Can You Afford to Offer Palliative Care?

Neil Chesanow


March 26, 2013

In This Article

Understanding Return on Investment

The most cost-effective use of a palliative physician is not for work that a medical oncologist is able to perform but rather to manage symptoms in complex patients that are often beyond the skillset of a medical oncologist.

For example, a lung cancer patient with metastases to the spine is having adverse events related to long-term, long-acting morphine with breakthrough morphine. The patient's pain continues to escalate, the patient experiences some twitching and confusion thought to be related to the higher dosage of morphine as well as other issues, there is the potential for myoclonus, and delirium is suspected.

"There are a number of oncologists who might feel comfortable working through that scenario," Muir concedes, "but that would certainly be a reasonable time to call in a subspecialist."

Not only can handing off to a palliative physician improve the quality of care for complex patients, but it saves a lot of time on the part of the medical oncologist who would otherwise need to wrestle with treatment issues for which that doctor has not been trained. Time is money in oncology. Time regained is one way to view profitability.

In the study that Muir led, for example, time-based billing for palliative care consultants was used as a surrogate for time "saved" by staff oncologists. In other words, "we assumed that if a palliative specialist were not available, the oncologist would otherwise be busy the same amount of time doing the same work," he says.

The Importance of Time Saved

In the first year of outpatient palliative care consultation, the total time saved for the Fairfax practice, which was the study's focus, was 3440 minutes. This increased in year 2 by more than 280% to 9720 minutes (162 hours). The average saving of provider time per referral to palliative care was estimated to be 170 minutes.

Why is this important? Reimbursement for palliative care is "woefully inadequate," Muir says. "The current fee schedule from Medicare for an initial palliative consultation in the outpatient setting for a little over an hour's worth of work is about $120 per charge, and the collection rate on that amount is quite variable, depending on the patient's insurance coverage."

In addition, many frail patients are unable to make their appointments. Cancellations are frequent. "You book an hour for a new consultation and the patient ends up being hospitalized the night before, so you don't have anyone lined up to come in," Muir says. "You've just chucked an hour of provider time, which is very expensive. It's one downside of the current reimbursement."

A medical oncologist's time is thus more lucratively spent on seeing new patients, for whom the reimbursement is higher, than it is on offering palliative care to existing patients, particularly complex patients, for whom the reimbursement is less. "If you're interested in access and seeing more patients and being more available to new people with cancer, in our study, it ended up being about 4 weeks a year of additional open slots for new cancer patients," Muir says.

Muir envisions palliative specialists being even more cost-effective in the future by serving as the point persons in advanced illness care coordination, about which papers are just starting to be published.[3,4] In this, the palliative physician in the borrowed office in an oncology practice receives the patient discharged from the hospital who is often too frail to undergo chemotherapy or otherwise be seen by a medical oncologist. The palliative doctor reviews the patient's medications, ensures that pain management is adequate, oversees the transition to the patient's home setting, and then tightly monitors the patient over the next 4 weeks to reduce readmission to the hospital.

"There's the potential to save tens of thousands of dollars from that kind of care coordination," Muir believes. "This is where palliative specialists have a tremendous amount to offer for some of the biggest problems in healthcare."


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