The system operates a $3 million palliative-care 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
See chart on coverage in the hospice setting vs. the hospital (PDF).
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 money-saver, 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 benefit, 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 advanced-practice nurses are reimbursed for initial consultation and follow-up in the hospital,” Ceronsky says.
“There is nothing in the law that would preclude pain control and symptom management being provided by a nurse or physician to a Medicare patient in a hospital or skilled-nursing facility,” Kahn says. Payment for those services would be included in the bundled payment amount to the hospital or in the physician fee-schedule payment.
However, other members of the palliative-care team—a chaplain, social worker or bereavement counselor, for instance—are not able to generate revenue. Those team members are not reimbursed in the hospital setting, regardless of whether the payer is Medicare or a private payer, Ceronsky says.
In most instances, the hospital covers the cost of these services, or in some cases, philanthropy.
Some palliative-care teams, especially in smaller hospitals, do not have a dedicated chaplain or social worker and collaborate with the unit social worker or chaplain to care for patients and families. It's less than ideal, but given the financial challenges hospitals face, it's a common approach, Ceronsky says. Susan Pisano, a spokeswoman with America's Health Insurance Plans, agrees that new models, in addition to research and data, are needed to figure out the best care for patients with life-threatening illnesses.
“We would agree with others who have indicated that giving people access to supportive services when they have a life-threatening disease but still maintaining their options to continue to seek curative care” is very important, Pisano adds. “The encouraging thing is many of our members are developing models for palliative care and sharing their ideas with others in the insurance industry.”
One payer trailblazing this effort is Kaiser, which began its coverage of hospital-based palliative care in Colorado in 2002, but since then “has requested that all of their hospitals develop such programs,” says Porter Storey, a physician specializing in palliative care for the Colorado Permanente Medical Group.
Storey, who's also executive vice president of the American Academy of Hospice and Palliative Medicine, says that the program does pay attention to the psychological, spiritual and social needs of the patients and that such services are covered under the benefit. However, “I don't believe there's a bereavement program in place,” he says.
In his view, palliative care works in favor of patient and insurer “because the patients get what they need and get out of the hospital.”
For the more seriously ill patients with a life-expectancy of six months or less, “we help them get more comfortable and make decisions so they get the care they are looking for. This usually means needing less hospital care,” Storey says.
In speculating why insurers don't offer more comprehensive coverage at the hospital level, “Quite honestly, I don't think there is an existing mechanism for them to model,” Morrison says.
“If you think about it, there is no existing inpatient model that encompasses the time-intensive interdisciplinary care provided by palliative care under Medicare or private insurance. It means creating an entirely new and innovative reimbursement structure,” he says.
Clearly, palliative-care reimbursement is on an unstable platform right now—but getting Congress to look at a new Medicare benefit for palliative care is slim, as the lawmakers are all recovering from health reform, Schumacher says. Finding a revenue stream for expanding coverage under Medicare or Medicaid is also unlikely, since providers are already getting targeted as revenue sources themselves to pay for reform, he says.
While the new health reform law doesn't specifically call for new funds for the service or language to reconfigure the way hospitals get reimbursed for it, some in the industry are hopeful that new payment models will pave the road to better payment for the service.
In light of the fact that hospitals are being asked to reduce their Medicare and Medicaid payments by $155 billion over the next 10 years to reduce costs under the new law, some palliative-care advocates worry that this added financial burden may make it more difficult for some hospitals to maintain their programs.
Whenever any type of cut comes along to Medicare or some other type of reimbursement, “any sort of program that's not highly reimbursed is one that is vulnerable to budget cuts,” Morrison says. While palliative care improves quality, is fiscally responsible and saves dollars, such programs are not revenue-generators, “and I worry these programs may be at risk in some hospitals,” he says.
Various bills have been introduced to boost reimbursement for these types of services, but haven't gone very far in Congress. One promising piece of legislation was the Senior Navigation and Planning Act, introduced by Sen. Mark Warner (D-Va.), which would have given a Medicare bonus payment of 1% to 2% to hospitals with accredited palliative-care programs, and a 1% penalty after 2020 for hospitals without such programs.
Any legislation that focused on palliative care became “politically untouchable” last summer, however, when the rhetoric over death panels sprang out of control, Morrison says.
Meier of the Center to Advance Palliative Care thinks palliative care will eventually become a more comprehensive benefit because new models of reimbursement such as bundled payments and the “medical homes” being tested under the new health reform law won't be successful without it.
