The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine

Issue No. 3
January 2010
In This Issue
Interview with HPM Physician Alexander Nesbitt, MD
Relative Value Units
Compensation
Billing Corner: Understanding the Recent Changes in Visit/Consultation Codes

News Notes

EOL News from the UK and Elsewhere:
While the U.S. Congress continues to debate large-scale health care reform, with significant but as yet undefined implications for providers of hospice and palliative care, news from Europe suggests the various ways end-of-life care can be addressed in public policy. "Better Investment: Better Dying" is a conference planned for Feb. 24 in London, England, focused on measurement and benchmarking of optimal end-of-life care, as well as on "collaborative commissioning for end-of-life care," which refers to how the UK National Health Service purchases services from providers. The National Council for Palliative Care in that country recently issued an "End-of-Life Care Manifesto," urging five pledges for political leaders. They include fully implementing the national end-of-life care strategy, making training in palliative and end-of-life care a core curriculum requirement, and equipping the public to become more confident about discussing wishes and priorities for end-of-life care.
 
The UK-based open access journal BMC Palliative Care recently reported research on the "out-of-hours" (i.e., after-hours) medical coverage that increasingly is provided in the UK, Denmark and the Netherlands by large cooperatives of general practitioners. Slightly less than one percent of all calls to these GP cooperatives were about patients who needed palliative care, and half of those calls resulted in a home visit. When information on palliative care patients was transferred to the GP cooperative, such as by a dedicated fax system, there were fewer hospitalizations of those patients.
 
Meanwhile, closer to home, the New England Journal of Medicine's online edition recently published an article, "Ending End-of-Life Phobia: A Prescription for Enlightened Health Care Reform," by Benjamin Corn. Dr. Corn complains that end-of-life care, with its disproportional concentration of health care expenditures, is not receiving its due in the national health care reform debate, except via distractions such as the "death panels" controversy sparked by Sarah Palin and others. The New York Times on December 26 ran a Page 1 story on "palliative sedation," which Pallimed blogger Dr. Drew Rosielle described as "a long and confusing article... (with) some things it gets spot on, while others I found deeply troubling." (See the original article and NHPCO's statement responding to the article.)

CAPC Update: Dr. Diane E. Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine in New York City, one of four current resident Health and Aging Policy Fellows of the Atlantic Philanthropies, has taken a one-year post on the Senate Health, Education, Labor and Pensions Committee. The HELP Committee, chaired by Sen. Tom Harkin (D-IA) has jurisdiction over issues such as workforce, medical education and the National Institutes of Health. Dr. Meier's twitter feed can be followed at www.twitter.com/dianemeier. CAPC is now encouraging palliative care programs to register for 2010 with the National Palliative Care Registry, which was launched one year ago with metrics developed by CAPC consensus committees to operationalize the National Quality Forum's "National Framework and Preferred Practices for Palliative and Hospice Care Quality" in real world settings. The registry offers participants an opportunity to generate customized reports comparing their performance with peers through anonymous aggregate data via "Palliative Care Compare."
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Featured Practice Opportunities

VP, Medical Services
Leadership opportunity within a highly regarded, not-for profit Midwestern hospice to develop a high-performing medical staff and an accountable palliative care organization within one of America's "most livable cities". While there are clinical and teaching expectations in this position, the principal accountability is to align the medical staff's performance (clinical and financial outcomes) with the organization's ambitious strategies.  The scope and influence of this senior executive position reaches beyond the immediate hospice (and its growing home-based and inpatient unit programs) and into the community's hospitals, long-term facilities, and educational institutions. 

Medical Director, Hospice
You'll showcase your clinical expertise as well as consultative and collaborative practice style as you provide medical direction for a hospice interdisciplinary team. You'll have the opportunity to promote and maintain a culture of clinical excellence with a strong interdisciplinary team by applying your knowledge of the best practices of palliative medicine. With the support and resources of one of the more progressive hospices in Florida, you'll have the professional opportunity to align the team's activities with organizational performance improvement goals. 
This position offers practice variety - you will enjoy a blended position with direct patient care (inpatient consultations, home and outpatient visits), management, and educational (fellowship program and trainee rotations) responsibilities that will enrich your palliative medicine portfolio of competencies.  On-call responsibilities are shared among one of the largest hospice medical staffs in Florida. Senior management has made a concerted effort to design practice opportunities with reasonable, well-articulated workloads which strive for a sought-after work-life balance.


To learn more about these opportunities (confidentially, of course), send an email to Tim Cousounis at tcousounis@digital-action.com
or click here

The DAI 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 benefit you. 

Quick Links
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Contact Us

Tim Cousounis
Managing Director,
DAI Palliative Care Group
Phone: (610) 941-9419
tcousounis@digital-action.com

Larry Beresford
Editor
Phone: (510) 536-3048
larryberesford@hotmail.com
www.larryberesford.com
Larry's Blog
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Greetings for the New Year!

Welcome to the third 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.

In this issue we profile Dr. Alexander Nesbitt, a family-practice turned palliative care physician with a success story of building a full-time HPM practice.
 
Tim Cousounis
Alexander Nesbitt, MD
Dr. Alexander Nesbitt: Pulled to Palliative Care
Interview with HPM Physician
Alexander Nesbitt, MD, by Larry Beresford
     
Dr. Alexander Nesbitt was an established family practice physician and very part-time hospice medical director in Williamsport, PA, when he heard a 2003 presentation by Dr. Diane Meier, director of the Center to Advance Palliative Care (CAPC). "I had never heard of palliative care, but I became convinced that it was a really good idea, and that somebody in Williamsport should do it. I realized that probably that would have to be me, because nobody else here was into it like I was."

He attended the Program in Palliative Care Education & Practice at Harvard Medical School (www.hms.harvard.edu/Pallcare/PCEP.htm) and began working toward board certification in HPM, earning that credential in 2004. He pursued an expanded role in Susquehanna Hospice and started advocating for a palliative care consultation service at 180-bed Williamsport Hospital & Medical Center. Both belong to the local Susquehanna Health System.

"The idea of starting a new program, which included hiring a full-time nurse practitioner to staff it, was an uphill push. I had to convince the hospital's administration that we should spend the money, even though the system was undergoing financial difficulties. Fortunately, CAPC has highly practical tools to use, well adapted to just that purpose."

The inpatient palliative care service launched in January 2005 and grew rapidly, while the hospice census was also rising to its current level of about 100 patients. "Meanwhile, we realized that patients were coming toward their dying time in the hospital with the support of palliative care but without a dedicated place to provide top-level symptom management. Plus, we had patients in our outpatient hospice in need of aggressive symptom management, and there was no good place to do that."

So Dr. Nesbitt went back to the system's administrators and persuaded them to open seven-bed Gatehouse Inpatient Hospice in July 2006 in a medical office building two miles from the acute hospital, with him as its medical director. However, this growth in HPM work was not compatible with full-time family medicine commitments, and reluctantly he gave up his 20-year practice.

"I delivered a lot of babies, took care of these families for a long time and felt very engaged with my patients. So it was a sad day to step away from my practice," he says. "But I realized I needed to do palliative care. I was pulled toward it. Just like family medicine, palliative medicine is patient-focused and family-centered, broadly defined, and I find it very rewarding to get involved with these families."

Assembling the Pieces

Dr. Nesbitt is an employee of the health system, which employs about half of the physicians in its region. "I had been working with administrators every step of the way, persuading them of the importance of this work - for patients and families, as well as for the system - and sharing outcomes data." When it came time to transfer full-time to hospice and palliative care, the various responsible parties were ready to sign off on the change. Dr. Nesbitt's salary is based in part on billing income from palliative care and inpatient hospice consultations, annualized, as well as an hourly rate for dedicated administrative responsibilities, which amount to nearly half of his roughly 50-hour week.

"Although initially I wasn't so sure, I felt I could set it up piece by piece, and make a job of it," with the combination of hospice and palliative care a good package for the system, he says. "There's increasing information out there that this work is beneficial for the patient and family, for the reputation of the hospital, for customer satisfaction, for the bottom line, and for readmission rates."

But making the case required speaking directly to the biggest concerns of each target audience, Dr. Nesbitt says. "As I prioritized it, first was to do the right thing for the patient and family. I talked about documented problems in the national health care system, such as inadequate symptom management, lack of support for patients and families, lack of understanding of treatment options. And I always included personal stories, which are very important for engaging people. Another piece of making the case is data sharing, showing how palliative care benefits the system. Each audience can hear that message if it's framed specifically for them. I also think it helps to have a physician leading the effort. I can say, 'Let me tell you about one of my patients and families.'"

In the beginning, Dr. Nesbitt took the lead on hospital palliative care consults, but as the program established its credibility, the nurse practitioner now makes over half of the visits. Another palliative care physician, Karen Brown MD, joined the team in 2007 and sees patients in affiliated, rural Muncy Valley Hospital, 10 miles away, and in the region's nine long-term care facilities. In addition to the hospital-based nurse practitioner, there is a second nurse practitioner based in the nursing homes, and an advanced practice nurse who sees patients in nursing homes and coordinates professional education events.

"Within the (HPM) team, each of us has a primary base, but we also work to float extra team time to wherever it is needed," he explains. The five members meet monthly to discuss practice issues. Growing demand for services is a problem, and the team tried to manage growth in sustainable ways while it extended services into the long-term care setting. Recently, it was decided to limit weekend palliative care consults to emergency cases only. "Sometimes we're really busy on the weekends, so we're working to make that part of this work more manageable," Dr. Nesbitt says.

Dr. Nesbitt starts a typical workday by rounding on patients in the inpatient hospice unit, and then, depending on demand for palliative care that day, goes to the hospital. He makes occasional home visits to hospice patients and sees some patients in his office in the medical building. So far there is no formalized outpatient clinic setting or schedule for palliative care, although that may change in the next year, perhaps in conjunction with the system's Cancer Center. Dr. Nesbitt takes night and weekend call every third week, and he also meets regularly with various administrators within the health system's organizational chart.

A lot of his time is spent educating physicians about hospice and palliative care, individually or in groups, and speaking to community groups. He participates in twice-weekly hospice interdisciplinary team meetings, inpatient hospice and palliative care staff meetings, and various clinically focused committees and councils in the hospital. Other hospice responsibilities include chart reviews, patient certifications and recertifications, and writing appeal letters for denied claims.

He often has ideas for how to better manage issues that come up in hospice team meetings, which may lead to new assessment forms, documentation tools, protocols or drug formulary adjustments. An example is a recently adopted protocol for administering Ketamine to treat refractory pain. "I spend time in chat rooms for palliative care around the world, where issues from difficult cases are discussed, or I may get ideas from my readings or attending conferences," he says. "I work with a wonderful team of hospice nurses who ask a lot of good questions and are motivated to learn. I am also involved in quality improvement activities, clarifying what we want to learn and how we can best collect and present the data to answer our questions."

Synergy and High Outcomes

Dr. Nesbitt finds wonderful synergies between his hospice and palliative care work, with enough responsibilities to fill a full-time medical practice. "Developing the palliative care program has been very helpful for hospice, and having a hospice that gives great care is a helpful option for referring palliative care patients who have advanced symptoms," he notes. "These are two separate populations, but they have significant overlap. Communicating carefully about difficult issues and managing difficult symptoms for the two populations is essentially the same skill set, and it makes sense to have both parts working together."

Williamsport is a city of about 30,000, 180 miles from Philadelphia, in a county of 117,000. Although Susquehanna Hospice is established as the community leader in end-of-life care, reflecting its inpatient unit and palliative care links, in recent years two for-profit hospices opened in the community, although one subsequently folded.

Based on DAI Palliative Care Group's analysis of Dartmouth Medical Atlas data, Williamsport and its health system are high performers on palliative outcomes measures. In fact, overall Susquehanna outperforms well-known, exemplary health systems like Geisinger Medical Center and Lancaster General Hospital on such measures as percentage of decedents seeing 10 or more physicians in the last six months of life, total ICU days during the last six months of life (and proportion of ICU deaths), and hospital days during the last six months of life.

Dr. Nesbitt says he'd like to take some of the credit for these outcomes, although the data mostly precede the opening of his palliative care service. He thinks the numbers will be even better in the next Dartmouth Atlas. He also points to recognized medical practice in the community and the involvement of ICU physicians in communicating with patients and families. "I think we have a great medical community that understands hospice and palliative care."

He spearheaded a POLST (physician orders for life-sustaining treatment) initiative in the region, working with the hospitals and nursing homes. The State of Pennsylvania does not give legal recognition to POLST, but a study group is working toward initiating a statewide form. He also chairs the hospital's ethics committee

In 2008 Dr. Nesbitt received the Heart of Hospice clinician award from the National Hospice and Palliative Care Organization. He and his wife have three adult children and he has taken several mission trips to Guatemala, Ecuador and Mexico to provide medical services for children. One of his hobbies is harmonizing with other members of Gatehouse Hospice Singers, who sing in groups of eight or ten to dying patients in their homes, nursing homes or the Gatehouse Hospice Unit.
           
The growth of palliative care in Williamsport has affirmed for Dr. Nesbitt the difference that one person who feels strongly about an issue can make. Clearly, much of the local impetus for this development came from him. "We had a good hospice but it was small. The palliative care nurse practitioner happened to be here at the right time. But it takes someone to convene the meetings and start the dialogue. A physician who can find like-minded people to work with can make a heck of a difference in what happens to patients in your community."

HPM Practice Insights

Relative Value Units

RVUs are a comparable service measure used by many health care organizations and payers (including Medicare) to permit comparison of the amounts of resources required to perform various services within a single department or between departments. It is determined by assigning weight to such factors as personnel time, level of skill, and sophistication of equipment required to render patient services. RVUs are a common method of calculating physician bonuses based partially on productivity. We are seeing greater use of the RVU concept by hospices to value the work of HPM practitioners.

What's the "big picture" rationale for RVUs? A major benefit of RVUs is standardizing physicians' work across types of patients and settings of care. What you want from a pay system is to fairly allocate income according to work inputs. That's what RVUs do. RVUs also cut across reimbursement systems and therefore remove concerns about a patient's coverage. They are blind to charity care. They shield physicians from nonpayment risk. They are familiar because of their use in Medicare. They are comprehensive, covering every CPT code. They save an HPM group from having to make up a system for equating disparate workloads. They adjust for one physician taking care of another's patients. That's why they're usually a better measure to use in HPM practitioner performance plans than collections, charges or visits.
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Compensation

Almost 40 percent of full-time physicians earn between $140,000 and $170,000 in compensation, including salary and other monetary incentives, according to the 2009 HPM Physician Compensation Report, compiled by the DAI Palliative Care Group.
 
Compensation continues to lag behind other sub-specialties. Surely, one reason is that patient service revenue, or billings, generated by HPM physicians lags well behind that of other specialties, with the exception of geriatrics. While new roles continue to open for palliative medicine physicians interested in full-time practice opportunities, such opportunities, whether sponsored by hospitals or hospices, require either "subsidies" for practitioner income guarantees or "stipends" for administrative activities. Continuing reimbursement pressures on hospices and hospitals suggest that subsidy or stipend increases for HPM physicians will be modest, at best, for the immediate future.
 
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 productivity incentives. To learn more about models of compensation, plan to attend the AAHPM Annual Assembly workshop presented by Drs. Ed Martin and Chuck Wellman and Tim Cousounis on Friday March 5, 2010 at 3:15 pm.
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Billing Corner: Coding for Palliative Medicine Consultations

Effective January 1, 2010, the consultation codes are no longer recognized for Medicare Part B payment. Understanding the recent changes in how Medicare reimburses for consultations is paramount for HPM practitioners, as these services typically account for a large percentage of your patient encounters. While it is unclear how and when commercial payers may follow Medicare's lead in these changes, they typically do so. With the changes come significant adjustments to the way your initial visits are reported. However, the following scenarios currently apply only to traditional Medicare patients:

Home Setting
 
Where in 2009 you would have billed outpatient consults (99241-99245), you now must bill using either new patient or established patient home visit codes.
If the patient has NOT been seen by you or another physician/non-physician practitioner in your group within the last three years, you now bill with a new patient home visit code (99341-99345). If the patient has been seen by you or another physician/non-physician practitioner in your group within the last three years you now bill with an established patient home visit code (99347-99350).
 
ALF/Rest Home
 
In 2009 you would have billed outpatient consults (99241-99245). You now must bill using either new patient or established patient Domiciliary/Rest home visit codes. If the patient has NOT been seen by you or another physician/non-physician practitioner in your group within the last three years, you now bill with a new patient home visit code (99324-99328). If the patient has been seen by your group within that time range, you now bill with an established patient home visit code (99334-99338).
 
Inpatient Hospital
 
Visits you would have billed in 2009 as inpatient hospital consults (99251-99255) now will be billed with the initial inpatient visit codes (99221-99223). For this code set it does not matter whether the patient is new or established.
 
Nursing Facility
 
For visits you would have billed in 2009 as consults in a nursing facility (99251-99255), you now bill the initial nursing facility visit codes (99304-99306). For this code set it also does not matter whether the patient is new or established.
 
What is important to remember is that the codes you will now be reporting in lieu of consultations typically have a shorter time requirement, allowing in many cases the ability to append a prolonged service code. This should significantly offset the reduction in revenue. For example; code 99255 has a time requirement of 110 minutes and in 2009 paid approximately $211, whereas in 2010, assuming you met the prolonged service requirements for a visit of 100 minutes, you would be able to bill a 99223 plus 99356, which together amount to about $287.


Chris Acevedo is a partner with Acevedo Consulting Incorporated, a firm providing on-site education and consultative services on reimbursement and coding-related concerns for the HPM Practitioner billing for hospice and palliative care services. He can be reached by phone at (561)-278-9328 or by e-mail at: cacevedo@acevedoconsulting.com
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Interested in learning more about the physician billing changes? Register for the 2nd Annual Hospice & Palliative Care Physician Billing Seminar hosted by Acevedo Consulting Incorporated, January 27-29, 2010 in Orlando, FL. Please click here for more seminar information.