Business/Practice News and Views for Physicians
Hospice and Palliative Medicine
|Issue No. 4 February 2010
HPM Practitioner was launched last fall with the single goal of supporting the
development of the specialty of Hospice and Palliative Medicine (HPM) as a
medical practice -- and a career.
We have pursued that goal primarily by illustrating successful,
real-world HPM practices, showing how physicians who decided to make HPM a
full-time career have organized their practices and work days to
address fundamental issues such as billing and revenue, administrative
versus clinical time, and the other nuts-and-bolts challenges of having a
medical practice in this field.
We think that is the most valuable and unique service we can offer to a field
that all too often, despite its commitment to relieving the suffering of
advanced illness in all its manifestations, doesn't quite believe this can be a
We know there are as many ways to organize a practice as there are HPM
physicians, but we hope to provide examples that may inspire or inform other
HPM physicians. Therefore, we have decided to offer not one but two portraits
in this issue of practicing HPM physicians and how they made it work for them.
Dr. Michael Nisco: Knowing What You Are Worth
Interview with HPM Physician
Michael Nisco, MD
by Larry Beresford
physicians credentialed in HPM create busy, thriving, financially viable,
full-time medical practices specializing in hospice and palliative care? Dr.
Michael J. Nisco of Fresno,
CA, president of the independent
medical corporation California Palliative Care, Inc., answers with a resounding
yes -- although the pace of his HPM practice might make your head spin.
Dr. Nisco's medical
corporation employs eight other physicians in part-time capacities and
contracts with St. Agnes Medical Center for medical direction of its palliative
care service; with St. Agnes Hospice for medical director services; with the
University of California-San Francisco (UCSF) Fresno campus for consulting and
to direct its developing palliative care fellowship program; and with Hinds
Hospice inpatient facility for consulting and clinical services. But that's
just the beginning, since he has been asked to participate in two other
Dr. Nisco himself
works seven days a week. But between contractual stipends to the corporation
and billing revenues, "I make well above what I ever could have made as an
employed physician or in family practice, and the people who work for me are
He advises other
credentialed HPM physicians not to sell themselves short. "Whether you
realize it or not, chances are the hospitals and hospices that you work with
know how much they can benefit from having an experienced HPM physician on
staff. Hospice and palliative physicians are in big demand, and at this point
most hospitals are aware that they need palliative care for reasons of quality,
satisfaction and throughput," he says. Establishing a new palliative care
program requires a lot of time just walking around talking to people, so HPM
physicians should not be shy about asking for a stipend and the support needed
to run a successful service.
Although his practice
in Fresno has
grown rapidly, "in no way did I try to build an empire. My only goal was
to help hospitals and hospices address palliative care needs and do the best I
could for patients. I was never driven by who would pay me the most, and most of
my relationships in fact began with me volunteering my time to discuss
opportunities with institutional committees interested in building HPM
programs. I think if your intentions are principally to support providers as
they struggle to improve the quality of care for their patients, people will
recognize that and they'll want you on their side."
Finding His People
Trained in family
practice, Dr. Nisco felt a pull to end-of-life care, based on both family
experiences and an end-of-life care research project in medical school that
took him to China.
In his first family practice group position, he became the default, go-to
end-of-life care provider. "But I did it after work and on weekends, and
it wasn't highly valued in my group," Dr. Nisco says.
Eventually he landed a
fellowship in HPM at Harvard
"That was a life-changing experience, doing my fellowship with Andy
Billings and Susan Block. I had gone into family practice to get involved with
patients and families in meaningful ways. But it wasn't satisfying, because of
the time pressures. Now, in palliative care, I was able to really connect with
patients and families, to be invited into their lives during such an intimate
After the fellowship
was over, Dr. Nisco's wife Yen chose Fresno, in California's Central Valley, as a place to settle, given
the highly rated Clovis
School District and the
slower pace and not-too-urban lifestyle. He began sending emails to local
hospital and hospice administrators. "They agreed to meet with me, but it
quickly became apparent that none of them had any idea what to do with a
physician who wanted to practice HPM full time." One hospital offered him
a 0.2 FTE stipend to run a palliative care service. But with minimal other
support or resources, it was not enough to overcome the huge barriers to
implementation, such as the attitudes of oncologists and primary care
A year out of his
fellowship, Dr. Nisco was approached by the newly hired medical director and
director of oncology services at St. Agnes Medical Center in Fresno, both of
whom had worked at other hospitals with palliative care programs. St. Agnes
also belonged to a larger Catholic health system that was pushing palliative
care implementation. "I no longer had to prove to them the value of
palliative care, they already got it. They offered me a half-time stipend, two
nurses, an office and administrative support."
Based on the
challenges at the other hospital, Dr. Nisco made a strong commitment to treat
every referring physician as a customer, getting to know them personally and
respecting boundaries. "I tried my hardest to let them view me as
supporting them and their relationships with their patients." His medical
corporation provided the structure for his working relationship with the
months, I was overwhelmed by my success. There were so many inpatient referrals
that I literally couldn't do it all myself." So out of necessity, the
service was reorganized, with most of the initial contacts coming from the
palliative care nurses, who talk with him several times each day about who
needs to be seen by the doctor.
A year later, St.
Agnes' hospice program, with an average census of 100 patients, asked him to be
its medical director. The inpatient team continued to grow, evolving into a
true interdisciplinary team. Suddenly there was a list of doctors who wanted to
be part of the service, from fields such as emergency medicine, internal
medicine and family practice. Next step is to open a 30-bed palliative care
unit, slated for later this year, and Dr. Nisco is right in the middle of its
"I had become
frustrated with patients having to die on telemetry units, cared for by
telemetry nurses who themselves were stressed and frustrated due to a lack of
specialized training in end-of-life care and discomfort with caring for dying
patients." This new unit will admit hospice patients in need of general
inpatient-level care, but mostly it will focus on "any patient in the
hospital who has palliative care needs unique to the skill set of palliative
care nurses, in a nice private room. That's better for the nurses, better for
the patients, and better for the hospital."
Incredibly Busy, but not Always
Dr. Nisco acknowledges that he is
incredibly busy. "But I've never been happier. I wake up every day and
love what I'm doing. I love working with hospice and palliative care people.
I'm helping so many different hospices and hospitals develop programs. I'm giving
lectures and doing all sorts of education. I'm sitting down with administrators
every day to develop new care systems. I have a broad reach, and I'm still able
to get daily face-to-face encounters with patients." The only downside is
the hours, which he estimates at more than 80 per week. "And when I'm not
on an airplane, I'm reachable by cell phone 24 hours a day."
Roughly 30 percent of
that time is purely administrative, 30 percent is education and teaching, 25
percent is palliative care consultations in the hospital, and the rest of Dr.
Nisco's work week is spent filling the hospice medical director role, although
without a lot of patient visits. "After two years, the nurses finally got
the idea of what a physician at the table can bring to hospice, but they're
still not entirely used to physicians making home visits. We're making
progress, though, and I'm in the process of interviewing a doctor specifically
to make regular home visits to hospice patients." He also spends time
developing policies and procedures, such as ICU, pain or ethics protocols, and
an inpatient DNR order set, used in three local hospitals, which is fully
aligned with California's
POLST (physician orders for life-sustaining treatment).
In the middle of this
cyclone of activity, Dr. Nisco noticed a lack when he met with hospital
administrators, who sometimes seemed to be talking over his head with terms
like return on investment. So he has been pursuing an MBA with a health care
emphasis from UC-Irvine, four days a month, and will earn the degree in June of
this year. "We often joke as physicians about administrators as being from
the 'dark side,' but this education has made a huge difference in my ability to
understand and be flexible and align myself with the hospitals' goals," he
Does he see keeping up
this pace indefinitely? "I hope not. My goal is to look back in 10 years
and see a wonderful, thriving palliative care community in Fresno, with a qualified physician group
offering end-of-life care to patients throughout the area by contract to
multiple agencies, via a group of full-time providers, including mid-level
practitioners." In the meantime, he says, "If any hospice and
palliative care physicians want to work in Fresno, give me a call. We need you!"
Featured Practice Opportunity
your palliative medicine portfolio of competencies with a full-time practice
opportunity that "blends" direct patient care in a variety of
settings with management and teaching responsibilities. In this role, you will
join a group of three experienced, highly respected, and certified HPM
physicians serving a hospice and hospital palliative consult service located in
a highly desirable suburb of a major Midwestern city. You'll join just in time
to assume a leading role in the management of an inpatient hospice unit, slated
for opening in the summer of 2010.
You will have at your fingertips an exceptional professional development
environment and an opportunity to develop a thriving practice in all aspects of
hospice and palliative medicine. And senior management has made a concerted
effort to design this practice opportunity with reasonable, well-articulated
workloads which strive for a sought-after work-life balance.
In this practice, you'll showcase your clinical expertise as well as
consultative and collaborative practice style, and 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
This is a high-impact, high-profile role where success will lead to potential
leadership opportunities and a thriving clinical practice.
To learn more about this opportunity (confidentially, of course), send an email
to Tim Cousounis at firstname.lastname@example.org
For more opportunities, click here.
Visit with Tim Cousounis at the AAHPM Assembly Job Fair (Thursday, March 4th,
5-7 p.m.) to learn about other career advancement opportunities for HPM
physicians. Information will also be available about HPM Physician Performance
Profiles. Find out more about one of the newer tools used to manage
expectations and performance while reducing role confusion.
Compensation and the Evolving Role of the HPM Practitioner
roles of HPM physicians expand beyond the traditional ones of Hospice Medical
Director or Hospital Palliative Consultant, the contractual arrangements (based
upon hourly pay) common to these roles are yielding to more complex
compensation arrangements. Today, as more HPM practitioners take on
full-time roles, we see employment relationships becoming the norm, accompanied
by income guarantees and practice subsidies. What does the future hold for
compensation models, as more HPM physicians take on full-time roles that
include a significant component of direct patient care, in the form of home
visits, hospital encounters, and inpatient hospice visits?
We're seeing more compensation plans utilizing metric-based incentives and
tiered models, as a means to raise the physician's earnings potential and
align physician and organizational objectives. Regardless of the type of
organization and the incentive chosen, certain tactics are key to successful
compensation plan design.
Learn more at the AAHPM Annual Assembly, where on Friday, March 5th, at 3:15
p.m., Drs. Edward Martin and Charles Wellman, along with Tim Cousounis, will
present a one-hour educational session on Physician Compensation Models.
Included in the presentation will be case studies of hospices which have moved
to incentive compensation models.
Click here for more information about the DAI
Palliative Care Group 2009 HPM Physician Compensation Report.
DAI Palliative Care Group
Phone: (610) 941-9419
Phone: (510) 536-3048
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.
What 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 learn?
Click here to send us your comments.
Dr. Janet Bull: One Quality Consultation at a Time
Interview with HPM Physician
Janet Bull, MD
by Larry Beresford
Dr. Janet Bull, Chief Medical Officer of Four Seasons in Hendersonville,
NC, a fellow of the American Academy of Hospice and Palliative Medicine (AAHPM)
and board-certified in HPM, entered this field from the unusual vantage point
of obstetrics. She was drawn to the work after watching her office manager die
at a young age in a major teaching hospital without the benefit of good
After moving to Asheville, NC, and taking a three-year sabbatical to be
with her children, she started as a volunteer hospice physician and became
hooked. She was Four Seasons' first part-time paid physician in 2000 and,
starting in 2003, its first full-time staff physician. The organization
experienced tremendous growth in hospice census -- 250 percent in two years --
after launching a highly successful palliative care program. Now she's back
working long hours, which she estimates at 60 to 70 hours per week.
Hendersonville is a retirement community of
about 100,000 people, 20 miles from Asheville in
the hills of Western North Carolina. Four
Seasons serves a current census of 250 hospice patients and, in conjunction
with its palliative care program, cares for 74 percent of all patients who die
in Henderson County. The palliative care consultation
service, launched in 2003 and offered seven days a week in two local hospitals,
nursing homes, assisted living facilities and patients' homes, has a current
daily census of 400 patients. About half of the hospice's patient referrals are
generated from palliative care.
According to data analysis from the DAI Palliative Care Group, the Asheville region, which includes Henderson County,
outperforms national averages and some better known palliative care communities
on Dartmouth Atlas-derived measures of end-of-life care.
Today, Four Seasons employs four nurse practitioners, four physician assistants
and two physicians dedicated to palliative care, under the direction of Dr.
John Morris, a pulmonologist and critical care physician. The team is rounded
out by a full-time social worker, part-time chaplain, full-time scheduler and
other administrative support. The hospice program has 5.5 FTEs of physicians.
That roughly breaks down as 1.5 FTEs covering Four Seasons' 19-bed freestanding
inpatient facility; 1.5 FTEs seeing patients in nursing homes; and 1.5 FTEs
visiting patients at home -- plus Dr. Bull herself.
"We are very heavy in physician staffing, and think that is a good real
positive," with the physicians mainly out making billable visits to
hospice patients and serving as attendings or consultants on about 80 percent
of patients enrolled in hospice care, she explains. "They actually paid
for themselves last year."
In 2005, Four Seasons started a research department, which offers clinical
trials to patients for a variety of symptom management issues. It collaborates
with academic institutions like Duke
and M.D. Anderson, as well as pharmaceutical companies. Participating in
clinical trials offers patients access to treatments not currently available,
and the generated revenue supports palliative care services, Dr. Bull says.
In collaboration with Dr. Amy Abernethy at Duke, Four Seasons launched a
multi-site palliative care benchmarking initiative called the Palliative Care
Database Project. Its purpose is to support quality assessment and improvement
by providing critical data collection and data management infrastructure,
identifying patterns of access, utilization, symptoms and advance care
planning. "For example, our data show that chronic obstructive pulmonary
disease patients are less likely to complete advance directives, suffer a high
symptom burden and require multiple hospitalizations."
In 2009 Four Seasons established the Center for Excellence, which provides
on-site training, consultation and mentorship for other end-of-life care
programs and professionals. This service experienced a spike in demand after
the American Hospital Association gave Four Seasons its Circle of Life Award in
2009. A disease management program targets hospice patients with conditions
such as cardiac or pulmonary disease for special interventions and focused
"My role as Chief Medical Officer is overseeing the hospice side of
operations, and also the research component," Dr. Bull explains. "Dr.
Morris oversees the palliative care division. We complement each other and both
of us sit on the senior leadership team, giving the agency two strong,
visionary physician leaders." Dr. Bull makes clinical visits to research
study participants, provides overflow coverage at the hospice house, makes
assessment visits when more information is needed for terminal certifications,
and does scheduled on-call shifts. As hospice medical director, she oversees
day to day clinical operations, supervises the other physicians, and leads
special projects like the Center for Excellence and the state Palliative Care
She frequently travels to research meetings and serves on AAHPM's research
committee and Palmetto's Hospice-Intermediary Advisory Committee. She makes educational
presentations on evidence-based prognostication, hospice eligibility, appeal of
claims denials and physician billing, with a preconference presentation on
billing and coding scheduled for the AAHPM annual meeting in Boston on March 3.
Integrating Palliative Care with Hospice
Dr. Bull says it was not a difficult decision for Four Seasons to commit to
palliative care. "It was an emerging field, and it made so much sense for
our patients. We could incorporate this holistic model of care earlier in the
disease trajectory and use it to take better care of our patients. We didn't
anticipate quite such rapid growth, but it goes to show that once people have a
good framework for making personal treatment decisions, they often choose
comfort care," she says.
In the program's early stages, the Center to Advance Palliative Care was a
useful source of technical assistance and tools. "It's mind-boggling how
much there is to learn about this field -- even basic things like billing and
coding. We had a tremendous amount of help early on. We had a community that
supported moving in this direction, and we've been fortunate to enjoy ongoing
support from the Duke Endowment," she explains.
"We are also very cognizant that you're never going to make money
providing palliative care. You can be smart, efficient and effective in how you
deliver the care -- but you must be fiscally responsible, making sure to keep
your losses at a minimum. We establish visit expectations for professional
staff, and we provide a support system so that the providers, who work
virtually based out of their homes, don't spend their time calling patients to
arrange appointments or doing administrative tasks. We follow the National
Consensus Project guidelines and, basically, teach the importance of one
quality consultation at a time."
Essential to the palliative care program's success was being clear on what
kinds of patients it would see -- or not see. "We learned early on that we
can't be all things to all people. We didn't want to be a chronic pain service
or post-acute, post-surgical consultants. We wanted to stay focused on serious,
advanced illness, generally for patients with three years or less to live. At
Four Seasons, we are all about delivering quality care and looking at
measurable outcomes. We take our patient and family satisfaction surveys very
The program emphasizes continuity of care across care settings. "From the
get-go, we saw patients where they were, and we followed them from one setting
to the next," she says. Integrating the hospice and palliative care
departments was also a priority. "Many organizations bump up against the
problem of palliative care being viewed as a step-child to hospice. Here we
value the great things palliative care brings, and how it complements
hospice," Dr. Bull says.
"We consider ourselves one big team, whether palliative care or hospice,
with a lot of interface between the two. Patients can flow both ways between
these programs. We used an explicit strategy of building the connections between
the two. Some employees serve both programs, and we share resources and
administrative tasks, integrating them whenever we can," she reports.
"Often at staff meetings we'll have presentations by palliative care
leadership or providers, explaining their work to hospice staff. We focus on
education, both internally and externally, explaining the differences between
hospice and palliative care, and how they complement each other. We inform
patients that hospice offers many more services than palliative care."
How the agency managed rapid growth has also been important. "I think you
need to have strong leadership. That's an essential ingredient of our success.
We brought on CEO Chris Comeaux about the same time as launching the palliative
care initiative," she says. "Chris has been an essential ingredient
to our success by bringing in a thoughtful leadership structure. Yes, there
have been growing pains. When you grow that quickly, you outgrow systems and
processes. So it's important at times to stop and catch up."
Work Hard, Play Hard
"It's really true that birth and death have many similarities," Dr.
Bull observes. "As a physician at the bedside, you're caring for a patient
at a very intimate time of life. It's very rewarding and very much a privilege.
So it wasn't such a big stretch for me to move from obstetrics to hospice. Of
course, I had to learn palliative medicine. But I had good mentors. I read
often, went to conferences, and was never afraid to ask questions," she
"I work hard, and really enjoy the variety that each day offers. I love my
job and working for an organization that is so focused on its mission and
values. Luckily, I don't require much sleep. I get up early and can get a lot
done. Essentially, I can work from anywhere, as long as I have my laptop. The
flexibility allows me to attend my kids' athletic and school events, something
that was hard to do as an obstetrician. My motto is: work hard and play
hard." That includes world travel, road bicycling, snowboarding, camping
and yoga, as well as enjoying Hendersonville's
beautiful mountain setting.
Billing Corner: Meeting the Split/Shared Visit Requirements
By Chris Acevedo
hospital-based palliative care services has been accompanied by the increased
use of non-physician practitioners (NPP). Accordingly, substantiating split (or
shared) visits requires a good understanding of documentation requirements for
billing these Medicare Part B visits.
please note that split/shared visits do not apply in an outpatient
setting, nor do they typically apply to hospice physician services.
defines a split/shared visit as, "... a medically necessary encounter with
a patient where the physician and a qualified NPP each personally perform a
substantive portion of an E/M visit face-to-face with the same patient on the
same date of service. A substantive portion of an E/M visit involves all or
some portion of the history, exam or medical decision making key components of
an E/M service."  Thus, to be covered by Medicare (or any payer that follows
Medicare guidelines for split/shared visits), the documentation must
substantiate that both the physician and NPP personally performed
a substantial portion of the face-to-face Evaluation and Management service.
The documentation should be clear to a reviewer exactly who provided which
portion of the service. A statement by the physician attesting to the clinical
merits of the NPP's findings will not suffice.
Part B contractors, like WPS, have clearly stated the following, "When the
supporting documentation does not demonstrate that the physician performed a
substantive portion of the E/M visit face-to-face with the same patient on the
same date of service as the portion of service performed by the NPP, a service
billed under the physician's Provider Transaction Access Number (PTAN) will be
following examples, provided by WPS, illustrate just what type of physician
documentation is not adequate to substantiate a split/shared visit to be billed
as a physician visit:
- "I have personally seen and examined the patient
independently, reviewed the PA's Hx, exam and MDM and agree with the
assessment and plan as written" signed by the physician
- "Seen and examined and agree with above (or
agree with plan)" signed by the physician
- "As above" signed by the physician
- Documentation by the NPP stating "The patient
was seen and examined by myself and Dr. X., who agrees with the plan"
with a co-sign of the note by Dr. X
the use of NPPs into your palliative service practice can be an effective way
to "extend" your time, but extra caution needs to be taken to ensure
compliance with rules and regulations of Medicare and other payers.
IOM Publication 100-04, Chapter 12, Section 30.6.13 (H)
Provider Communication 11-17-2009
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: email@example.com
Note for AAHPM Annual Assembly attendees: Chris Acevedo will be one of
the presenters of a Preconference Workshop on Wednesday, March 3rd, at 1p.m.,
addressing hospice and palliative care billing and coding.