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Palliative Care and the ICU

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Post Getting hospital financial support
Author: mjsearcy
Date: Oct 28, 2010 8:55 am
I am a palliative care physcian who works full time in the intensive care units (80 bed) at the largest private hospital(>600 beds) in our state. I have focused on terminal extubations for the last two years (250 deaths since 2008). I attend each death, staying at the bedside to titrate medications and lend family support (am boarded in psychiatry and consult psychiatry). Most often I conduct a lengthy family meeting in the am and extubate in the afternoon, often giving the family 4 hours of uninterrupted time. Family satisfaction expressed at the bedside is very high (I have not measured). This method saves at least 1 ICU day @ $10,0000 per day. As you can imagine, I am unable to bill for all my time and have never been able to salary myself more than $60,000 a year (three board certifications). Hospital Administration seems deaf when I try to talk about cost savings (easily measured) and don't seem interested in making changes so I can transfer patients out of ICU for terminal care. Can I charge critical care codes for attending extubations? I want to continue doing terminal care. University and VA on a hiring freeze. Can anybody else use my expertise?
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Re:Getting hospital financial support (by jbcassel on 10/28/2010)
One of our billing experts will address your question about critical care codes, and I will try to address the larger questions you raise. A couple of thoughts: it may be that hospital administration would listen to one of the ICU leaders (medical director, dept chair) if they articulated the value you add for them, for patients & families, and for the hospital, and conveyed that your hard work is not sustainable under the current financial model (billing alone). Are the ICU leaders your allies in this effort, to the extent that they would "carry the water" for you? Secondly I think you're on the right track regarding potential ICU days. While currently you may help to make 125 ICU bed-days available for other patients, earlier intervention for de-escalating the care to a med-surg acute unit for several days per case could tally up to hundreds of ICU days. If ICU days are important to hospital administrators in your institution (that is, if the ICUs are truly a bottleneck and they can quantify missed opportunities), then the larger # may speak more loudly to them, and help you make the case for subsidizing some of your salary. As the Norton study demonstrated, ICU days "saved" in tertiary hospitals can be significant (Crit Care Med 2007;35:1530-1535). Above and beyond that, are you functioning alone or are you part of a full multi-disciplinary team? Extubations can be viewed as a rather narrow part of palliative medicine, though certainly important, and I wonder if a broader team that helped to improve the care of hundreds or thousands of not-imminently-dying patients in your facility would garner more formal and sustainable support from the hospital. I would encourage you to explore whether the hospital would explicitly support a full team. Let me know if this is of any help.
- Brian Cassel, VCU Massey Cancer Center, Palliative Care Leadership Center
Re:Getting hospital financial support (by JulieP on 10/28/2010)
When billing critical care you've got a few issues; Is the attending in the ICU also billing for critical care and does what you're doing for the patient qualify as critical care? According to AMA and CMS the definition of critical care; a critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patients condition. If the patient meets the definintion of critical you could potentially bill all the floor/unit time bearing that it bears directly on the management of the patient. It sounds like that may not be the case if you're trying to have them transferred out of the ICU? Although I'm not a physician and each case is different. I'm unsure about reimbursement by the carriers to a pyschiatrist for critical care. You're billing CC would definitely be out of the norm. If the patient isn't critical but remains the in the ICU, you're stuck with subsequent visits and maybe some prolonged care, although Medicare only allows prolonged when you are face to face with the patient.

Julie Pipke-CPC, CAPC Consultant

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