Benefits and Costs of Palliative Care
The benefits of palliative care are many and varied. First and foremost, PC purports to increase the quality of life of the patient, family, and caregiver. The treatment plan developed by the PC interdisciplinary team (IDT) is based on the needs of the client and family, not on the prognosis of the disease. The treatment is designed not only to decrease suffering, but the accompanying symptoms and progression of the disease itself. There is no duration on the length of time services can be provided; the only stipulation being that there must be a benefit to the services provided (Levine, 2019).
There are other benefits as well. Reducing patient suffering and symptoms may decrease stress on the patient and caregiver. This can alleviate caregiver burden and may delay or prevent hospital admissions, unnecessary procedures, and even institutionalization (NHPCO, 2019). Financial benefits can be associated with all these issues. In addition, there are economic savings in remaining at home.
Psychosocial needs of the patient and family can also be addressed, and the family physician can continue to be involved in care decisions. The PC model excels in maximizing patient control over treatment, even addressing end of life issues and late-stage symptoms (Levine, 2019).
Palliative care services are designed to decrease medical costs not only to the patient, but to the medical service providers as well. This occurs from the coordination of care, elimination of nonbeneficial procedures and treatments, and an increase in patient and family satisfaction with provided care. This high satisfaction rating and record of beneficial results (called CQI – Continuous Quality Improvement) can save providers as well as patients much money in the long and short run (Mehta et al, 2012).
Palliative Care can be paid for in several ways. Medicare Part B, private insurance, private pay, HMOs, and Medicaid can all pay for PC, with Medicare Part B being the most common reimbursement source according to the NHPCO (2019). It’s important to note that Medicare does not use the term palliative: benefits fall under the MHB or Medicare Hospice Benefit. PC services provided by physicians, nurse practitioners, and physician assistants are paid as fee-for-service by Medicare based on time and intensity of services. These same providers can also be reimbursed for advance care planning conversations. Transitional care management to a different setting (ex. from a hospital to home) can also be billed for up to 30 days. Chronic care management, when directed by a physician, can be paid under Medicare Part B (Brandt, 2019). There are some stipulations for advanced practice nurses and physician assistant services: these services cannot be billed when delivered in a hospital or long-term care facility and the supervising physician must be physically present at the site to provide direct supervision. Clinicians providing services must hold credentials in hospice and palliative care medicine. For this reason, Medicare assigns a specialty code for PC claims and the setting where care is being provided (called an E/M or evaluation management service code and each setting has its own set of CPT codes for reporting E/M services). Medicare views physicians who are part of the same group and same specialty as one physician, so billing can be somewhat complicated (Lewis, 2017). In summary, careful coding, documentation, and collaboration by the PC IDT can result in more accurate billing and payment.
Medicaid coverage varies by state and is based on limited income. Private insurance and HMOs may have a defined limit with only a certain number of days’ coverage available and coverage can vary by plan. It is imperative that potential patients of palliative care services meet with a social worker or financial consultant from the PC team for clarification of and help with payment options prior to agreeing to such services.
Sources:
Brandt K. Getting reimbursed for community-based palliative care. CSU Institute for Palliative Care, 2019. Retrieved July 12, 2019 from https://csupalliativecare.org/medicare-reimbursement.
Levine H. The 411 on palliative and hospice care. Brain & Life, 2019; Feb/March:8-9.
Lewis S. Billing palliative care services: Invaluable care, big billing challenges. Today’s Hospitalist, May, 2017. Retrieved from https://todayshospitalist.com/billing-palliative-care-services/.
Mehta Z, Giorgini K, Ellison N, Roth ME. Integrating palliative medicine with dementia care. Aging Well, 2012;5(2):18.
NHPCO Clinical Practice Guidelines for Quality Palliative Care, 4th Edition (2018) from the Center to Advance Palliative Care, 2019.