The HPM Practitioner

Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
Issue No. 8                                                                                  December 2010
Greetings!


Physicians come to the specialty of hospice and palliative medicine (HPM) in many ways. Some have formative personal experiences of encountering death and dying. Others meet inspiring teachers who help direct them down this path. And some just discover they have a knack for working with patients and families at this level of emotional intensity, or perhaps all of the above. Once they decide to pursue HPM as a career, they may settle into a hospice medical director role, or they may be more comfortable on a hospital palliative care consultation service. Increasingly, HPM physicians are finding ways to combine these roles and settings, and to balance administrative responsibilities with face-to-face clinical time with patients and families. In this issue, we present two more stories of HPM physicians who have found through trial and error and experimentation their own personal balance of these roles and responsibilities. We hope they will be inspiring to you as you seek your unique balance within a field that continues to post dramatic growth and opportunities for advancement.


Tim Cousounis


In This Issue
HPM Practitioner Profile - Dr. Matthew Kestenbaum
WilliamsonGrowing the Physician's Role in HPM
Interview with HPM Physician
Matthew Kestenbaum, MD,   
by Larry Beresford

Dr. Matthew Kestenbaum


Active physician involvement is essential to the growth of hospice and palliative care programs, asserts Matthew Kestenbaum, MD, Chief of Medical Staff for Capital Hospice, Falls Church, VA. And he has the experience to prove it.


Dr. Kestenbaum's first job after completing an internal medicine residency in 1997 was hospice physician for Hospice of Washington (DC; now called Community Hospices). During his first day on the job, he learned that the hospice's medical director was leaving, so her position---- with all of its medical administrative responsibilities---- suddenly was his.


Over the course of nine years, at first as its only physician, Dr. Kestenbaum participated in the hospice's growth from 20 to 250 patients, its geographical expansion beyond the District of Columbia, and the gradual addition of other physicians to the staff. He credits this growth in part to his outreach to referring physicians and hospitals, doing lots of grand rounds and one-on-one lunches, and making home visits to patients whenever possible. "After every home visit, you call the attending and talk about the plan of care, which shows the physician that there's more to this specialty of hospice," he explains.

 

For the past year and a half, Dr. Kestenbaum has overseen a medical staff at Capital Hospice that includes 26 physicians, four nurse practitioners and two registered nurses. The agency has a census of 1,000 hospice patients and expects 3,000 new palliative care patients and 15,000 palliative care visits this year. It contracts with five (soon to be seven) large hospitals to provide palliative care consultation services, operates a freestanding and several contract inpatient hospice units and five outpatient palliative care clinics, and also has a presence in area long-term care facilities.

 

He spends one day a week of protected clinical time staffing an outpatient palliative care clinic in Leesburg, VA, and the rest of his time is the day-to-day running of this large medical group, medical education and orientation for incoming staff, and participation on the agency's clinical and quality committees. The medical group has seven regions, each with a general manager. "But I also need to be involved as much as possible."

 

Dr. Kestenbaum fills in when needed to cover hospice physician functions, takes his turn on-call, and spends a lot of time in his car, using a hands-free phone headset, visiting Capital Hospice's offices and facilities in DC, Northern Virginia and suburban Maryland. Another current priority is working on new physician productivity tools derived from RVUs (relative value units, used by Medicare to determine physician fees) but reflecting the true nature of hospice and palliative care.

 

"It's very important to maintain your clinical activity as a physician. But I also derive a lot of satisfaction from being able to make the lives of our clinical staff easier and allow them to do their jobs more efficiently. That way I can impact on more patients' lives," Dr. Kestenbaum says. The hospice's medical group may or may not be the largest in the country, but it has grown steadily over the past seven years.

 

"At this point, the amount of clinical activity we're doing is limited only by the amount of clinicians on staff." Because of the shortage of fellowship-trained HPM physicians, he adds, the agency is more or less in constant recruitment mode. But the fellowship program it jointly sponsors with the National Institutes of Health has been a great source for bringing qualified physicians on board.

 

Capital Hospice invests heavily in the salaries of its extensive physician staff, although much of that investment is returned through billable visits and contracts for their services, along with the usual medical functions under hospice conditions of participation. "Clearly, you need a committed organization, because there still is difficulty getting the funding to cover what we do, especially on the palliative care side. Third-party payers do not reimburse adequately, and that's just for the physician. If you want other team members, you really need a committed organization," he says.

 

"On the hospice side, if run properly, that is a more sustainable model," factoring in a portion of hospice per-diem reimbursement to support the physician's role. However, heightened regulatory scrutiny and anticipated changes in hospice reimbursement and claims review make Kestenbaum, along with many other hospice leaders, concerned about how this picture could change.

 

Credibility for Outpatient Care 

 

Capital Hospice's commitment to outpatient clinics has also grown gradually, and is likely to expand in the near future, both in number of sites and hours of coverage per week. Currently, clinics are offered a half or full day per week, and are located at hospital campuses, oncology outpatient clinics and the hospice's freestanding facility. Each arrangement is different, but in some cases Capital rents space and staff like receptionists and office nurses at fair market rates while doing the scheduling centrally from its office.

 

"We focused initially on partnering with our oncology colleagues, because we felt we'd have the most buy-in from them. That allowed us to get the feel of how outpatient clinics really work and to develop a degree of credibility we could take to other providers. Then you begin to get word of mouth. That's what led to our heart failure clinic," he says. Referrals come from hospital palliative care physicians, from hospitals outside of the service area for patients returning home, from community-based primary care physicians looking for palliative care, "and from patients who heard about us through a friend. There's a real nice continuity to outpatient palliative care, and the more palliative care we do, the more we see patients earlier in their disease trajectory or with non-terminal diagnoses," he reports.

 

Right Place at the Right Time

 

Dr. Kestenbaum did his residency at Northwestern Medical Center in Chicago, after which he planned to pursue business or law school, rather than a clinical career. While he never shied away from dying patients or end-of-life conversations, hospice wasn't part of his plans until one day, as senior resident, when he led a pack of interns and students into the room of a patient dying of liver cancer.

 

"He was scared about what was happening to him, and what would happen to him," Dr. Kestenbaum recalls. "I made everybody on the team grab a chair. We sat down and had a typical end-of-life and goals-of-care conversation, because that's what you're supposed to do as a doctor." The patient found the conversation helpful and the students also felt good about what had gone on.

 

"Coming out of the room, one of the interns said to me: 'Wow, that was really good. Why don't you consider doing that as a career?' I said, 'Can you do that?' She said, 'I think you can, and I think we even have a hospice here at Northwestern.'"

 

Dr. Kestenbaum had already encountered Charles von Gunten, MD, founder of the hospice service at Northwestern, as a teaching attending. "I had thought Charles was tremendous, although I didn't know exactly why. The more I got to know who he was in this field, it just seemed like a natural fit. For whatever reason, there's something inside of me that was meant for this work. I always felt that ease (with patients), which made it easy for me to choose hospice and palliative care as a career," he says.

 

"Charles was able, with my program director, to schedule my third year of residency as a kind of mini-fellowship in hospice and palliative care, with tailored rotations better suited to my new career goal, such that when I came out I felt I was reasonably well prepared to do this work," he says. "I was lucky to be in the right place at the right time." But when he started at Hospice of Washington, he needed to learn many of the administrative requirements on the job.

 

After nine years of growing with the hospice, he decided he needed a break. His children were young and he wanted to spend more time with Alex and Nicholas, who are now 13 and 10. He and his wife Kathleen, who is a physical medicine and rehabilitation doctor, moved out to rural Haymarket, VA. "I took a part-time job as team physician in Loudoun County for Capital Hospice. It gave me more time to be at home, and enabled me to regain a sense of balance in my life. I did that for three years, which I enjoyed a lot. In the course of time, I was asked to become senior medical director for Capital Hospice's Western Region," he says.

 

Then the hospice's chief medical officer, Cameron Muir, MD, who had been instrumental in establishing and building its medical group, accepted a position as Capital's Executive Vice President for Quality and Access. He asked Dr. Kestenbaum to step into his former role, "again because I had a fair amount of experience as a hospice medical director. This job now allows me to be where I need to be, both personally and professionally."

 

Currently he works between 45 and 50 hours a week, although sometimes much more. "For being a two-physician family, I think we do very well in being there for our kids' sporting events and music lessons. We've found a good space to balance that." Contact Dr. Matthew Kestenbaum at: MKestenbaum@capitalhospice.org.


PracticeOpportunityFeatured Practice Opportunities


Chief Community Palliative Care Officer
 

We invite emerging HPM leaders to have a confidential conversation with Tim Cousounis about a compelling medical leadership opportunity with a not-for-profit hospice repositioning itself into a community-based palliative care enterprise.

 

Located in a waterfront city on the East Coast, this hospice enjoys a solid relationship with the leading medical center in the community, and has joined with that highly-regarded hospital in serving the palliative care needs of its patients.

 

Expectations of this position are high, of course, yet will be compensated accordingly.

 

Most prominent of these lofty expectations is the building of a high-performing network of physicians and advanced practice nurses which will serve as the de facto provider of hospice and palliative care throughout this community.

 

Inspire referring physicians and HPM medical staff members to meet clinical outcomes and family satisfaction metrics. Disseminate throughout the community the use of metrics and evidence-based practices to hold practitioners to high standards of performance. And partner with a visionary CEO to envision and stimulate a change process that coalesces the community around new models of late-life care. All in this chief medical officer opportunity.


If you're considering advancement along your career path and would like to learn more about currently available physician leadership opportunities, contact Tim Cousounis at tcousounis@digital-action.com or (610) 941-9419


For more opportunities, click here.

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

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.

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StratonThe Hospital was Happy to Have Us
Interview with HPM Physician
R. Scott Lake, MD

by Larry Beresford 

Dr. Scott Lake


R. Scott Lake, MD, director of palliative medicine services for the three-hospital Roper St. Francis Healthcare System in Charleston, SC, believes that HPM is a wonderful field in which to work, "not easy, but exciting, although perhaps under-compensated. I think sometimes some people think that what we do is a lot easier than other fields of medicine," he observes. "I enjoy coming in and being able to fix or negotiate through difficult situations that no one else has been able to do. I also think we have an opportunity to transform the way people view dying---- not just patients but the larger society."

 

While completing an internal medicine residency at Rush Presbyterian Hospital in Chicago, Dr. Lake did an HPM rotation with Dr. Martha Twaddle of the Midwest Palliative & Hospice CareCenter. When he moved back to his hometown of Charleston, he contacted a friend and colleague, Dr. Angus Baker, an oncologist, and started volunteering alongside him for Hospice of Charleston while establishing an internal medicine practice. When the hospice began planning a 20-bed freestanding inpatient unit, it created an opportunity for full-time work for both doctors as hospice co-medical directors, making home visits to patients as well as inpatient rounds, growing the hospice's business and establishing a palliative care consult service with the local hospitals.

 

About two years ago, the non-profit hospice was acquired by the for-profit home health and hospice company Gentiva. "Even before the buyout, it was already clear to us that palliative care consulting was most beneficial for the hospitals and their patients, but we didn't have enough time to meet the demand," Dr. Lake says. He and Dr. Baker transitioned over to the hospital system to build palliative care at Roper, St. Francis and a third affiliated hospital, while continuing to round on the hospice unit under a contract with Gentiva. "The hospitals were happy to have us, and we're happy to have them."

 

The two doctors, as well as a third physician, who is now per diem but hoping to get a staff position, work for a primary care-heavy medical group called Physician Partners, affiliated with the hospital, under a vice president who also supervises the system's hospitalists. But they also cultivate relationships with the hospitals' administrative leadership and promote palliative care in the hospitals. And the hospice unit represents a third reporting relationship. Recently, Dr. Lake has been presenting information on a new ICU quality communication bundle developed by Judy Nelson and Peter Pronovost to relevant hospital boards and medical executive committees---- and he has made the same presentation six times.

 

"Right now there are no performance targets for us, which is another complex situation when we attend medical staff meetings and see the relative value units posted for other physicians in the group," he says. "But we're busier than we've ever been, and we've been riding this groundswell of national attention to palliative care." The physicians submit bills to the hospice for inpatient visits and to third-party payers for palliative care consults. Payment is forwarded to the hospital system, which pays their salaries. "To be honest, I feel reasonably well compensated for the work I do, but I will be interested to see what comes from the AAHPM salary survey," he says.

 

Growing Administrative Responsibilities

 

The three Charleston palliative care physicians trade off assignments every week, with one week spent providing seven days of coverage in the hospice unit plus on-call responsibility. The other two weeks are spent with normal working hours doing palliative care consultations at one of the other hospitals. Currently there is one advanced practice nurse and one social worker assigned to the palliative care team, both employed by the health system, and they divide their days between the hospitals. Sometimes palliative care consultations get overwhelming at one hospital or the other, and the physicians will flex and cross over as needed.

 

For Dr. Lake, there are additional responsibilities as the nominal medical director of palliative care, while Dr. Baker attends to more of the administrative responsibilities at the hospice unit. "My day is a mixed bag of seeing patients, administrative duties and trying to take the program to the next level," he says. "I spend more of my time in the hospital. Today, for instance, I met with the ICU's quality person about adopting the ICU communication bundle." Other administrative duties include committee meetings "and backroom negotiations trying to figure out how to talk the hospital into hiring someone to manage the bundle. I've also been speaking to the state hospital association, which is interested in using our system as a demonstration project for palliative care."

 

In February of 2010, a palliative care outpatient clinic was opened in a geriatrician's office attached to the hospital, one-half day per week. "We opened it without an expectation or even ability to offer a robust service. We're really too busy doing all of the other things we do. But we saw the need for another avenue to access palliative care." The service was getting at least one call a week from people in the community who needed help with palliative care issues. "Now we have an avenue where we might see one or two patients per week. As we continue to evolve and, hopefully, have more staff, I see that as a growth area for us. I've also felt that a palliative care unit in the hospital would be another direction for growth."

 

Currently, hospitalists are the number one referrers for palliative care, along with hospital-employed intensivists and intensive care unit managers. Recent growth has come via the HealthGrades health consulting company, working with Roper's cardiac unit, and its recommendation of the need to refer for earlier access to palliative care consultations. A new full-time director of ICUs for the system is also interested in palliative care. "We are working with him to implement the ICU communication bundle. All of this has increased our visibility and evolution in the system---- making for an exciting past few months. We're really headed in the right direction. The health system board is excited, as are the hospitals' grant writers."

 

However, the various administrative roles Dr. Lake fills, often by stealing time from patient visits, "can be a little overwhelming, although exciting. I thrive on that. Professionally, I've seen my role gradually evolve into doing more of the administrative stuff, including working with medical students from Medical University of South Carolina, which is located across the street," he says.


"Right now we're doing 1,000 consultations per year. I'm not a writer or a researcher, and bedside medicine is what I love best. I hope to continue that." But he also sees further evolution of his role toward more education about palliative care for both health professionals and the public, helping to raise awareness about what it can do. He is looking forward to the system hiring two additional advanced practice nurse and social workers, to have teams at each hospital. That may happen next year, along with hiring a full-time chaplain for palliative care.

 

A Place for Social Media                     

 

Dr. Lake is active on Twitter (@doclake), a social networking site that he considers "a pretty remarkable way to follow death and dying issues, the science and legislative activity. Some of my most important day-to-day discoveries about what's going on in medicine happen there. I'm also able to take it back to our staff, boards and my meetings with doctors. I check in mornings when I wake up, if I have time during lunch and then again in the evening. I have 500 followers and I have 'tweeted' 500 times. I also follow a fair number of health care blogs."

 

He is married to a psychiatrist he met in medical school at Tulane University. They have two girls, aged eight and five, and live close to his parents in Charleston. "One thing I enjoy about this job is that most of the time I'm able to run home, take care of important family things, such as attending my daughter's swim meets." He also loves to sail his parents' sailboat. For more information, contact him at rslake@homesc.com or see his Twitter feed: @doclake. 

CompensationPractice Insights

Beginning January 1, 2011, face-to-face recertification visits with hospice patients will no longer be simply good practice.  The Centers for Medicare and Medicaid Services ("CMS") has implemented certain provisions of the Patient Protection and Affordable Care Act of 2010 and regulates that such visits become mandatory.

 

Face-to-face encounters may not occur earlier than 30 calendar days prior to the start of the benefit period for which it applies. Certifications may not occur earlier than 15 calendar days prior to the start of the benefit period for which it applies. A required face-to-face encounter must occur prior to its associated certification.

 

This requirement will better enable hospices to comply with hospice eligibility criteria, and to identify and discharge patients who do not meet those criteria. How to best comply with this regulation will be a determination made upon specific circumstances of each hospice's medical staff, including:

  • variability in clinical commitment of current staff, including nurse practitioners
  • nonclinical commitments that may include administration, teaching, and research
  • productivity data to analyze MD capacity to absorb additional volumes

Several points to keep in mind as you develop a plan to comply with the requirement:

  • The face-to-face encounter by the hospice physician or the NP for the purpose of gathering clinical findings to determine continued eligibility for hospice care is NOT billable. The face-to-face requirement is part of the recertification process, and therefore is an administrative activity included in the hospice per diem payment rate.
  • The certification or recertification of terminal illness is not a clinical document, but instead is a document supporting eligibility for the benefit and is considered an administrative activity of the hospice physician.
  • Providing reasonable and necessary non-administrative patient care services during the face-to-face encounter is billable: If a physician provides reasonable and necessary non-administrative patient care, such as symptom management, to the patient during the visit (for example, the physician decides that a medication change is warranted), that portion of the visit would be billable.
  • Billing for medically necessary care provided during the course of a face-to-face encounter should flow through the hospice and be billed as physician services under Part A, as the hospice physician or NP who sees the patient is employed by or, where permitted, working under arrangement with the hospice (for example, a contracted physician).
  • If there is a billable portion of the visit, hospices must maintain medical documentation that is clear and precise to substantiate the reason for the medically necessary services separate from the face-to-face encounter related to recertification. Documentation of the face-to-face encounter and any other medically necessary patient care services provided during the visit can be included in one note. Visit documentation should, of course, clearly support any billable services that were provided.
  • Medically necessary care provided during the course of a face-to-face encounter by an NP can be billed only if the NP has been designated as the patient's attending physician.
  • There is no requirement that the visit must take place in the patient's home---- it could take place in practitioner's office.
  • Electronic signatures are permitted on hospice certifications and recertifications. Narrative and the face-to-face attestation are parts of the certification or recertification and may also be signed electronically.
  • Use of telemedicine to perform the visit is not permitted.
  • Attendings cannot do the face-to-face visit without becoming a "hospice physician".

Much to consider, to be sure. The AAHPM

website http://www.aahpm.org/news/default/news6.html offers a guide to assist you in developing a plan. Or ask aboutthe

DAI Palliative Care Group medical staff planning service.

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