When to call Palliative Care? A cost analysis of early versus late consultations in hospitalized patients.
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1 When to call Palliative Care? A cost analysis of early versus late consultations in hospitalized patients. Matthew Mavissakalian, DO James Fitzpatrick, MD
2 What is Palliative Care? Service specifically designed with goal to provide comfort to patients: 1 Enhance the quality of life for patients and families faced with a serious or life-threatening illness Appropriate at any stage of disease Early, accurate assessment to address pain and other physical, psychological, spiritual problems Optimize function, help with decision making, establish goals of care Delivered concurrently with curative, life-prolonging care, or as the main focus of care Differs from Hospice Care, the most intensive, refined form of palliative care: 1 Holistic approach (physical, psychological, social, and spiritual) recognizing incurable disease, acknowledges that time is limited to months at best Symptom control and quality of life are of utmost importance Independent organization outside of the hospitals devoted to care of patients and families 1. Hui, David, et. al. Concepts and definitions for supportive care, best supportive care, palliative care, and hospice care in the published literature, dictionaries, and textbooks Support Care Cancer Mar; 21(3):
3 Palliative Care s Cost Savings Potential Palliative care services have been shown to save hospitals money and improve patient outcomes Temel et. al. found that patients with metastatic cancer survived approximately two and a half months longer with palliative care services rather than without. 2 Hospital stay costs are lessened with palliative care Penrod et. al. found palliative care in the VA caused 42% less patients to go to the ICU and saved the hospital an average of $240 per day. 3 Ciemins et. al. states that palliative care has a potential to save hospitals $2.2 million a year 4 Finally Starks et. al. found that patients with palliative care consults and generally shorter lengths of stay save the hospital more money Temel, Jennifer, et. al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer New Engl J Med, Penrod, JD, et. al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J. Palliat Med, Ciemins, EL, et. al. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J. Palliat Med, Starks Helene, et. al. Cost Savings Vary by Length of Stay for Inpatients Receiving Palliative Care Consultation Services J. Palliat Med, 2013
4 Evaluation of the Importance of Time of Consultations No analysis found that evaluates the cost savings associated with the timing of a palliative care consultation in relation to the number of days a patient has been in the hospital Aim of this project Determine the difference in cost savings for medical patients receiving a palliative care consult placed early versus late in a patient s hospital stay Examine the impact an appropriately early consult would have on patient length of stay Expected Outcome An early consult will result in significant cost savings for the hospital and shorter length of stay for patients
5 Study Method Retrospective chart review of all palliative care consultations during 2015 at Kenmore Mercy Hospital, sorted into two groups: Received a palliative care consult within 3 days of admission Received a palliative care consult after 3 days of admission The finances of each case were recorded including: Total hospital stay cost The reimbursement to the hospital How much profit or loss was generated for the case A total of 228 cases were reviewed 119 cases had consults within 3 days of admission 109 cases had consults after 3 days of admission
6 Patient Demographics and Comorbidities * Less than 3 days (n=119) More than 3 days (n=109) Years Average Age Percent Male Cancer COPD CVD CHF CKD Acute MI Patient death * Denotes statistically significant difference, p <0.05
7 Results Average and Expected Lengths of Stay * Less than 3 days More than 3 days 16.3 Days * Average Length of Stay Expected Length of Stay Length of stay as assigned by the Center for Medicare and Medicaid Services for specific diagnoses. * Denotes statistically significant difference, p <0.05
8 Results Cost Analysis $3,000,000 $2,000,000 * Less than 3 days $2,058,556 More than 3 days * $2,498,404 $1,000,000 $709,987 $1,127,652 $417,665 $439,848 $0 Total Hospital Bill Total Expected Reimbursement Total Revenue * Denotes statistically significant difference, p <0.05
9 Results Cost Analysis: Average Per Case $30,000 $25,000 $20,000 Average Hospital Bill Average Reimbursement Average Revenue $18,886 $22,921 $15,000 $10,000 $5,000 $5,966 $9,476 $3,510 $4,035 $0 Less than 3 days More than 3 days
10 Primary Analysis Discussion Initial data shows no significant difference in revenue Total hospital cost and expected reimbursement were significantly different Disparity due to a minority of surgical cases with disproportionately high hospital costs and reimbursements Cases with procedures will generate higher reimbursement compared to cases without procedures For example, five surgical cases in the late consult group cases generated over $250,000 in profit. More than half the total revenue of the late consult group
11 Primary Analysis Discussion Data reexamined removing the surgical cases from the analysis Aim of project is to assess the benefit of palliative care consultation for medical cases specifically Surgical cases were determined using the patients Diagnosis Related Group (or DRG) which separates patients into Surgical and Medical cases Four surgical cases removed in the early consultation group Twenty three surgical cases removed in the late consultation group
12 Patient Demographics Medical Cases * Less than 3 days (n=115) More than 3 days (n=86) Years Average Age Percent Male Cancer COPD CVD CHF CKD Acute MI Patient death * Denotes statistically significant difference, p <0.05
13 Results Medical Cases Average and Expected Lengths of Stay Less than 3 days More than 3 days * 14.1 Days * Length of Stay Expected Length of Stay Length of stay as assigned by the Center for Medicare and Medicaid Services for specific diagnoses. * Denotes statistically significant difference, p <0.05
14 Results Medical Cases Total Cost Analysis $2,000,000 Less than 3 days More than 3 days $1,500,000 * * $1,312,332 $1,373,951 $1,000,000 $1,052,984 $500,000 $677,984 $375,000 * $0 Total Hospital Bill Total Expected Reimbursement $61,619 Total Revenue * Denotes statistically significant difference, p <0.05
15 Results Medical Cases Cost Analysis: Average per Case $20,000 Average Hospital Bill Average Reimbursement Average Revenue $15,000 $15,260 $15,976 $10,000 $9,156 $5,000 $5,896 $3,261 $0 Less than 3 days More than 3 days $717
16 How Early Consults Save Money: Analysis of Daily Costs Three similar cases chosen to show how an early consultation can save costs All three cases had the same admission code ( Severe sepsis or septicemia ) Each case had the same Expected Length of Stay and actual Length of Stay Case A and B had early consultations, on Day 2 and Day 3 respectively Case C had a late consultation on Day 6 Case Emergency Room Labs/ Tests Pharmacy Day 1 Radiology Respiratory Therapy Room Rates Total Day 1 A $261 $181 $112 $35 $78 $1,348 (ICU) $1,996 B $315 $195 $204 $35 $564 (Floor) $1,313 C $293 $190 $67 $75 $539 (Floor) $1,164
17 Costs Per Day: Day 2, Case A Receives Palliative Consult $4,000 Case A $3,000 Case B Case C $2,000 $1,000 $0 Day 1 Day 2 Case Labs/ Tests Pharmacy Radiology Respiratory Therapy PT, OT, ST Room Rates Total Day 2 A $54 $127 $20 $1,348 (ICU) $1,548 B $201 $143 $40 $29 $50 $564 (Floor) $1,025 C $319 $173 $321 $117 $30 $1,348 (ICU) $2,307
18 Costs Per Day: Day 3, Case B Receives Palliative Consult $6,000 Case A $5,000 Case B $4,000 Case C $3,000 $2,000 $1,000 $0 Day 1 Day 2 Day 3 Case Blood Bank Labs/ Tests Pharmacy Radiology Respiratory Therapy Room Rates Total Day 3 A $25 $84 $564 (Floor) $673 B $275 $71 $98 $99 $564 (Floor) $1,106 C $293 $170 $93 $58 $1,348 (ICU) $1,963
19 Costs Per Day: Day 6, Case C Receives Palliative Consult $12,000 Case A $10,000 Case B $8,000 Case C $6,000 $4,000 $2,000 $0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Case Labs/ Tests Pharmacy Respiratory Therapy PT Room Rates Total Day 6 A $50 $564 (Floor) $614 B $35 $39 $32 $564 (Floor) $671 C $43 $143 $58 $1,348 (ICU) $1,593
20 Costs Per Day: Day 8 $15,000 Case A $12,000 Case B $9,000 Case C $6,000 $3,000 $0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Case Labs/ Tests Pharmacy Respiratory Therapy Room Rates Total Day 8 A $32 $627 (Hospice) $658 B $50 $48 $29 $564 (Floor) $692 C $81 $627 (Hospice) $708
21 Costs Per Day: Total $15,000 $12,000 Case A Case B Case C $9,000 $6,000 $3,000 $0 Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9
22 Costs Per Day Case Total Hospital Bill Reimbursement Revenue A $7,389 (Expired) $10,643 $3,253 B $7,579 (Discharged) $10,260 $2,681 C $12,745 (Expired) $10,673 -$2,072 All three patients had nine day hospital stay Expected stay was seven days per the Center for Medicare and Medicaid Services All cases received similar Reimbursement regardless of Hospital Bill Most of the charges relate to room rate Based largely upon nurse:patient ratio Theoretically if Case C had earlier consult, may have moved to the floor sooner and had lower charges Evident that as the hospital bill increases, the reimbursement does not always cover the total charges
23 Discussion From the data, it is apparent that for Medical patients, an early palliative care consult generates more revenue for the hospital o$375,000 vs $61,619, early vs. late (p <0.05) Early consultation also results in shorter lengths of stay for both Medical and Surgical patients. o6.03 days vs 16.3 days, early vs. late, Medical and Surgical patients (p <0.05) o5.97 days vs 14.2 days, early vs. late, Medical patients only (p <0.05) As seen by the day-to-day cost analysis, shorter lengths of stay for medical cases may result in greater revenue for the hospital.
24 Conclusion and Recommendation If a provider feels that a patient would benefit from palliative care, it is recommended that the consult be placed as early as possible in a patient s hospital stay. Earlier consultation will benefit the patient, the patient s family, and the hospital. Reduce length of stay Reduce hospital costs and increase revenue
25 Limitations This retrospective data serves as a preliminary report with intent to continue the study in a prospective manner, where the following limitations will be addressed: 1. Appropriateness of a palliative care consultation Not every patient in the hospital needs to be seen by palliative care New patients will be assessed by the Palliative Performance Scale (PPSv2), a validated tool to determine palliative care appropriateness 2. Patients may not need palliative consult on admission, but may become appropriate later in an admission Case C may fall into this category Subset of data analyzing consults placed based on time patient became palliative care appropriate 3. Only analyzed hospital revenue and length of stay No data to determine patient or family satisfaction in regards to palliative care As the study continues, a validated palliative care satisfaction survey will be offered to the patient or their family
26 Acknowledgements Dr. James Fitzpatrick Research Mentor, Director of Palliative Medicine, Kenmore Mercy Hospital Dr. Henri Woodman Program Director, Internal Medicine Training Program Tisha Luciani Director of Financial Services, Kenmore Mercy Hospital
27 References 1. Hui, David, et. al. Concepts and definitions for supportive care, best supportive care, palliative care, and hospice care in the published literature, dictionaries, and textbooks Support Care Cancer Mar; 21(3): Temel, Jennifer, et. al. Early Palliative Care for Patients with Metastatic Non- Small-Cell Lung Cancer New Engl J Med, Penrod, JD, et. al. Cost and utilization outcomes of patients receiving hospitalbased palliative care consultation. J. Palliat Med, Ciemins, EL, et. al. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J. Palliat Med, Starks, Helene, et. al. Cost Savings Vary by Length of Stay for Inpatients Receiving Palliative Care Consultation Services J. Palliat Med, 2013
28 Questions? Thank you
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