicaid children to receive all immunization treatment - and adults on Medicaid were up to 10 times as likely to get comprehensive diabetes care. How does Grand Junction stack up for its palliative care practices? The Community Palliative Performance Profile, compiled by DAI Palliative Care Group, graded Grand Junction as an A-plus (an exemplar community). Why did Grand Junction earn this superlative? For starters, less reliance in the final months of life upon intensive care (less than half of national average) and one of the lowest percentages of deaths occurring in a hospital (20.7%). Plus, hospice enrollment is nearly 30% greater than the national average. In a future issue, we'll probe more deeply into what palliative medicine physician practices are like in the Grand Junction area.
Among the top three reasons why hospice and palliative medicine (HPM) physicians seek new practice opportunities is the desire for better compensation. What could an HPM physician expect to find in the marketplace? Results from the 2008 Palliative Medicine Compensation survey, complied by the DAI Palliative Care Group, offer some insights. The median compensation for HPM physicians in staff (non-executive) positions is $148,558. Compensation at the 75th percentile (meaning that this figure is higher than all but the top quarter) is $167,870. Probing deeper into the survey results, Tim Cousounis states that the competency most valuable in securing higher compensation is a track record of performing palliative care consults for hospital inpatients.
This fall, DAI Palliative Care Group will be releasing an updated Compensation Report.
Look for information in the next newsletter about how to purchase the 2009 Palliative Medicine Compensation Report.
Featured Practice Opportunity
Showcase both clinical expertise and business savvy to "manage" the relationship between a hospice and academic health center. This opportunity is an employment-based position with one of the leading not-for-profit hospice and palliative care enterprises (more than $60 million in patient service revenues) serving multiple states along the Atlantic Coast. The service promises to redefine how end-of-life care is provided in one of the premiere academic health centers on the East Coast. This service has generated significant interest among key stakeholders, who are eager to integrate its palliative care protocols into their practices.
To learn more about this opportunity (confidentially, of course), just send an email to firstname.lastname@example.org
| Contact Us
DAI Palliative Care
Phone: (610) 941-9419
Phone: (510) 536-3048
Palliative Care Group is a national consultancy partnering with
hospices and palliative care practices to build their medical staffs.
Recruiting, medical staff development planning, physician performance management and opportunity assessments for palliative medicine practices
are our competencies. We invite a discussion of how a partnership would
do you think of our publication? How can we best serve the needs of the HPM
community? What would you like to know about the business and practice issues
facing HPM doctors today? What do you know that your HPM colleagues need to
Click here to send us your comments.
to the inaugural issue of The HPM
Practitioner. We have launched this e-newsletter because we believe the physician
community of hospice and palliative medicine needs a forum to exchange
questions, concerns, information and best practices regarding the business and
practice management of HPM.
you have attended a national conference of the American Academy
of Hospice and Palliative Medicine, you know how eagerly participants learn and
exchange clinical knowledge. And a variety of resources are available to help
satisfy that hunger.
the business of hospice and palliative medicine - its organization, structure,
productivity, compensation, billing and coding, and other essential challenges
of practicing as an HPM physician or group - is not as well established.
do we know this? Well, consider that there are some 4,000 hospices and perhaps
1,500 hospital-based palliative care programs in the United States. But the best
available evidence suggests that the majority of physicians who belong to
AAHPM, who have earned board certification in HPM, and/or who have positions as
medical directors of those hospices and palliative care programs are only
There are about 2,800 physician
members of AAHPM, and a roughly equivalent number of physicians who are
board-certified in HPM, either by the now-defunct
American Board of Hospice and Palliative Medicine or under the new
certification established by the American Board of Medical Specialties. We know that
HPM physicians fill a variety of different roles. Some are
hospice medical directors, with responsibilities defined by Medicare's conditions of
participation. Others are physician members of hospital-based
palliative care services, while a few others essentially practice as a lone wolf or a palliative
care team of one in inpatient or outpatient settings - or some combination of
We believe that increasing the
hours of physician involvement in hospices and palliative care services and the number
of physicians working full-time in HPM is good - for the field,
for the quality of patient care and, in some cases,
for the career enhancement and job satisfaction of individual physicians.
therein lies the puzzle that persuaded us to create this newsletter: an emerging and growing field of
physicians who are committed to mastering the art and science of palliation -
but who in many cases have not yet translated their commitment into full-time
HPM practice as a career. Is that because
of salary disparities for the field, or questions about whether HPM constitutes
a viable, long-term full-time career path for physicians?
do we intend to address this puzzle? First by endeavoring to serve as the town
crier for the essential business and practice issues of hospice and palliative
medicine physicians, with your input on what you want and need to hear. We
will illustrate how some of your peers have answered the evergreen professional practice issues by
profiling in each issue an HPM physician or group, starting with the interview
with Dr. John Mulder in this issue. We will also let you know about
relevant news and resources.
return, we'd like to know what you think. Is HPM a distinct community, with its
own unique culture and professional aspirations - even though it is divided
between full-timers and part-timers, between hospice and palliative care? Do
you view HPM as a viable career choice - and why or why not? What will it take
for you or your colleagues to go that next step in the commitment to HPM by
becoming full-time at it?
I have been working on HPM
physician recruitment, compensation and performance for more than ten years.
Editor Larry Beresford has written about all aspects of hospice and palliative
care for a variety of trade and professional publications for more than two
decades, including co-authoring the "Notes from the Field" column in the Journal of Palliative Medicine.
Together, we aim to be partners in the field's growth and development - with
the hope that business and practice issues could receive the same attention
that clinical aspects of palliative medicine already enjoy.
Thank you for your interest,
Balancing Clinical and Administrative Roles:
Interview with HPM
John Mulder, MD
"I find that my passion to
make sure no one suffers needlessly outweighs my desire to go home from work at
5 pm," John Mulder, MD, says to explain how his commitment to hospice and
palliative medicine (HPM) shapes his balancing act of clinical and
administrative responsibilities for Faith Hospice and the Spectrum Health
hospital system, both based in Grand Rapids, MI.
Dr. Mulder formed a
professional corporation in order to contract with his two primary clients,
Spectrum and the hospice's parent company, Holland Home. For Spectrum he
provides palliative care consultations in two acute care hospitals (with two to
three new consults ordered per day) and fills a variety of administrative roles
aimed at promoting and advancing palliative care within the system. These include
strategic planning, one-on-one meetings with physicians, and attendance at
tumor board and cancer interdisciplinary meetings.
For the hospice, he serves as
vice president of medical services and sits on its leadership team. Recently,
he relinquished to a colleague, Dr. Martha Ording, the responsibility of hospice
medical director as spelled out in Medicare's conditions of participation. His current
role emphasizes quality initiatives such as protocol development, a new HPM
fellowship program, and medical management of the hospice's freestanding,
20-bed inpatient facility. "That's the daily clinical environment for my
hospice physician practice."
Dr. Mulder also carries a
beeper 24 hours a day ("I've always done that; I feel very possessive of my
patients"), although with the option of arranging for back-up as needed. Time
management remains an ongoing challenge, and it can be difficult to precisely parse
out which is hospice versus palliative care or administrative versus clinical (and
"But I don't stand on
protocol. I feel comfortable with how my time is spent, as do the folks to
whom I'm accountable," he says. "At the end of the day, I want to make sure
that they have gotten their money's worth. And there is the intangible value of
my availability as a hospice and palliative physician - that existential
presence, that leadership role brings value in and of itself. It's all about
establishing relationships and building trust in my role and in what HPM offers."
Dr. Mulder recently took a phone
call from a colleague who is well known as a pioneer in the field of HPM, and
is considering a job change from an academic to a hospice setting. "She asked
about the business aspects: employed versus contracted, how to negotiate salary
and benefits, things like that. These are basic issues for those who are
immersed in the business, but they can be confusing if you've never had to deal
In Dr. Mulder's previous job
as chief medical officer of Alive Hospice in Nashville, TN,
the position was structured in a way that allowed him to learn on the job the
business and practice management aspects, gaining a clearer sense of what the
medical director contributes to hospice and palliative care.
"(CEO) Jan Jones understood
and fostered the medical component of hospice, and emphasized my education as
medical director and medical leader," he relates. One of the keys was attending
national hospice educational meetings.
"It's not only having a seat
at the table for the physician's role, but sharing what I know. Which affects
how care is given, and the policies that are developed - just being able to
exercise what you know as a doctor to be a partner on the team."
How to Find Satisfaction - and Make a Living
Dr. Mulder was instrumental
in convening an informal group of about two dozen HPM physicians practicing in Western Michigan. They now meet every other month to talk
about both practice and clinical issues, and they are in discussion with a
local managed care company about establishing a contracted physician network
that could provide expanded hospice services and covered palliative care
benefits, including in the outpatient setting.
Several of these physicians
work full-time in hospice or palliative care, others are part-time, and a few
are board certified in HPM but not currently working in the field. "Two or
three others have a deep interest in palliative medicine and want to do it some
day," he explains.
At the group's first meeting
in January, "I could see doctors huddled in groups of three or four. They
couldn't stop talking. There was such a hunger for this exchange," Dr. Mulder
reports. "We want to communicate through this dialogue how you can make a
living, how you can find satisfaction, meaning and personal growth in HPM - but
also that the work requires a personal commitment to scientific, cutting-edge
medicine and a willingness to be truly present with patients and families."
He agrees that it is curious
that so many physicians who are motivated to become board-certified in HPM have
not gone the next step to full-time positions practicing this specialty.
"A lot of part-time hospice
docs, because of their hospice compensation and the hospice's lack of
commitment to the medical role, don't believe that this can be a career option.
It's hard to extrapolate from their experience to how it could turn into a
full-time job. And if they don't believe it can be, they will remain shy in
their contract negotiations with the hospice, even though a portion of every
per diem the hospice collects is meant to cover the medical director's role."
physicians too often are underused, overused, misused or abused. "Their responsibilities
are defined by people who may have very little understanding what physicians do
- or could do. The physician's role and responsibilities in hospice care need
to be viewed in different ways. Not that the doctor is more special than other
members of the hospice team, but what he or she brings to the table is
different," Dr. Mulder says.
"If a hospice wants someone simply
to come to meetings and sign documents, that's how it will structure the
position. But if you truly want what a physician can contribute to increasing the
skill levels of all staff and the quality of the care that is provided, that's
a whole different ball game. It requires a different level of commitment by the
Just as palliative care
consultations in the hospital more than pay for themselves through decreased
length of stay and reduced use of expensive, unbeneficial treatments, the
active presence of a substantially full-time physician raises the hospice's
exposure in the medical community and can lead to increased referrals and
lengths of stay and better decisions about drug therapies and other palliative
treatments for hospice patients.
"We're fortunate to have a
very strong, high-quality hospice program here in Grand Rapids, respected by physicians and the
community at large," Dr. Mulder says. In fact, data from the DAI Palliative
Care Group, derived from the Dartmouth Atlas of Health, gives the Grand Rapids region an A
grade for its end-of-life care. The region has fewer deaths occurring in
hospitals or associated with ICU admissions than state or national averages and
a higher percentage of decedents (46 percent) enrolled in hospice than national
(31 percent) or state (38 percent) averages.
Dr. Mulder was trained in
family medicine and practiced obstetrics. He was first asked to serve on the
Board of Directors of a local hospice in 1985, and became intrigued by its
work. "When they asked me to be the medical director, I began learning what a
difference hospice made at the bedside."
Today, he finds HPM a great
field to work in. "I am well compensated, and have never been more satisfied.