- As physicians across the country mull over their New Year’s resolutions this week, the overarching desire for a healthy revenue cycle will likely be a common theme.
Physicians often struggled with how to keep money flowing as easily as New Year’s Eve champagne this year as financial reimbursement woes related to end-of-life Medicare and Medicaid reimbursement snafus unfolded.
Christopher Comfort, MD, Calvary Hospital’s Medical Director, recently chatted with RevCycleIntelligence.com about what healthcare providers should consider regarding a recent proposal from the Centers for Medicare & Medicaid Services (CMS) for end-of-life Medicare reimbursement. Here is the second part of our two-part conversation.
“Palliative care grew out of a need where institutions need to understand care preferences and have a mechanism for that discussion that goes beyond a discussion with an admitting physician,” says Comfort.
Physicians need an alternative means of executing this discussion in a more structured and systematic fashion, he states.
“Hospitalists are unfortunately in a situation where they have no experience with the patient in terms of psychosocial dynamics. This puts physicians in the position of having to discuss prognosis and discontinuation of treatment almost in a vacuum.”
“People realize many of these decisions are not appropriate to make in the heat of battle, at a time when the patient is faced with sometimes extremely difficult decisions in near emergency situations.”
Getting to core cost matters may alleviate hospitalization cost burdens
CMS is addressing the movement of palliative care from a hospital environment into an office or outpatient setting with a rule stemming from legislative mandate, says Comfort.
Discussions currently taking place within hospital settings are nonetheless shifting accordingly to office and outpatient settings as well.
A generalist palliative care movement implies every doctor can effectively discuss care preferences, understand prognosis, and advise when treatment may not necessarily prove beneficial, says Comfort.
Late state disease is tied to a significant cost burden for the healthcare system. Understanding the root of cost is imperative, he asserts.
“Most data comes from Medicare, with quotes at 25 percent of expenditures occurring within the last year of a patient's life. If you drill down on that, about 10 to 15 percent of recipients have about 70 percent of the charges to Medicare in the last year of life.”
The most expensive costs for these types of patients’ care are not home care, hospice care, outpatient care, radiation, or chemotherapy. They are hospitalization, Comfort states.
Preventable hospital readmissions alone cost Medicare an annual $26 billion, $17 billon of which is perhaps avoidable, declared the Center for Health Information and Analysis (CHIA).
Is death becoming a quality issue?
“The majority of cancer patients in New York City who die of cancer die in hospitals. If you look at the most recent data, probably about 60 percent of deaths that occur from cancer in New York City every year occur in institutions,” Comfort says.
Palliative care can also impact cost regarding goal setting and appropriate treatment, he adds.
“For quality parameters for oncologists, death within two weeks of chemotherapy administration is seen as a quality issue because of the issue of patients being treated with chemotherapy well into their course of their illness and at a time where it's very hard to demonstrate the clinical benefit of the chemotherapy.”
“If you look at chemotherapy administered six weeks before death in cancer patients, that number is as high as 25 percent of patients.”
Most patients on hospice home care have an average survival rate of 30 days tops, says Comfort.
Comfort highlights “fascinating” research as noteworthy focus
Referencing a 2010 study published in the New England Journal of Medicine (NEJM) of 151 lung cancer patients, Comfort says when researchers looked at outcomes related to treatment, the group receiving chemotherapy and palliative care lived nearly 3 months longer than those receiving chemotherapy alone.
Researchers from Massachusetts General Hospital confirmed the following:
Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care. …
Among patients with metastatic non–small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival.
“The authors of the study thought the presence of a palliative care group involved in treatment allowed for a conversation with an oncologist earlier and addressed the difficult issue of whether or not chemotherapy was really beneficial to the patient,” Comfort explains.
“They postulated by discontinuing chemotherapy earlier, perhaps you were taking very ill individuals who would not tolerate chemotherapy well and were actually sparing them the morbidity of chemotherapy that in late stage patients may be associated with premature death.”
Editor's Note: 12-Week Outcomes of Mood Assessments— HADS-D: Hospital Anxiety and Depression Scale with depression symptoms; HADS-A: Hospital Anxiety and Depression Scale with anxiety symptoms; PHQ-9: a 9-item measure evaluating major depressive disorder symptoms
Making the chronic illness / palliative care RCM connection
Complicating matters of palliative care and cost even further is the escalating issue of chronic illness.
One in four adults with multiple chronic conditions will benefit from palliative care, said Lee Goldberg, Director of the Improving End-of-Life Care Project at The Pew Charitable Trusts.
“The need for palliative care — the comprehensive care and management of the physical, psychological, emotional, and spiritual needs of patients with chronic, debilitating, or life-threatening illness and their families — is growing rapidly,” she stated in a November letter to CMS.
Chronic illness comprises the vast majority – over 90 percent – of Medicare spending. In 2010, among the 14 percent of Medicare beneficiaries with 6 or more chronic conditions, over 60 percent were hospitalized. These beneficiaries had hospital readmission rates 30 percent higher than the national average.
Although nearly 90 percent of large hospitals have palliative care programs, few measures adequately address care quality, asserted Goldberg.
“Since Medicare regulations only allow prescribing providers to bill for services in an outpatient setting, it is therefore difficult for community-based organizations and small practices to provide the full interdisciplinary team that is a key component of palliative care.”