Wednesday, January 16, 2013

Understanding Barriers to Palliative

This won’t be news to any Intensive Care physician. But as I try to better grasp what often segregates the palliative care speciality from patients who would benefit, a review at the online resource (“all the best in pulmonary & critical care”) was illuminating.

The piece is titled “Burnout syndrome among critical care healthcare workers.” It reviews a report in journal Chest, April 2012 edition, titled “How to bill for palliative care in the ICU ... legally.” 

Even the latter headline told me something I didn’t know: that bringing palliative into the ICU can require an artful dance. In fact, it’s one in a series of artful dances, some emotional, some financial, some medical.

“To an intensivist,” writes, “providing palliative care often means having multiple time-consuming and emotionally challenging interactions with families struggling to cope with the impending loss of their loved one. The emotional content of these interactions can be strongly positive, negative, or somewhere in between, but frequently it’s an intense and draining experience, possibly contributing to burnout among ICU physicians. So at least you should get paid for it, right?”

Burnout, whether among physicians or nurses in the ICU, is of special interest to me now as the the Community Ethics Committee nears completion of a study of the intractable disputes that arise when continued medical treatment is considered futile by the care team. Burnout and the stressors behind it, at least in part, are what made the CEC feel an obligation to study the issue.

The financial dance is over Medicare reimbursement. Chest reported: “Split or shared service performed by a physician and a qualified nonphysician provider of the same group practice is not reportable as a critical care service; only cumulative critical care time provided by physicians within a group is reported as such.” 

“In other words,” added, “midlevels cannot bill for palliative care services,” and “the above goes for residents’ work, as well, at teaching hospitals, where attendings must also document care well enough for it to justify billings independent of the resident’s note.”

Really understanding the bureaucratic complexity of all that is above my pay grade, as are all the codes and details of legitimately billing for palliative services. But with palliative increasingly seen as a perhaps uniquely capable of serving a patient’s best interests and values, financial disincentives for its use seem especially short-sighted and thoughtless.

But Medicare policy on ICU billing isn’t the only barrier to broadening palliative’s reach. A commentary at (“home of the journal Oncology”) describes both benefits that oncologists are seeing in palliative care, and barriers to collaboration.

One barrier is “the lack of a ‘standardized’ palliative intervention,” according to the authors.

But palliative’s benefits to patients are well appreciated.

“It is well accepted that palliative interventions derive much of their success from a fundamentally patient-centered, rather than illness-centered, approach to care,” the authors write. “With a patient-centered focus, the physical, psychological, spiritual, and social needs of patients, as well as the needs of their caregivers, are addressed.”

This points to the benefits of a comprehensive, team approach, which leads to the next barrier: no surprise, it involves money.

“The lack of financial and educational resources often limits the ability to provide such a comprehensive team. ... (And yet) attempting to integrate palliative care into oncology care is still a worthwhile endeavor even when resources are limited.”

To make palliative and oncology more collaborative, the authors say, it is “critical” to develop an integrated outpatient model. “By utilizing the same clinic space and hours, the potential for timely communication among palliative and oncology providers is greatly enhanced. Feasibility of integration is further enabled by eliminating the need for a separate palliative clinic location and personnel. Furthermore, convenience for patients is increased by providing complementary services under one roof, optimally during the same visit.”

The authors cite another benefit of such a palliative-oncology collaborative -- its potential to lessen the burden on the care team.


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