Abstract
Abstract
Background:
There is increasing interest in expanding palliative care (PC) services in the community-based outpatient oncology clinic. However, there is a paucity of data on the economics of integrating palliative medicine in this setting.
Objective:
Provide scheduling and financial data on PC physician encounters, charges, and reimbursement in a community-based oncology practice.
Design:
Retrospective review of billing data and scheduling software at a single practice.
Setting:
A community-based oncology practice comprised of 25 medical oncologists in 8 suburban offices. PC physicians were integrated into the practice.
Measurement:
Billed PC physician charges were analyzed on an annual basis for a four-year period from initial start-up of the PC clinic on September 2, 2014 to August 31, 2018.
Results:
During year 1, a single PC physician saw 483 new patients and 827 follow-up encounters in four different office locations. In year 2, he saw 471 new patients and 1229 follow-up encounters. Actual collected revenue for those 1700 encounters was $228,168. In year 3, a second PC physician was added and services were expanded to a total of six offices. In year 4, two PC physicians billed for 832 new encounters and 2450 follow-up encounters for a total collected revenue of $454,356.
Conclusions:
In a suburban community-based oncology practice, a PC physician can support a substantial part of his or her cost to an oncology practice.
Introduction
The integration of palliative care (PC) services into the longitudinal care of cancer patients has been promoted by the oncology community.1,2 PC has been shown to improve symptom management and support the psychosocial needs of cancer patients and their families.3,4 The majority of outpatient palliative medicine programs are connected to academic medical centers. Models for integrating outpatient PC into the academic medical center have been discussed.5,6 However, even in the tertiary cancer center, there is limited data published on outpatient billing metrics, such as the number of patient encounters a PC physician might see in a day. Although community-based oncology clinics have also been encouraged to employ specialist PC physicians in their offices, there is a paucity of literature on the mechanics of integrating PC physicians into community clinics. Before the widespread hiring of PC physicians to work in oncology practices, insight on the financial implications is required. We provide financial data for PC physician encounters from the initiation of PC services in a community oncology practice through the first four years. The annual review of these data enabled us to further develop our own PC program.
Methods
Population and setting
In September 2014, a newly hired full-time PC physician salaried by a community-based oncology practice began seeing patients in four of their eight suburban oncology offices. The practice supports 25 oncologists divided between the eight offices. In addition to medical oncologists, provider staff includes 2 radiation oncologists, 2 breast surgeons, 1 orthopedic oncologic surgeon, and 13 nurse practitioners. Annual data for 2018 show the practice saw 6272 new oncology and 5126 new hematology patients for the year. This is a well-insured population in the northern Virginia suburbs of Washington, DC. Of the total encounter charges, 61.5% were billed to commercial health insurance. The remaining 38.5% were covered mostly by Medicare, and by Medicaid, self-pay, and charity care. Two years after the program start-up with a single PC physician, a second PC physician was added in September 2016, and PC services were expanded to six of the eight practice offices.
Interdisciplinary team
Initially the interdisciplinary team was formed from existing practice and community resources. The PC physicians coordinate with the unique nurse navigator for each patient, rather than with a dedicated PC nurse. On average, each nurse navigator covers the patients of two oncologists. We have also continued our relationship with a nonprofit group of cancer social workers. In year 3, we were able to hire our first practice social worker under the auspices of the PC program. At the end of year 4, we hired our second social worker. We have provided ongoing educational sessions and handouts for practice physicians, nurse practitioners, nurses, and medical assistants.
Data collection
A retrospective review of billed charges and actual collected revenues for the PC physicians for a four-year period from September 2, 2014 to August 31, 2018 was collected and analyzed on an annual basis. Charges were submitted directly by the PC physicians through the electronic health record at the time of the patient encounters. The actual collected revenues were obtained from practice billing software. The PC physician days in the clinic offices available for patient encounters were collated by the review of scheduling software.
Results
At the end of the first year, from September 2014 to August 2015, the PC physician saw 483 new consults, for an average of 40.25 new consults per month. There were 827 follow-up PC encounters in the first year. Actual revenue collected from these new and established PC encounters for the first year was $194,589.
In the second year, new consults decreased slightly to 471—or 39.25 consults per month, as room was required in the physician's schedule for the increase in follow-up appointments. Established patient encounters increased to 1229. Collected revenue for combined new and established encounters in the second year was $228,168.
The “if you build it they will come” phenomenon often seen with the arrival and staffing of a new PC program was also seen in our offices. Because of demand, a second PC physician was added in September 2016, at the start of our third year. This represented 1.8 full time equivalent PC physicians, as the initial PC physician decreased his clinic time to four days per week. Together the 2 PC physicians saw 726 new consults in year 3. This represented a drop in per physician new consults in year 3, as services were expanded to an office with less familiarity with PC programs. In year 4, total new consults had again increased to 832. Combined established patient encounters for the two PC physicians in year 4 were 2450. Total collected encounter revenues for the two PC physicians in year 4 were $454,356 (Table 1).
Annual Physician Encounters and Revenues
If we look at the actual clinic days worked by the two physicians, we are able to quantify the average number of patients seen per PC physician per day. In year 4, Physician 1 worked 176 clinic days and Physician 2 worked 214 clinic days. Per clinic day worked, Physician 1 saw an average of 2.48 new consults per day and 6.86 established encounters, for an average of 9.35 patients per day. Physician 2 saw an average of 1.84 new consults and 5.80 established encounters per clinic day worked, for a total of 7.64 patients per day.
Discussion
Our experience from start-up through our first four years demonstrates that PC physicians hired by a community oncology practice for outpatient care can cover a substantial percentage of their cost and overhead through reimbursement for patient encounters. Annual review of these data enabled the hiring of a second PC physician by the end of year 2. We work in a well-insured suburban practice and our experience is not generalizable to other settings. We would invite other outpatient palliative programs to share similar data.
We remain uncertain as to appropriate paradigms for scheduling patient visits. Initially the scheduling templates for our PC physicians provided 60-minute slots for new consults and 30-minute slots for follow-up. Starting with year 3, Physician 1 changed his template to allow 80 minutes for new consults and 20 minutes for follow-up encounters. With the start of year 5, Physician 2 is experimenting with a template of 20-minute follow-ups and 60-minute consults. It would seem appropriate to schedule a maximum 4 new consults per day along with an additional 8 or more established patient follow-ups, for a total of 12 PC patients per day.
Scheduling is complicated by a significant no-show rate. Whereas patients may have compelling reasons to meet with their oncologist, they may view a meeting with the PC physician as more discretionary. In year 5, we have initiated live check-in calls with patients one day before all PC visits and we are seeing improved PC appointment attendance. These check-in calls also enable us to fill any cancelled slots with those patients waiting to be seen by the PC physicians.
The PC physicians will often need more than the allotted 20 minutes for a follow-up encounter. However, with an ∼20% no show rate, extra time is often available. If we consider that an average of nine patients are seen over the 420 minutes of a 7-hour clinic schedule (9 AM to noon and 1 to 5 PM), this suggests that significantly more than the scheduled 20 minutes is often available per patient.
An oncology practice differs from other medical specialty practices, perhaps most significantly in the frequent in-office administration of parenteral medication infusions. Administration of antineoplastic treatment requires a large number of staff and provides additional revenues. It is, therefore, easier to support the overhead of a PC physician among the large clinical staff of an oncology practice in a way that might be more difficult in other medical specialty settings.
Conclusion
In our practice setting, we are able to provide outpatient PC physician services with a schedule of 20–30-minute follow-up encounters and 60–80-minute initial consult slots. We continue to improve our billing and scheduling efficiencies. At the end of year 4, we have demonstrated an ability to support a significant part of the salaries and overhead of the PC physicians. Although we should come close to covering all of the PC physician costs based on revenues from patient encounters in year 5, this is likely not possible in a practice with a more challenging payer mix.
Moving forward, a challenge for our field is to develop and share paradigms for patient and provider engagement with PC physicians in a variety of outpatient clinical settings. We hope other palliative medicine providers will share their experiences with outpatient scheduling and billing. Innovative collaborations between the academic research community, financial managers, policy experts, and clinical practitioners will need encouragement. How do we maximize patient access to PC physicians? We hope our experience will inform this necessary discussion.
Footnotes
Author Disclosure Statement
No competing financial interests exist.