Published in the January 2007 issue of Today’s Hospitalist.
Given their role in quality improvement and in caring for complex patients, it’s no surprise that hospitalists are emerging as the leaders of palliative care services at their hospitals.
That was the message delivered by Steven Pantilat, MD, a hospitalist and national authority on palliative care, during a presentation at the University of California, San Francisco (UCSF) meeting in October, 2006, on managing hospitalized patients. Judging by the interest level of the physicians who attended his session, hospitalists from around the country are beginning to agree.
During the presentation, Dr. Pantilat answered questions on a wide range of topics, from issues of reimbursement to concerns about how to get referrals. While the session provided a rare look at the nuts and bolts of how palliative care programs work, many of Dr. Pantilat’s answers pointed out obvious parallels between hospital medicine and palliative care.
According to Dr. Pantilat, who is director of the palliative care program at UCSF, hospitalists are attracted to palliative medicine in part because they, perhaps more than any other physician group, stand to benefit from providing and receiving palliative care consults.
At the same time, he added, physicians’ experience as hospitalists gives them a good understanding of how palliative care programs work. For one, hospitalists know how to present a program like palliative care that may not pay for itself through professional fees, but can nonetheless save the hospital money and conserve resources.
They also understand how to cope with physicians who may balk at the idea of bringing in a consult service to care for their patients. And they know how to manage another trait that palliative care programs share with hospitalist services: the very rapid growth that takes place as referrals roll in and a once fledgling program becomes indispensable.
The business case for palliative care
On the most basic level, physicians doing palliative care consults bill payers like Medicare for their services using the same ICD-9 codes they use when working as specialists. But while an oncologist might bill for treating a patient’s cancer, a hospitalist providing palliative care would bill for treating the individual’s abdominal pain.
As with most hospitalist programs, however, professional fees alone don’t cover all of a palliative care service’s expenses, so the hospital must be willing to provide some support. But even though palliative care groups may operate in the red on paper, Dr. Pantilat said, they actually save hospitals significant sums of money.
He estimated that on average, a palliative care program will save three dollars for every dollar invested. If a hospital spends $100,000 on a palliative care program, for example, it can expect to save about $300,000.
Where do those savings come from? By spending the time it takes to elicit patients’ preferences, palliative care programs tend to reduce the amount of time that patients spend in the hospital and improve resource utilization.
"I’m convinced that there are people we get out of the hospital that we wouldn’t have otherwise," he said. Patients who would have stayed in the ICU, for example, may be transferred to a med-surg bed, a skilled nursing facility or a community hospice, once a palliative care consult has been called.
The service also eliminates the daily labs and procedures that are common in the ICU. "Our costs of care tend to be low," Dr. Pantilat said of the UCSF service. "We spend less money on central lines, daily chest X-rays and ECGs."
And palliative care sharply reduces the amount of money hospitals spend on medications. "The most common drug we use is morphine, which costs pennies a day," he said. "The second most common drug we use is Blistex, to treat patients’ dry lips."
Providing comfort and dignity
Palliative care consults also help when hospitals are being paid a diagnosis-related group (DRG) rate, which is often the case with patients covered by Medicare. Because DRGs essentially pay a flat fee for an episode of care, hospitals receive the same fee regardless of the level of services they provide.
"To the extent that the hospital gets X dollars for all of a patient’s care," Dr. Pantilat said, "if I order fewer X-rays or if I put someone in a less acute or intensive setting, the hospital will benefit."
Yet boosting the hospitals’ bottom line, Dr. Pantilat was quick to point out, is a by-product, not a goal, of palliative care.
"When you offer very sick patients a choice of treatment options," he said, "many choose care focused on comfort rather than on continued invasive interventions."
By spending an hour with the family to understand its goals for the patient and then transferring the patient out of the ICU, stopping antibiotics and beginning IV morphine, "the patient is more comfortable and the family is very satisfied. They actually want therapies that focus on symptom management, comfort
Who should be on the team?
One reason why palliative care services run into the red, Dr. Pantilat added, is that they need more staffing than just physicians. High-functioning teams must also have a social worker, a chaplain and other support staff.
If you have only physicians on the team, he said, "you’ll be limited in what you can do." Before the UCSF program had a dedicated social worker, for instance, the in-hospital mortality rate of the palliative care service was 78 percent.
"Once we got a social worker, our mortality rate dropped to 56 percent," he said. "Why? Because she knows how to get people out of the hospital and get the services they need, and I don’t."
Social workers also serve as a bridge to the outpatient services that are so critical to patients who need palliative care. If you’re going to discharge patients who no longer need an acute care setting, Dr. Pantilat said, you need to know where to send them, particularly if they don’t have family or friends to care for them. Even if patients qualify for a skilled nursing facility, he added, they can’t always get top-notch palliative care.
And if you’re thinking you can just work with the hospital’s social workers on an as-needed basis, think again. Social workers at many hospitals function more or less as discharge planners, Dr. Pantilat pointed out, so they don’t always understand the mission of palliative care.
"We have found that some social workers can make things worse, telling patients that they have to leave the hospital because they’ve been there too long," he said. "We told our hospital that we needed our own social-worker expertise."
Finding referrals from colleagues
One question on the minds of several hospitalists at the presentation was a practical one: How does a new palliative care program get referrals from other physicians, particularly in the early days? Dr. Pantilat’s advice could just as easily apply to hospitalist services as to palliative programs.
"You need to appeal to physicians, to tell them that you are going to help them," he said. "You also need to assure them that you’ll act as that physician’s representative. When I’m consulting, I always tell patients, ‘Dr. X asked me to come by to help take care of you.’ Any good work you do is seen as a reflection of the person who referred the patient to you."
What about the oncologists who you’re sure will never use a palliative care service?
"Ignore those people," he said. "You know that there are physicians in the hospital who are inclined toward palliative care, so go to them first." Your first stop, he added, should be your fellow hospitalists.
Once physicians start using your service, you can expect word of mouth to spread. "You don’t need a thousand consults in your first year," he noted. "You want a manageable number that you can grow into."
Estimating case load
That advice led to another question: What exactly is a manageable number? How many consults can a new service expect its first year, and how many physicians will it need?
To estimate a new program’s patient load, Dr. Pantilat said to start with the average number of patients who die in your hospital each year.
Suppose that number is 200. Over time, he said, you could expect to see 75%-or 150-of those patients. Besides seeing patients who die in the hospital, you should plan to see an equal number of patients who will need a palliative care consult, but who will be discharged from the hospital while they’re still alive.
That would leave a target population of about 300 patients. In its first year, Dr. Pantilat said, a new service could expect to see 20% to 30% of those patients.
How many days would a palliative care team spend with each of those patients? Because the palliative care team is brought in at the end of the patient stay, Dr. Pantilat said, his palliative care service typically sees patients an average of four days. In hospitals with longer lengths of stay overall, the palliative care team might expect to see patients for longer.
To see all 300 patients, you would need staffing to cover 1,200 patient days a year (300 patients times four days), or 3.5 patients a day. A new service that sees only 30% of those patients, by contrast, would need to cover about 360 patient days (90 patients times four), or about one per day. That number would likely translate into one to two new consults a week.
From there, you have to determine how much time you’ll need from a physician, a social worker and other staff to handle the daily patient load and two new consults a week. It might be one-quarter of a physician, for example.
But keep in mind, Dr. Pantilat said, that despite the best planning, most palliative care services become busy very quickly. While new services always worry that no one is going to call for a consult, most soon begin to look for ways to slow down the accelerating pace.
"They tell us that they can’t see everybody, that they can’t do any follow-ups because they’re so busy," he said. The bottom line: In today’s health care climate, palliative care services need to plan for growth.
Edward Doyle is Editor of Today’s Hospitalist.
In next month’s issue
How do you talk to patients about death and dying? How do you respond when families ask you not to tell a patient bad news? Palliative care expert Steven Pantilat, MD, discusses how to communicate with patients facing the end-of-life, in the February issue of Today’s Hospitalist.
Providing palliative care: a look at the benefits for hospitalists
What kind of benefits do palliative care teams offer hospitalists? As someone who works as both a hospitalist and palliative care physician, hospitalist Steven Pantilat, MD, director of the palliative care service at University of California, San Francisco, has a unique perspective.
When it comes to individual physicians, he said, palliative care teams help busy hospitalists by taking time-consuming tasks off their plate. Even hospitalists who enjoy palliative care often don’t have the time to give patients and their families the attention they need.
When he’s working as a hospitalist, for example, Dr. Pantilat regularly calls the palliative care team for a consult. "It’s not that I’ve forgotten my palliative care skills," he explained. "It’s just that I don’t have time to visit that family to get the whole picture. I want help from a social worker and a chaplain, so I bring in the whole team."
That ability to call in a team improves hospitalists’ efficiency. It also adds value to their programs and gives them new sources of revenue.
"It expands the portfolio of activities that hospitalists can participate in that help improve the quality of care," he said. At the same time, it gives physicians clinical variety, which can give a big boost to the hospitalist program.
"There are many physicians who, like me, enjoy doing palliative care," Dr. Pantilat said. "To the extent that hospital administrators care about retaining and recruiting hospitalists, that’s a good reason to have a program."