Palliative Care Growth
and Challenges: America needs an alternate strategy for mid-career
physicians who want to shift into hospice and palliative medicine but are not able
to take a year off to complete a fellowship, said Russell Portenoy, MD, chair
of pain medicine and palliative care at Beth Israel Medical Center in New York during
an Oct. 27 audio conference on challenges and opportunities in HPM, sponsored
by the American Academy of Hospice and Palliative Medicine. Starting in 2013,
completing a year-long fellowship will be the only recognized path to medical board
certification for the HPM subspecialty, but current fellowship programs can
generate perhaps a hundred new graduates a year for a workforce demand in the
One key to operationalizing the various formal definitions
of palliative care to the bedside, Dr. Portenoy said, is to view HPM as a
therapeutic model that defines best practice for the routine care of all
patients with serious or life-threatening illnesses (i.e., generalist-level
care) and access to specialist-level care for those patients who need more
intensive interdisciplinary support. Beyond the workforce shortfalls in all
palliative care disciplines, other challenges include a business model that
depends on demonstrating cost reductions; limited continuity of care in transitions
beyond the hospital; and inadequate linkages between hospital programs and hospices,
nursing homes and home care. The hospice industry faces reimbursement uncertainties
because the government wants to control hospice costs and Congress is expected
to make changes in the Medicare benefit. An "open access" model of hospice care
cannot grow unless the current reimbursement system changes, Dr. Portenoy said.
HPM leaders traveled to Capitol Hill in late October to urge lawmakers to
consider the needs of people with serious illnesses in their deliberations on
national health care reform. AAHPM President Gail Austin Cooney, MD, and other
HPM leaders went there "to ensure that the needs of the most vulnerable
patients are represented in the process." AAHPM's agenda for health care reform
includes support for the National Pain Care Policy Act, the Life-Sustaining
Preferences Act, and Sen. Ron Wyden (D-OR)'s proposal for Medicare hospice
concurrent care demonstration projects to test the simultaneous provision of
hospice care and curative treatment. (See AAHPM Press Release for more information.)
Meanwhile, hospice advocates were working to try to minimize
the impact of proposed "productivity factor adjustments" that would reduce the annual
inflationary increases in Medicare hospice benefit rates. Other hospice
provisions in Congressional reform proposals include concurrent care for
children under Medicaid, recognition of physician assistants as attending
physicians for hospice patients, and a mandate for public Medicare hospice
quality reporting by 2014. (See NHPCO update and other commentary for more information.)
Psychiatry and Palliative Care: The Palliative Care Psychiatry Program of San Diego
Hospice was recently honored with the 2009 Gold Award of the American
Psychiatric Association. Directed by psychiatrist Scott Irwin, MD, PhD, this is
the only full-time psychiatry service focused on the mental health needs of
hospice and palliative care patients and their loved ones, and on addressing the
under-recognition and under treatment of psychiatric symptoms at the end of
life. The program emphasizes rapid interventions to find and reduce symptoms of
psychological distress among hospice patients, research into better assessment
and treatment of mental health concerns, rotations for University of
California-San Diego psychiatry residents, and training for palliative care
fellows from around the world. For more information, contact Dr. Irwin at firstname.lastname@example.org.
Dementia in the Literature: A study of nursing home patients with advanced
dementia, published in the Oct. 15 New England Journal of Medicine, found that while comfort was the identified goal of
care for these patients, at least 40 percent received burdensome interventions such
as hospitalizations, emergency room visits or feeding tubes. Researchers led by
Susan Mitchell of Harvard
found that residents whose proxy decision makers had an understanding of their
poor prognosis and expected clinical complications were far less likely to
receive these burdensome interventions.
A study by McCarty and Volicer, published Oct. 17 in the online American Journal of Alzheimer's Disease and
Other Dementias, found that hospice care is still underused for individuals
dying with advanced dementias. They determined that hospices offering bridge or
transition programs had on average four times greater dementia caseloads than
those without such programs. Providers identified the biggest barriers to
hospice use for dementia patients as prognosis, education and finance.
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The opportunity is an
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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
| Contact Us
DAI Palliative Care
Phone: (610) 941-9419
Phone: (510) 536-3048
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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.
Welcome to the second issue of The HPM Practitioner. We launched this e-newsletter in August because
we believed the physician community of hospice and palliative medicine needed a
forum to exchange questions, concerns, information and best practices regarding
the business and practice management of HPM. Response to our inaugural issue
suggests that there indeed is an avid audience for this kind of information.
But with the rapid pace of changes in the HPM subspecialty - and in larger
currents of health care reform - this kind of information is more important than
ever to physicians interested in turning hospice and palliative medicine into a
Once again, we
profile a successful HPM physician practice in terms of its workload,
scheduling, compensation and other fundamental practice management concerns,
this time an interview with Dr. Amy Mohler of Hospice and Palliative Care of
Western Colorado in Grand Junction.
But we also include current information about HPM's place in health care reform
and a few highlights from a recent American
Academy of Hospice and
Palliative Medicine teleconference. We introduce a new feature, Billing Corner, with concrete tips and
perspectives on billing for HPM professional services by Chris Acevedo, a billing consultant experienced in palliative care. As always, please let us know what you think, whether we are addressing
the real concerns of your HPM practice, and what else we ought to be covering.
Dr. Amy Mohler: Providing Hospice in a Town that Prizes Primary Care
Interview with HPM Physician
Amy Mohler, MD
Grand Junction, CO,
was recently lauded in the news media and at a town-hall meeting with President
Obama as "a health community that works" - for controlling health care costs while
maintaining high quality. Data from the Dartmouth Atlas and from the DAI
Palliative Care Group show it to be an exemplary palliative care community as
well, based on metrics such as lower rates of in-hospital deaths, fewer
hospital readmissions, less reliance on ICU care and higher hospice enrollments.
(For more information on DAI's palliative care community metrics, see www.DAIpalliativecaregroup.com
can't take all of the credit," quips Dr. Amy Mohler, a board-certified hospice and
palliative physician and the Chief Medical Officer of Hospice and Palliative
Care of Western Colorado (HPCWC). The local medical culture emphasizes the role
of primary care physicians. Grand
Junction's non-profit hospitals and health plan came
together 16 years ago to establish HPCWC as hospice provider for the entire
have been in Grand Junction
for decades, and our medical culture has grown from the ground up. But for the
past 16 years, HPCWC has been an integral part of that system," Dr. Mohler
says. "I see great collaborative relationships here, and our local physicians
are very open to our palliative expertise and to getting calls from us whenever
we see opportunities to improve our patients' symptoms and quality of life."
census has grown to 250 in a metropolitan area of less than 140,000 people.
HPCWC also offers in-hospital and community-based palliative care consultations,
community bereavement services, grief programs for children and teens, and a
cadre of 1,200 volunteers. It operates three satellite hospice teams an
hour or more from Grand Junction.
"Grand Junction is like the poster child for
primary care, and this is fertile ground to be passionate about your work," says
HPCWC CEO Christy Whitney. "Even before our hospice existed, there was a very
active non-profit HMO, Rocky Mountain Health Plans, that closely monitored
hospital days. But I believe we have helped considerably to lower hospital days
at the end of life, which means lower end-of-life costs. Having excellent
hospice physicians who are available for teaching other physicians has also helped
us make inroads."
Scheduling, Compensation and Call
Mohler and two physician colleagues work full-time for HPCWC, dividing up
medical responsibilities for 12 hospice interdisciplinary teams based in home
settings, nursing homes and assisted living facilities. Four days a week, Dr.
Mohler sees patients at the hospice's freestanding 13-bed inpatient unit, which
opened last October. The other doctors put in four-day work weeks heavily
tilted toward direct patient visits, which are scheduled and geographically
bunched by an administrative assistant. They generally make four or five home
care or six to eight facility-based visits per day, and the local geography
does not impose long driving times. "We try to get all of our new hospice
patients seen early in their admission, especially since we see 30 percent of them
for seven days or less," Dr. Mohler says.
spends about an hour a week on interdisciplinary team meetings, with each team coming
together every other week for a tightly structured reporting format to get
through 20 to 25 patients within 30 minutes. "We used to be quite fantastic
about allowing the IDT to run for hours, which wasn't helpful to anybody," Dr.
Mohler says. Regular contacts between IDT meetings include "mini-team" updates
and frequent phone calls.
This year HPCWC
implemented a productivity model for compensating its staff physicians, based
on their billable visits, with a base salary to cover essential administrative
activities. "I think everyone is happier with it, in terms of their workload.
If they want to make more money, they know they can work harder and make more
visits. If they like their balance of quality of life versus workload, that's
okay too. The expectations are clearer and there's a feeling of shared
responsibility," Dr. Mohler says.
Between them, the three
doctors also divide up evening on-call coverage, "physician-of-the-day"
responsibilities, including first response for palliative care consultations,
and three-day weekend call, including daily patient visits at the inpatient care
center. The three-day weekend shift is designed to give the doctor on call more
time to acclimatize to the needs of those patients.
That may seem like
a lot of call responsibilities, especially with the spectacular scenery of Western Colorado so close at hand. But it really isn't as
bad as it sounds, Dr. Mohler says. "We find the schedule is still reasonable, because
of the emphasis on primary care physicians in this community, their investment
in what happens to their patients, and our commitment to supporting that
relationship. That translates, when we are on call, into serving more as specialists
consulting on their patients, so that our responsibilities aren't such a huge
deal," she explains.
"Our staff knows
that when something is going on with a patient, their first line of help is the
primary care physician. They still may call me to spend a few minutes running through
the scenario and what might be most helpful for the patient, before they call
the physician. I tell the nurses they need to know what they want to ask for
from the doctor in a given clinical situation before they place that call."
Still, the hospice
is finding that three physicians are not enough to cover everything that needs to
be done, especially since a nurse practitioner who made most of the in-hospital
palliative care consultation visits moved away earlier this year. "When you are
the doc of the day, you're in the hot seat. You may get the consultation call
that comes in at ten minutes before five. But we're not doing a huge volume of inpatient
palliative care consultations right now. We also have a community-based nurse
and social worker palliative care team that uses more of a case management
model, with a current census of 58," she says.
teams in the three satellite offices draw upon local community physicians in
part-time or volunteer roles to staff their hospice teams. The three full-time hospice
doctors in Grand Junction
are HPM-certified, but the four part-time satellite physicians, who have
full-time clinic practices in internal medicine or family practice, are not.
The satellite team physicians don't make many home visits. "If there are
complex patients who need to be seen, we try to make special arrangements for
seeing them out of this office," Dr. Mohler says. The agency also has a medical
suite available at its inpatient unit to see patients who may be in central Grand Junction for other
Dr. Mohler would
like to have more time for visiting the satellite sites and working hands-on with
their physicians and teams, rather than doing that by phone and email. Current
plans are to recruit a fourth full-time physician for HPCWC while perhaps
involving other Grand Junction physicians in on-call coverage and encouraging
the satellite office physicians to enhance their palliative care skills through
occasional shifts at the inpatient unit.
A Representative of Hospice
Mohler's job is largely clinical, covering the inpatient unit Monday through
Thursday, Friday is spent in the hospice office on administrative functions.
These include supervising the other physicians, participating in quality
improvement activities and on the hospice's senior leadership team, teaching in
a local family practice residency program, staff teaching, educating the local
physician community and the public about hospice care, and "quite a lot of
social networking as a representative of hospice."
"We have made a
big investment in physician services. At our best we cover only 50 percent of
medical costs from billing revenues," Whitney says. "But we decided to make
that commitment, and having Amy, with her geriatric background, has been
fabulous for our patients. My feeling is that hospice and palliative medicine
is a specialty. Having our physicians available by phone supports our nurses,
who sometimes have a hard time reaching the attending physician when they're
out in the field. It brought a higher standard of care to our patients, and it
gives us the opportunity to truly practice evidence-based medicine."
Dr. Mohler has
been with HPCWC for seven years and its Chief Medical Officer, a position
created to oversee the medical care provided by the other hospice physicians,
for the past 18 months. An Arizona native, she
trained as an internist and did a geriatrics fellowship at Good Samaritan
Hospital in Phoenix.
"I always knew that I would do geriatrics and, specifically, long-term care.
But I became interested in end-of-life care during my residency," she says. "I
spent so much time in the hospital and ICU and attended so many deaths there
that I just felt there had to be a better way."
Your Service is Growing: When to Add an HPM Physician
hospice and palliative medicine (HPM) programs and practices are finding
increased demand for their physician services. These growing pains, obviously, can
put a strain on current staff and the practice's infrastructure. A
physician practice that is stretched beyond capacity because of an unfilled
position cannot carry the patient and on-call load of a larger group for an
extended period of time. The overtaxed and overwhelmed physicians are prime
candidates to leave the practice, seeking opportunities where they can find
better control over their workload. In other words, unfilled positions beget
unfilled positions. That is why turnover is often referred to as the "silent
killer" of a practice.
One of the most challenging tasks for a HPM
medical director or practice manager is determining how many physicians are
needed to staff the program. Since most HPM practices do not generate revenue greater than their
compensation, knowing when to add a full-time physician is not an easy decision
to make. But it is important to consider the costs and lost revenue associated
with an unfilled position as well as the salary it takes to fill it.
a hospital inpatient palliative care consult service, for example. A 2008 study
by the National Palliative Care
found that savings from palliative care consults for hospital inpatients ranged
from $1,500 to $5,000 per admission. A palliative medicine physician who
performs 40 such consults per month will produce savings of at least $60,000
per month for the hospital. Or take a hospice program with a palliative care
consultation service and a physician making home visits to palliative care
patients. One-third of those patients can be expected to transition to the
hospice benefit, generating, on average, $1,500 in hospice revenue per patient.
An HPM physician visiting 30 patients per month on the palliative service will
produce $15,000 in patient service revenue for the associated hospice.
While these guidelines are
handy in building a case, alone they do not make a clear case for when a
physician should be added. Nor will the conceptual approach,
projecting the work for a time period (e.g., 5,000 home visits/year) and
dividing that projection by the amount of work performed by one FTE HPM physician (e.g., 920 home visits/year). Careful consideration of
several other factors will also enhance the decision-making process: use of
non-physician providers, such as nurse practitioners; variation in workload
(need to staff higher than the average to address spikes in service demand);
expectations around nonclinical commitments that may include
administration, teaching and research; and the need for off-hours coverage, vacations
and the like.
right timing in adding a physician to a HPM practice will likely accelerate
success. Mistiming will stymie program (and practice) growth. The next issue of
The HPM Practitioner will look more
closely into effective ways to attract the right candidates to your practice.
Compensation for full-time HPM physicians continues to lag
behind other primary care subspecialties, according to preliminary findings of
the 2009 DAI Palliative Medicine Compensation Report. While median compensation
for HPM physicians increased by 8.5% over the previous year, compensation still
lags that of family practitioners by 9%, and internists and hospitalists by nearly 15%.
While overall numbers do not yet suggest a groundswell
movement, more employers/practices are shifting away from straight salary to a
combination of income guarantee and productivityincentives. To learn more about models of compensation, plan to attend the
AAHPM Annual Assembly workshop presented by Ed Martin and Chuck Wellman, March 3-6, 2010 in Boston, MA.
look in your email inbox next month for more information on how you may
purchase the 2009 HPM Physician Compensation Report. Among the uses of the report previous
purchasers have found:
- easily benchmarking current physician salaries
against those within a peer
- a source
of compensation information to
bolster program case statements to senior management;
implementing a physician
recruitment strategy using
compensation as a competitive edge
|Billing Corner: Substantiating Your Visits
(Editor's Note: The following article by
Chris Acevedo addresses some of the basic issues in billing for HPM
consultation services concurrent with primary physician services. Billing
remains a fundamental challenge for most hospice and palliative physician
practices, essential to growth and long-term viability even though unlikely to
cover the full costs of providing the service. We offer this billing information
to help contextualize that challenge and share some of the techniques of
successfully maximizing billing reimbursement for HPM physicians.)
As your palliative
care program continues to expand, ensuring that physician and non-physician
practitioner (NPP) services are not viewed by payers as duplicative will
be imperative to your program's success. The Medicare Policy Manual (Chapter
15, Section 30 E) clearly
warns Medicare contractors to "assure that the
services of one physician do not duplicate those provided by another." Thorough,
concise documentation is your best ally in substantiating that the services you
are rendering are medically necessary and non-duplicative. It also helps to
coordinate the care with your attending physicians and other specialists,
so that they have a clear understanding of your role. With many attending physicians
still uninformed about the benefits and roles that HPM practitioners
play, such communication is paramount.
specifically addresses concurrent care and states that "reasonable and necessary services of each physician rendering concurrent
care could be covered where each is required to play an active role in the
patient's treatment, for example, because of the existence of more than one
medical condition requiring diverse specialized medical services."
instructed its contractors to apply the following criteria in determining the
worthiness of concurrent care: (1) does the patient's condition "warrant the
services of more than one physician on an attending (rather than consultative)
basis"? and (2) are the services provided by each physician/NPP "reasonable and
necessary"? It is imperative that
your documentation supports your services as a necessary, concurrent but not
duplicative component of the patient's care. Although the patient's overall
condition and the underlying necessity for your services must be considered,
the recent recognition by Medicare of hospice and palliative care as a medical
subspecialty could determine whether or not the payer will question the
reasonableness of your services.
you have established the necessity for your services in general, then the focus
turns to substantiating the necessity for each visit. Again, this is an area
that takes coordination and communication among physicians. Typically what we
see are palliative providers addressing symptoms and attending physicians
addressing underlying or chronic conditions. In a hospital setting this can
work well, but for patients seen in a nursing facility or at home, you must be
sure to paint a clear picture of the services you are providing.
Think of Medicare
as any other health insurance payer. Certain items and services are covered, and
others are not. And those that are must meet the coverage criteria and at
minimum be "reasonable and necessary."
Chris Acevedo is a partner with Acevedo Consulting Incorporated, a firm
providing on-site education and consultative
services on reimbursement and coding-related concerns
related to HPM practitioner billing for
hospice and palliative care services. He can be reached by phone at 561-278-9328
or by e-mail: firstname.lastname@example.org