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What would motivate more attending physicians to request palliative care for their patients?

The humanitarian argument, of course, is that palliative care could improve the quality of life for these patients and for their families. The financial argument is that palliative care could reduce their hospital’s costs and improve its bottom line. Fortunately, for many attending physicians, the combination of these two arguments carries the day, and these “adopters” have learned to arrange palliative care for many of their seriously ill inpatients.

For other physicians, however, additional persuasion will be needed.

An Additional Argument: HealthGrades

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The HealthGrades® (or hospital quality ratings) argument often provides the needed extra nudge in the right direction. For those unfamiliar, hospitals and physicians pay attention to various grading, rating, and ranking systems—including HealthGrades—as good scores or rankings could be used for marketing themselves to patients who have multiple options for care. Thus, this argument, which is based on the marketing value of getting high “quality ratings” from HealthGrades,® goes like this:

  • HealthGrades® computes each hospital’s quality rating (from “5-star” to “1-star”) on each of thirty-four medical conditions or procedures from electronic Medicare data which it purchases annually from the Centers for Medicare and Medicaid Services (CMS) and from all-payer data from fifteen states.
  • To get a desirable “4-star” or “5-star” HealthGrades® rating on a particular condition or procedure (e.g., COPD, heart attack, or stroke), a hospital must achieve a below-average, risk-adjusted mortality rate among the patients hospitalized. For nineteen conditions or procedures, in-hospital and 30-day mortality are evaluated. For fifteen conditions or procedures, in-hospital complications (including mortality) are evaluated.
    • To achieve a below-average, risk-adjusted mortality rate for a condition, the hospital must not only provide high-quality care for patients with that condition; it must also take specific steps to ensure that HealthGrades® has access to all of the relevant “risk information” needed to risk-adjust the hospital’s reported mortality rate for the condition of interest.
  • To ensure that HealthGrades® has full access to patients’ risk status, the hospital and its physicians must collaborate to record specific risk-related information consistently in the patients’ electronic medical records (EMRs). When providers do so, their hospital’s widely publicized HealthGrades® “star” ratings are optimized, and members of their communities may be more likely to select the hospital and its physicians when they need inpatient care.
    • The lesson is that providers can increase their competitive advantage in their community by documenting risk data in their EMR to help HealthGrades® risk-adjust their mortality rates accurately.

For Patients with Serious Medical Conditions and Procedures

Focusing on the patient population living with serious illness, how could hospitals and attending physicians enhance their HealthGrades® scores and their image in the community, while also providing excellent disease-specific care? The simple answer: hospitals can increase their use (and documentation in their EMRs) of three forms of high-quality care for people living with a serious illness.

When documented properly in the EMR, the following are recognized by the HealthGrades® risk-adjustment formula as a “mortality risk.” They decrease the hospital’s risk-adjusted mortality rate, thereby increasing the hospital’s quality (“star”) ratings.

  1. For eighteen conditions or procedures, documentation of a palliative care consult during hospitalization (code V66.7/Z51.5). HealthGrades® interprets this as indicative of a patient with an increased risk of dying, so the outcome is attributed to patient characteristics rather than to hospital quality.
  2. A “do not resuscitate” (DNR) order (codeV49.86/Z66). For thirteen conditions or procedures, HealthGrades® interprets this as indicative of a patient with an increased risk of dying, so the outcome (death) is attributed to patient characteristics rather than to hospital quality.
  3. A discharge to hospice. HealthGrades® interprets such a discharge, whether to inpatient (GIP) hospice or hospice care at home, as indicative of a patient with a greatly increased risk of dying soon, and it removes the patient from the hospital’s mortality statistics.

How to Adopt HealthGrades

Making this HealthGrades® argument to groups of hospital attending physicians (e.g., at departmental provider meetings) can be accomplished in less than ten minutes, and is usually met with pleasant surprise and heightened interest in palliative care, hospice, and DNR orders.

To address some providers’ skepticism, however, it is important to note during these presentations that any of these three aspects of quality care for patients is not “gaming the system” (or “giving up on patients”), but, rather, providing an appropriate “extra layer of support”, while ensuring that the hospital’s widely publicized ratings are fair and reflective of the care provided—rather than the prognosis of its seriously ill patients. It’s a win for patients, a win for their families, a win for attending physicians, a win for palliative care, and a win for the hospital.

"It’s a win for patients, a win for their families, a win for attending physicians, a win for palliative care, and a win for the hospital."

The adoption of palliative care, like many other medical innovations, is a long, slow process, but one which can be accelerated by convincing potential adopters of additional, meaningful benefits of adoption. Advocates for palliative care can help motivate their clinical colleagues to collaborate with palliative care more often by ensuring that they are familiar with not only the humanitarian and financial arguments, but with the quality rating argument as well.

Acknowledgments

The author would like to thank two colleagues for their careful review and valuable input for this blog post: Diane E. Meier, MD, Director, Center to Advance Palliative Care; and, Brian Cassel, PhD, Associate Professor, Hematology/Oncology & Palliative Care, Virginia Commonwealth University Medical Center.