“If they don’t have the time or the skills, or if they expect a difficult meeting, for example, due to religious or cultural differences, send these patients our way. And when there are ethical issues that need to be addressed, or a particular need for educating patients and families about the disease process and what to expect, I like consultations like that.”
Bad Business or New Revenue Stream?
The traditional business model for palliative-care services has focused on the potential contributions to the hospital’s bottom line through reduced length of stay and cost avoidance for a group of patients who can be among the hospital’s most challenging and expensive. Palliative care saves time and money by working with patients and their families to clarify their values and treatment preferences, which routinely differ from standard treatment modes.
A recent multisite study of palliative care by Morrison et al found that the use of palliative care services saved from $1,700 to $4,900 per admission in direct costs, compared with similar patients who did not receive palliative care.3 The savings were realized primarily through reduced laboratory, pharmacy, and ICU costs.
Cost avoidance, combined with palliative care’s contributions to quality and patient satisfaction, is essential to the field’s growth. Even though physician consultation visits are billable, a palliative-care service rarely covers its staffing costs solely with billing revenue. A service requires nonbillable support from administration and midlevel providers, including nurses and social workers.
“Integrating palliative care into the work of hospitalists is a great idea,” says Jean Kutner, MD, head of the division of general internal medicine at the University of Colorado Denver. However, there are important issues related to scheduling, availability, and commitment that need to be explored before a group launches a new service. “I’d want to have discussions about how the palliative-care business model fits with our hospital medicine model and an agreement with the hospital on goals and metrics,” she says.
Hospitalists Fill a Need
Whether a full-fledged palliative-care service fits your group’s dynamic or not, hospitalists as a whole should be competent in basic palliative care. Community and rural hospitals need HM to bridge this gap and deliver quality care to seriously ill patients.
“I started at a community hospital, Eden Medical Center in Castro Valley, California. I had a personal interest in palliative care and realized there’s a tremendous need for it in community hospitals,” says Heather A. Harris, MD, a hospitalist at San Francisco General Hospital who previously worked with Dr. Pantilat’s palliative care service at UCSF. “We deal with end-of-life issues on a regular basis—whether recognized or not—based on our caseloads and requests for consultations.
“I got a little perspective about palliative care while a resident at UCSF. But as I’ve gotten further into this, I have come to realize that there is an actual skill set that needs to be learned to do it properly.”