Can You Afford to Offer Palliative Care?

Neil Chesanow

Disclosures

March 26, 2013

In This Article

Not Your Usual Business Model

Oncologists who consider adding palliative care to their line of services tend to think in terms of buying or leasing more space and hiring more staff. For smaller groups, Muir thinks that's ill-advised, at least at the outset. "It's a massive expense for zero patients on day 1," he warns. Practices that jump in prematurely may be forced to drop their programs in a few years because they aren't financially sustainable.

Instead, Muir recommends testing the temperature of the water first. One way to do this is to limit the time you initially make available to see patients who need palliative care. "Start with a half-day," he advises, "and channel all the patients whom you see over the course of a week who need palliative care into that 1 half-day period."

Another way to limit your exposure is to partner with a local hospice to provide palliative care in your practice for a half-day a week rather than hire a full-time palliative care subspecialist, whose salary can approach or exceed $200,000 a year in some locations, and who may not have enough patients to justify the expense.

Muir points out that there are approximately 5300 hospices in the United States. "Most decent-size towns have a hospice," he says. "And by law every hospice must have a medical director who's a palliative care subspecialist." Offer a doctor employed at a hospice an arrangement whereby he or she comes into your practice for a half-day a week and provides palliative care to those patients who need it, he suggests.

This doctor -- most likely accompanied by a nurse practitioner (NP) trained in palliative care -- will need someplace to work. It won't be at the hospice. There isn't space. Palliative care -- as opposed to end-of-life care -- is generally delivered in patients' homes. For that reason, the last place patients with cancer who need palliative care want to go is to a hospice, Muir says.

An Effective Way to Accomplish the Goal

Instead, the hospice leases office space from a clinic at fair market rates (to avoid running afoul of the Stark Law) for a half-day when the space is not in use. "Everyone has a day where 1 or 2 oncologists have an afternoon or day off," Muir says. "There's almost always someone in the practice who works Tuesday through Friday or rounds in the hospital every other week. It's not hard to find a half-day when an office is free."

In addition, 2 exam rooms are needed because "you have a physician and an NP working together," Muir explains. "The physician can see initial consultations and establish a plan of care, and on subsequent visits the NP can do the follow-ups and have the physician available to collaborate." In a typical half-day, Muir is able to see 4-5 new patients, while his NP is able to see 8-12 follow-up patients. If over time a practice has more patients requiring palliative care, adding a second half-day is an option.

In addition, the hospice team needs a medical assistant in the practice to be available for the half-day selected to greet patients, show them back to an exam room, and take their vital signs, Muir says. For this, the hospice also pays fair market rates.

In return, Muir thinks a "reasonable" rate for a palliative medicine physician is one tenth of the doctor's weekly salary time, figuring that the work week is divided into 10 half-days and that the doctor will see clinic patients on one of those half-days. In addition, it's necessary to ensure that liability coverage is appropriate for the work performed. But that's it. There are no staff salaries and benefits to fund, and you use existing space.

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