1. The HPM Practitioner
Business/Practice News and Views for Physicians in
Hospice and Palliative Medicine
January 2010 Issue No 3
In This Issue Welcome to the third issue of The HPM Practitioner. We launched this e­newsletter in
August because we believed the physician community of hospice and palliative medicine
• Interview with HPM
needed a forum to exchange questions, concerns, information and best practices
Physician Alexander
regarding the business and practice management of HPM. Response to our inaugural
Nesbitt, MD
issue suggests that there indeed is an avid audience for this kind of information.
• Relative Value Units
In this issue we profile Dr. Alexander Nesbitt, a family­practice turned palliative care
• Compensation physician with a success story of building a full­time HPM practice.
• Billing Corner:
Understanding the Tim Cousounis
Recent Changes in Dr. Alexander Nesbitt: Pulled to Palliative Care
Visit/Consultation Codes
News Notes
:
Interview with HPM Physician Alexander Nesbitt, MD, by Larry Beresford
EOL News from the UK and
Elsewhere:
While the U.S. Congress continues
to debate large­scale health care
Dr. Alexander Nesbitt was an established family practice
reform, with significant but as yet physician and very part­time hospice medical director in
undefined implications for Williamsport, PA, when he heard a 2003 presentation by Dr.
providers of hospice and palliative Diane Meier, director of the Center to Advance Palliative
care, news from Europe suggests
the various ways end­of­life care
Care (CAPC). "I had never heard of palliative care, but I
can be addressed in public policy. became convinced that it was a really good idea, and that
"Better Investment: Better somebody in Williamsport should do it. I realized that
Dying" is a conference planned probably that would have to be me, because nobody else
for Feb. 24 in London, England, here was into it like I was.”
focused on measurement and
benchmarking of optimal end­of­life
care, as well as on "collaborative He attended the Program in Palliative Care Education & Practice at Harvard Medical
commissioning for end­of­life care,"
School (www.hms.harvard.edu/Pallcare/PCEP.htm) and began working toward board
which refers to how the UK
National Health Service purchases certification in HPM, earning that credential in 2004. He pursued an expanded role in
services from providers. The Susquehanna Hospice and started advocating for a palliative care consultation service at
National Council for Palliative Care 180­bed Williamsport Hospital & Medical Center. Both belong to the local Susquehanna
in that country recently issued an
Health System.
"End­of­Life Care
Manifesto," urging five pledges "The idea of starting a new program, which included hiring a full­time nurse practitioner to
for political leaders. They include
fully implementing the national staff it, was an uphill push. I had to convince the hospital's administration that we should
end­of­life care strategy, making spend the money, even though the system was undergoing financial difficulties.
training in palliative and end­of­life Fortunately, CAPC has highly practical tools to use, well adapted to just that purpose."
care a core curriculum
requirement, and equipping the
public to become more confident The inpatient palliative care service launched in January 2005 and grew rapidly, while the
about discussing wishes and hospice census was also rising to its current level of about 100 patients. "Meanwhile, we
priorities for end­of­life care. realized that patients were coming toward their dying time in the hospital with the support
of palliative care but without a dedicated place to provide top­level symptom
The UK­based open access journal
BMC Palliative Care recently management. Plus, we had patients in our outpatient hospice in need of aggressive
symptom management, and there was no good place to do that."

2. reported research on the "out­of­
hours" (i.e., after­hours) medical
So Dr. Nesbitt went back to the system's administrators and persuaded them to open
coverage that increasingly is
provided in the UK, Denmark and seven­bed Gatehouse Inpatient Hospice in July 2006 in a medical office building two
the Netherlands by large miles from the acute hospital, with him as its medical director. However, this growth in
cooperatives of general HPM work was not compatible with full­time family medicine commitments, and reluctantly
practitioners. Slightly less than one
he gave up his 20­year practice.
percent of all calls to these GP
cooperatives were about patients
who needed palliative care, and "I delivered a lot of babies, took care of these families for a long time and felt very
half of those calls resulted in a engaged with my patients. So it was a sad day to step away from my practice," he says.
home visit. When information on
"But I realized I needed to do palliative care. I was pulled toward it. Just like family
palliative care patients was
transferred to the GP cooperative, medicine, palliative medicine is patient­focused and family­centered, broadly defined, and
such as by a dedicated fax system, I find it very rewarding to get involved with these families."
there were fewer hospitalizations
of those patients.
Assembling the Pieces
Meanwhile, closer to home, the
New England Journal of Medicine's Dr. Nesbitt is an employee of the health system, which employs about half of the
online edition recently published an physicians in its region. "I had been working with administrators every step of the way,
article, "Ending End­of­Life persuading them of the importance of this work ­ for patients and families, as well as for
Phobia: A Prescription for the system ­ and sharing outcomes data." When it came time to transfer full­time to
Enlightened Health Care hospice and palliative care, the various responsible parties were ready to sign off on the
Reform," by Benjamin Corn. Dr. change. Dr. Nesbitt's salary is based in part on billing income from palliative care and
Corn complains that end­of­life
care, with its disproportional
inpatient hospice consultations, annualized, as well as an hourly rate for dedicated
concentration of health care administrative responsibilities, which amount to nearly half of his roughly 50­hour week.
expenditures, is not receiving its
due in the national health care "Although initially I wasn't so sure, I felt I could set it up piece by piece, and make a job of
reform debate, except via
distractions such as the "death
it," with the combination of hospice and palliative care a good package for the system, he
panels" controversy sparked by says. "There's increasing information out there that this work is beneficial for the patient
Sarah Palin and others. The New and family, for the reputation of the hospital, for customer satisfaction, for the bottom line,
York Times on December 26 ran a and for readmission rates."
Page 1 story on "palliative
sedation," which Pallimed
blogger Dr. Drew Rosielle
But making the case required speaking directly to the biggest concerns of each target
audience, Dr. Nesbitt says. "As I prioritized it, first was to do the right thing for the patient
described as "a long and confusing
and family. I talked about documented problems in the national health care system, such
article... (with) some things it gets
spot on, while others I found as inadequate symptom management, lack of support for patients and families, lack of
deeply troubling." (See the
understanding of treatment options. And I always included personal stories, which are
original article and NHPCO's
very important for engaging people. Another piece of making the case is data sharing,
statement responding to the
article.)
showing how palliative care benefits the system. Each audience can hear that message if
it's framed specifically for them. I also think it helps to have a physician leading the effort.
CAPC Update: Dr. Diane E. Meier, I can say, 'Let me tell you about one of my patients and families.'"
director of the Center to Advance
Palliative Care at Mount Sinai
School of Medicine in New York
In the beginning, Dr. Nesbitt took the lead on hospital palliative care consults, but as the
City, one of four current resident program established its credibility, the nurse practitioner now makes over half of the
Health and Aging Policy Fellows of visits. Another palliative care physician, Karen Brown MD, joined the team in 2007 and
the Atlantic Philanthropies, has sees patients in affiliated, rural Muncy Valley Hospital, 10 miles away, and in the region's
taken a one­year post on the
Senate Health, Education, Labor
nine long­term care facilities. In addition to the hospital­based nurse practitioner, there is
and Pensions Committee. The a second nurse practitioner based in the nursing homes, and an advanced practice nurse
HELP Committee, chaired by Sen. who sees patients in nursing homes and coordinates professional education events.
Tom Harkin (D­IA) has jurisdiction
over issues such as workforce,
medical education and the National
"Within the (HPM) team, each of us has a primary base, but we also work to float extra
Institutes of Health. Dr. Meier's team time to wherever it is needed," he explains. The five members meet monthly to
twitter feed can be followed at discuss practice issues. Growing demand for services is a problem, and the team tried to
www.twitter.com/dianemeier manage growth in sustainable ways while it extended services into the long­term care
. CAPC is now encouraging setting. Recently, it was decided to limit weekend palliative care consults to emergency
palliative care programs to register
for 2010 with the National Palliative
cases only. "Sometimes we're really busy on the weekends, so we're working to make
Care Registry, which was launched that part of this work more manageable," Dr. Nesbitt says.
one year ago with metrics
developed by CAPC consensus

3. committees to operationalize the Dr. Nesbitt starts a typical workday by rounding on patients in the inpatient hospice unit,
National Quality Forum's "National
and then, depending on demand for palliative care that day, goes to the hospital. He
Framework and Preferred
Practices for Palliative and makes occasional home visits to hospice patients and sees some patients in his office in
Hospice Care Quality" in real world the medical building. So far there is no formalized outpatient clinic setting or schedule for
settings. The registry offers palliative care, although that may change in the next year, perhaps in conjunction with the
participants an opportunity to
system's Cancer Center. Dr. Nesbitt takes night and weekend call every third week, and
generate customized reports
comparing their performance with he also meets regularly with various administrators within the health system's
peers through anonymous organizational chart.
aggregate data via "Palliative Care
Compare."
A lot of his time is spent educating physicians about hospice and palliative care,
individually or in groups, and speaking to community groups. He participates in twice­
weekly hospice interdisciplinary team meetings, inpatient hospice and palliative care staff
Featured Practice
meetings, and various clinically focused committees and councils in the hospital. Other
Opportunities hospice responsibilities include chart reviews, patient certifications and recertifications,
VP, Medical Services and writing appeal letters for denied claims.
Leadership opportunity within a
highly regarded, not­for profit He often has ideas for how to better manage issues that come up in hospice team
Midwestern hospice to develop a meetings, which may lead to new assessment forms, documentation tools, protocols or
high­performing medical staff and
an accountable palliative care drug formulary adjustments. An example is a recently adopted protocol for administering
organization within one of Ketamine to treat refractory pain. "I spend time in chat rooms for palliative care around
America's "most livable cities". the world, where issues from difficult cases are discussed, or I may get ideas from my
While there are clinical and readings or attending conferences," he says. "I work with a wonderful team of hospice
teaching expectations in this
position, the principal nurses who ask a lot of good questions and are motivated to learn. I am also involved in
accountability is to align the quality improvement activities, clarifying what we want to learn and how we can best
medical staff's performance collect and present the data to answer our questions."
(clinical and financial outcomes)
with the organization's ambitious
strategies. The scope and Synergy and High Outcomes
influence of this senior executive
position reaches beyond the Dr. Nesbitt finds wonderful synergies between his hospice and palliative care work, with
immediate hospice (and its
enough responsibilities to fill a full­time medical practice. "Developing the palliative care
growing home­based and inpatient
unit programs) and into the program has been very helpful for hospice, and having a hospice that gives great care is
community's hospitals, long­term a helpful option for referring palliative care patients who have advanced symptoms," he
facilities, and educational notes. "These are two separate populations, but they have significant overlap.
institutions.
Communicating carefully about difficult issues and managing difficult symptoms for the
Medical Director, Hospice two populations is essentially the same skill set, and it makes sense to have both parts
You'll showcase your clinical working together."
expertise as well as consultative
and collaborative practice style as Williamsport is a city of about 30,000, 180 miles from Philadelphia, in a county of
you provide medical direction for a
hospice interdisciplinary team. 117,000. Although Susquehanna Hospice is established as the community leader in end­
You'll have the opportunity to of­life care, reflecting its inpatient unit and palliative care links, in recent years two for­
promote and maintain a culture of profit hospices opened in the community, although one subsequently folded.
clinical excellence with a strong
interdisciplinary team by applying
your knowledge of the best Based on DAI Palliative Care Group's analysis of Dartmouth Medical Atlas data,
practices of palliative medicine. Williamsport and its health system are high performers on palliative outcomes measures.
With the support and resources of In fact, overall Susquehanna outperforms well­known, exemplary health systems like
one of the more progressive Geisinger Medical Center and Lancaster General Hospital on such measures as
hospices in Florida, you'll have the
professional opportunity to align percentage of decedents seeing 10 or more physicians in the last six months of life, total
the team's activities with ICU days during the last six months of life (and proportion of ICU deaths), and hospital
organizational performance days during the last six months of life.
improvement goals.
This position offers practice variety
­ you will enjoy a blended position Dr. Nesbitt says he'd like to take some of the credit for these outcomes, although the data
with direct patient care (inpatient mostly precede the opening of his palliative care service. He thinks the numbers will be
consultations, home and outpatient even better in the next Dartmouth Atlas. He also points to recognized medical practice in
visits), management, and
the community and the involvement of ICU physicians in communicating with patients and
educational (fellowship program
and trainee rotations) families. "I think we have a great medical community that understands hospice and
responsibilities that will enrich your palliative care."
palliative medicine portfolio of

4. competencies. On­call
responsibilities are shared among
He spearheaded a POLST (physician orders for life­sustaining treatment) initiative in the
one of the largest hospice medical
staffs in Florida. Senior region, working with the hospitals and nursing homes. The State of Pennsylvania does
management has made a not give legal recognition to POLST, but a study group is working toward initiating a
concerted effort to design practice statewide form. He also chairs the hospital's ethics committee
opportunities with reasonable, well­
articulated workloads which strive
for a sought­after work­life In 2008 Dr. Nesbitt received the Heart of Hospice clinician award from the National
balance. Hospice and Palliative Care Organization. He and his wife have three adult children and
he has taken several mission trips to Guatemala, Ecuador and Mexico to provide medical
To learn more about these
services for children. One of his hobbies is harmonizing with other members of
opportunities (confidentially, of
course), send an email to Gatehouse Hospice Singers, who sing in groups of eight or ten to dying patients in their
tcousounis@digital­action.com homes, nursing homes or the Gatehouse Hospice Unit.
or click here
The growth of palliative care in Williamsport has affirmed for Dr. Nesbitt the difference
The DAI Palliative Care Group is a
national consultancy partnering that one person who feels strongly about an issue can make. Clearly, much of the local
with hospices and palliative care impetus for this development came from him. "We had a good hospice but it was small.
practices to build their medical The palliative care nurse practitioner happened to be here at the right time. But it takes
staffs. Recruiting, medical staff someone to convene the meetings and start the dialogue. A physician who can find like­
development planning, physician
performance management and
minded people to work with can make a heck of a difference in what happens to patients
opportunity assessments for in your community."
palliative medicine practices are
our competencies.
We invite a discussion of how a
partnership would benefit you.
HPM Practice Insights
Relative Value Units
Quick Links RVUs are a comparable service measure used by many health care organizations and
payers (including Medicare) to permit comparison of the amounts of resources required to
HPM Newsletter, August perform various services within a single department or between departments. It is
2009 determined by assigning weight to such factors as personnel time, level of skill, and
HPM Newsletter, October sophistication of equipment required to render patient services. RVUs are a common
2009 method of calculating physician bonuses based partially on productivity. We are seeing
greater use of the RVU concept by hospices to value the work of HPM practitioners.
About DAI Palliative Care
Group What's the "big picture" rationale for RVUs? A major benefit of RVUs is standardizing
Commentary on Palliative physicians' work across types of patients and settings of care. What you want from a pay
Care Success system is to fairly allocate income according to work inputs. That's what RVUs do. RVUs
also cut across reimbursement systems and therefore remove concerns about a patient's
coverage. They are blind to charity care. They shield physicians from nonpayment risk.
Contact Us They are familiar because of their use in Medicare. They are comprehensive, covering
every CPT code. They save an HPM group from having to make up a system for equating
Tim Cousounis
disparate workloads. They adjust for one physician taking care of another's patients.
Managing Director,
DAI Palliative Care Group That's why they're usually a better measure to use in HPM practitioner performance plans
Phone: (610) 941­9419 than collections, charges or visits.
tcousounis@digital­action.com
Larry Beresford Compensation
Editor
Phone: (510) 536­3048 Almost 40 percent of full­time physicians earn between $140,000 and $170,000 in
larryberesford@hotmail.com
compensation, including salary and other monetary incentives, according to the 2009
www.larryberesford.com
HPM Physician Compensation Report, compiled by the DAI Palliative Care Group.
Larry's Blog
Compensation continues to lag behind other sub­specialties. Surely, one reason is that
What do you think of our patient service revenue, or billings, generated by HPM physicians lags well behind that of
publication? How can we best other specialties, with the exception of geriatrics. While new roles continue to open for
serve the needs of the HPM palliative medicine physicians interested in full­time practice opportunities, such
community? What would you opportunities, whether sponsored by hospitals or hospices, require either "subsidies" for

5. practitioner income guarantees or "stipends" for administrative activities. Continuing
like to know about the business
and practice issues facing reimbursement pressures on hospices and hospitals suggest that subsidy or stipend
HPM doctors today? What do increases for HPM physicians will be modest, at best, for the immediate future.
you know that your HPM
colleagues need to learn? While overall numbers do not yet suggest a groundswell movement, more
employers/practices are shifting away from straight salary to a combination of income
Click here to send us your guarantee and productivity incentives. To learn more about models of compensation, plan
comments. to attend the AAHPM Annual Assembly workshop presented by Drs. Ed Martin and
Chuck Wellman and Tim Cousounis on Friday March 5, 2010 at 3:15 pm.
Billing Corner: Coding for Palliative Medicine Consultations
Effective January 1, 2010, the consultation codes are no longer recognized for Medicare
Part B payment. Understanding the recent changes in how Medicare reimburses for
consultations is paramount for HPM practitioners, as these services typically account for
a large percentage of your patient encounters. While it is unclear how and when
commercial payers may follow Medicare's lead in these changes, they typically do so.
With the changes come significant adjustments to the way your initial visits are reported.
However, the following scenarios currently apply only to traditional Medicare patients:
Home Setting
Where you would have billed in 2009 outpatient consults (99241­99245) you now bill
using either new patient or established patient home visit codes.
If the patient has NOT been seen by you or another physician/non­physician practitioner
in your group within the last 3 years you now bill with a new patient home visit code
(99341­99345)
If the patient has been seen by you or another physician/non­physician practitioner in
your group within the last 3 years you now bill with an established patient home visit code
(99347­99350).
ALF/Rest Home
In 2009 you would have billed outpatient consults (99241­99245). You now must bill using
either new patient or established patient Domiciliary/Rest home visit codes. If the patient
has NOT been seen by you or another physician/non­physician practitioner in your group
within the last three years, you now bill with a new patient home visit code (99324­
99328). If the patient has been seen by your group within that time range, you now bill
with an established patient home visit code (99334­99338).
Inpatient Hospital
Visits you would have billed in 2009 as inpatient hospital consults (99251­99255) now will
be billed with the initial inpatient visit codes (99221­99223). For this code set it does not
matter whether the patient is new or established.
Nursing Facility
For visits you would have billed in 2009 as consults in a nursing facility (99251­99255),
you now bill the initial nursing facility visit codes (99304­99306). For this code set it also
does not matter whether the patient is new or established.
What is important to remember is that the codes you will now be reporting in lieu of
consultations typically have a shorter time requirement, allowing in many cases the ability
to append a prolonged service code. This should significantly offset the reduction in
revenue. For example; code 99255 has a time requirement of 110 minutes and in 2009

6. paid approximately $211, whereas in 2010, assuming you met the prolonged service
requirements for a visit of 100 minutes, you would be able to bill a 99223 plus 99356,
which together amount to about $287.
Chris Acevedo is a partner with Acevedo Consulting Incorporated, a firm providing on­site
education and consultative services on reimbursement and coding­related concerns for
the HPM Practitioner billing for hospice and palliative care services. He can be reached
by phone at (561)­278­9328 or by e­mail at: cacevedo@acevedoconsulting.com
Interested in learning more about the physician billing changes? Register for the 2nd Annual Hospice & Palliative
Care Physician Billing Seminar hosted by Acevedo Consulting Incorporated, January 27­29, 2010 in Orlando,
FL. Please click here for more seminar information.