Be­hind the pal­lia­tive-care boom

Pal­lia­tive care grows de­spite re­im­burse­ment is­sues

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Hos­pi­tals are in­creas­ingly adopt­ing pal­lia­tive-care pro­grams de­spite the fact they of­ten have to pick up the tab for some ser­vices that in­surance com­pa­nies won’t pay for. That’s a bur­den many hos­pi­tal sys­tems say they’re will­ing to take on, as many in the in­dus­try be­lieve that a good pal­lia­tive-care pro­gram is a nec­es­sary in­vest­ment that will help save them money down the road and, most im­por­tant, im­prove the qual­ity of care for their se­verely ill pa­tients. A mem­ber of a pal­lia­tive-care team as­sists a pa­tient at a New York City Health and Hos­pi­tals Corp. fa­cil­ity. The sys­tem has seen a surge in pal­lia­tive-care ser­vices.

Pal­lia­tive care is a grow­ing busi­ness at New York City Health and Hos­pi­tals Corp., which has 11 acute-care hos­pi­tals. It re­cently re­ported a sig­nif­i­cant in­crease in the num­ber of pa­tients or their fam­i­lies seek­ing pal­lia­tive-care ser­vices to man­age se­ri­ous chronic or ter­mi­nal ill­ness.

The sys­tem op­er­ates a $3 mil­lion pal­lia­tive­care ini­tia­tive that has been ex­pand­ing at its fa­cil­i­ties since 2006. Specif­i­cally, pal­lia­tive-care teams cared for about 4,400 pa­tients in fis­cal 2009, a 33% in­crease from 2008. Dur­ing the same time pe­riod, out­pa­tient pal­lia­tive-care ser­vices rose 89% to about 1,870, the sys­tem re­ported.

The ini­tia­tive in­cludes doc­tors, spe­cial­ists, nurses, so­cial work­ers, chap­lains, psy­chol­o­gists, ethi­cists and oth­ers who help pa­tients and their fam­i­lies cope.

“Pal­lia­tive care is a highly spe­cial­ized med­i­cal ser­vice based on the prin­ci­ples of com­fort, sup­port, hope and dig­nity,” says Alan Aviles, pres­i­dent and CEO of the New York sys­tem. “The growth in our pro­gram shows that pa­tients and fam­i­lies want sup­port to make in­formed de­ci­sions in their own best in­ter­ests as they ap­proach the end of life, and those who are suf­fer­ing from the de­bil­i­tat­ing symp­toms of a ter­mi­nal or chronic ill­ness want re­lief so they can make the most of ev­ery day.”

The not-for-profit Cen­ter to Ad­vance Pal­lia­tive Care, or CAPC, de­fines this mode of treat­ment as a way to re­lieve the pain, symp­toms and stress of se­ri­ous ill­ness with a goal of im­prov­ing qual­ity of life. Un­like hospice care, it can be pro­vided at the same time as cu­ra­tive treat­ment, and it is not de­pen­dent on prog­no­sis.

It “ad­dresses the frag­men­ta­tion of the health­care sys­tem and puts the fo­cus back on com­mu­ni­ca­tion with the pa­tient and fam­ily,” says Diane Meier, di­rec­tor of the CAPC. “Hos­pi­tals to­day rec­og­nize that the cost in mis­ery and un­nec­es­sary hos­pi­tal stays of not pro­vid­ing this type of care is just too high.”

Such pro­grams are grow­ing rapidly in hos­pi­tals. An anal­y­sis re­leased in late 2009 by the CAPC and Na­tional Pal­lia­tive Care Re­search Cen­ter re­ported that the num­ber of pro­grams in U.S. hos­pi­tals with 50 or more beds in­creased from 658 (25% of all med­i­cal-sur­gi­cal hos­pi­tals) in 2000 to 1,486 (or 59% of hos­pi­tals) in 2008, a 126% in­crease. The anal­y­sis is based on data taken from the Amer­i­can Hos­pi­tal As­so­ci­a­tion’s An­nual Sur­vey Data­base. Pe­di­atric, psy­chi­atric and rehabilitation hos­pi­tals were ex­cluded from the sur­vey.

“More hos­pi­tals are open­ing pal­lia­tive-care pro­grams and more hospice care is ex­tend­ing ser­vices to in­clude pal­lia­tive care,” says Don­ald Schu­macher, pres­i­dent and CEO of the Na­tional Hospice and Pal­lia­tive Care Or­ga­ni­za­tion in Alexan­dria, Va. The care pro­vided in the hos­pi­tal is for pa­tients who are not nec­es­sar­ily ter­mi­nally ill, Schu­macher clar­i­fies. And it goes be­yond just pain man­age­ment: Pa­tients also re­ceive spir­i­tual and emo­tional sup­port from pal­lia­tive care, he says.

Schu­macher says the drive for hos­pi­tals to es­tab­lish pal­lia­tive-care pro­grams is buoyed by the grow­ing num­ber of ag­ing baby boomers. Some 70 mil­lion Amer­i­cans are ex­pected to die be­tween 2011 and 2028, he says, “so more and more peo­ple are go­ing to be look­ing for these ser­vices.”

As hos­pi­tals treat more chron­i­cally ill pa­tients, pal­lia­tive-care pro­grams be­come an ob­vi­ous so­lu­tion, says Lyn Ceron­sky, di­rec­tor for pal­lia­tive care at Fairview Health Ser­vices, Minneapolis. New qual­ity stan­dards also sup­port adop­tion of pal­lia­tive care, Ceron­sky says. As an ex­am­ple, the Amer­i­can So­ci­ety of Clin­i­cal On­col­ogy has called for the in­te­gra­tion of pal­lia­tive care with on­col­ogy care by 2020 for can­cer cen­ter cer­ti­fi­ca­tion.

The Joint Com­mis­sion is also con­sid­er­ing a cer­tifi­cate pro­gram in pal­lia­tive care, Ceron­sky says. “And there’s the Na­tional Qual­ity Fo­rum’s Pre­ferred Prac­tices for Pal­lia­tive and Hospice Care Qual­ity,” vol­un­tary clin­i­cal prac­tice guide­lines to en­cour­age ex­pan­sion of pal­lia­tive care, she says.

In gen­eral, hos­pi­tals are ap­proach­ing pal­lia­tive care in a dif­fer­ent light than the way they thought about those ser­vices decades ago, Schu­macher says. “In the olden days you got a lot of pas­toral care or spir­i­tual sup­port and so­cial work by the hos­pi­tal,” he says. But when DRGs first went into ef­fect in the early 1980s, and be­gan to force con­tain­ment of costs, hos­pi­tals be­gan to cut ser­vices, so­cial work and pas­toral care be­ing two of them.

Since then, how­ever, hos­pi­tals have caught on to the fact that pal­lia­tive care is a mon­eysaver, as it gets pa­tients out of in­ten­sive-care units and into reg­u­lar hos­pi­tal beds, po­ten­tially sav­ing the sys­tem thou­sands of dol­lars, he says. A per­va­sive be­lief is pal­lia­tive care pays for it­self,

as pa­tients’ symp­toms are bet­ter man­aged and they are more likely to com­ply with treat­ment.

Hos­pi­tals are also re­al­iz­ing that so­cial work and pas­toral care are in­te­gral to com­pre­hen­sive care of a se­verely ill pa­tient, so that’s why these ser­vices are get­ting re­newed sup­port, Schu­macher ex­plains.

On av­er­age, pal­lia­tive-care pro­grams can save a hos­pi­tal more than $2,600 per pa­tient per ad­mis­sion for pa­tients dis­charged and al­most $7,000 per pa­tient per ad­mis­sion for pa­tients who die in the hos­pi­tal, says R. Sean Mor­ri­son, di­rec­tor of the Na­tional Pal­lia­tive Care Re­search Cen­ter, New York.

Over­all, “you’re look­ing at a net sav­ings of $1.3 mil­lion per hos­pi­tal per year for a pal­lia­tive-care team in a 300-bed hos­pi­tal see­ing 500 pa­tients per year,” he says. “Pal­lia­tive-care teams take the most com­plex pa­tients, iden­tify their goals and val­ues, se­lect treat­ments that meet those goals, and fa­cil­i­tate de­ci­sions and tran­si­tions out of the hos­pi­tal. This type of goal-driven care re­duces un­nec­es­sary and un­wanted treat­ments and thus re­duces ex­pen­di­tures.”

It’s true that pal­lia­tive care can demon­strate a fi­nan­cial ben­e­fit to a hos­pi­tal through cost avoid­ance. For pa­tients or fam­i­lies with goals of care con­sis­tent with less in­ten­sive re­source use, a trans­fer from in­ten­sive care to a reg­u­lar hos­pi­tal bed will re­sult in re­duced re­source use and less cost, Ceron­sky says.

The down­side is not all ser­vices that fall un­der pal­lia­tive care are re­im­bursed un­der pub­lic and pri­vate in­surance pro­grams.

While cer­tain ben­e­fits are pro­vided to pal­lia­tive-care pa­tients in the hospice set­ting, “non­hos­pice pal­lia­tive care is over­whelm­ingly sup­ported by the hos­pi­tals them­selves,” Mor­ri­son says.

Medi­care of­fers a ben­e­fit where it cov­ers pal­lia­tive care through Medi­care-cer­ti­fied hos­pices for pa­tients whose prog­no­sis is six months or less to live and who are will­ing to forgo cu­ra­tive treat­ments. Also, some in­surance com­pa­nies will pro­vide pal­lia­tive care as a ben­e­fit in the hospice set­ting that mir­rors the Medi­care ben- efit, Mor­ri­son says.

How­ever, it does not have a sep­a­rate pal­lia­tive-care ben­e­fit that would cover and pay for these ser­vices out­side of the Medi­care hospice ben­e­fit.

On the Med­i­caid side, “Most state Med­i­caid ben­e­fit pro­grams pro­vide pal­lia­tive-care ben­e­fits in the hospice set­ting,” he says.

Hospice is by far the most used ben­e­fit for pal­lia­tive care un­der Med­i­caid, ac­cord­ing to CMS spokes­woman Mary Kahn. That said, there are ser­vices pro­vided un­der the Med­i­caid hospice ben­e­fit, such as coun­sel­ing, speech ther­apy and respite care that could be pro­vided in other set­tings, in­clud­ing the hos­pi­tal set­ting, she says.

Whether Med­i­caid pro­grams pro­vide these ser­vices on a con­sis­tent ba­sis state by state is un­clear, Mor­ri­son says. And with the ex­cep­tion of some Kaiser Per­ma­nente pro­grams, none of the ma­jor pri­vate in­sur­ers of­fers com­pre­hen­sive cov­er­age for pal­lia­tive care in the hos­pi­tal set­ting, he adds.

Bot­tom line is: Re­im­burse­ment for pro­fes­sion­als is the only guar­an­teed billing for pal­lia­tive care in the hos­pi­tal set­ting, sources say.

“Like any con­sul­ta­tive ser­vice such as car­di­ol­ogy or re­nal, pal­lia­tive-care doc­tors and

Mor­ri­son: Leg­is­la­tion on pal­lia­tive care be­came “po­lit­i­cally un­touch­able.”

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