Back in 2009, Dr. Amy Ship gave a moving acceptance speech when she received the annual Compassionate Caregiver Award from the Schwartz Center.
The most memorable tag line from the speech was, "There is no billing code for compassion." This resonated with so many of us -- patients and providers -- in part because it set forth the proposition that compassionate care should be an inherent aspect of medical services. The idea that some portion of a doctor's or hospital's payment should be tied to such an essential human value seemed ludicrous.
Or is it? A recent survey conducted by the Schwartz Center, entitled "The state of compassionate care in the United States," indirectly raises the issue. Those patients and doctors surveyed were overwhelmingly in favor of the idea that compassionate care was important to the successful treatment of patients. They agreed, too, that compassionate care makes a difference in how well a patient recovers from illness. Indeed, they believed that good communication and emotional support can make a difference in whether a patient lives or dies.
But there was a gap between what patients said was most important to them, in terms of compassionate care, and what they actually experienced during recent hospitalizations. And, looking forward, both patients and doctors are worried that the changes being made in our health care system will make it more difficult for providers to offer compassionate care.
Now, if we remove the word "compassionate" from the above discussion and instead insert "safety," "quality," "avoiding hospital acquired infections," or the like, our immediate response would be that we need to change the system of hospital and physician payments to provide financial incentives to change things for the better. Whether we might propose a pay-for-performance approach or some kind of global payment to encourage improvement, the current environment seems very comfortable with using the payment system to nudge behavior in the right direction.
So, why not pay for compassion? Surely, we can name those aspects of care that are most closely tied to compassion, and we can likewise document whether they occur.
While I will let this debate play out in the comments below, let me start it off by saying that I believe this would be a mistake. So many discrete aspects of medical care are already monetized that is hard to imagine a payment regime that would actually focus sufficient financial attention to motivate a doctor along the spectrum of less-to-more compassion. Beyond that, the idealist in me is offended by the idea of paying someone to, in essence, be more humane. In my view, this is not a matter of remuneration. It is a matter of societal values and a training program and ongoing supervision that imbues practice with those values.
But, let's hear what you have to say. Should there be a billing code for compassionate care?
Well, I am going to take your question figuratively instead of literally and ask, how do we measure compassion? Broadly, isn't compassionate care putting the patient first in all you do? And how often do we think we truly do that in our current system? (Answer: almost never). And if one assumes that every provider WANTS to provide compassionate care, then what is preventing them from it? Answer: being in a hurry. And why are we in a hurry? Because we have no system for delivering care - we have the antithesis of a system; we have chaos.
ReplyDeleteFortuitously, an hour before reading this post I read a long quote from a physician about the Virginia Mason system of care, which you have discussed in posts below. It's so long I will put it in a separate comment, because I think it deserves to be seen in its almost-entirety. It's an eye opener.
nonlocal
In this second part of my comment, here is the partially truncated quote from a primary care doctor who practiced for 19 years under the traditional system and 9 years under VMPS (Virginia Mason Production System, their version of the Toyota or Lean system which has been a smashing success). See if you think the system he describes is more likely to lead to compassionate care - and, is more compassionate to the caregiver also!
ReplyDelete"I was trained in a craftsman school of developing my own..techniques of getting things done..in a highly complex environment that's unstable, that's not self-organizing..you're going to have to adopt a SYSTEM. It's not going to happen by virtue of craftmanship methods..once [a structured system] sets you up, your life improves and all day long you get thanked and all day long you do not live in fear of what you just forgot and what you've got to remember.. we've got a cadre of doctors who've weathered the storm that's causing everyone to burn out..what VMPS has really done is preserve that 18-20 minutes with the patient and sometimes more, that is fun, that is creative".
You wouldn't need a billing code - you'd be doing it because that's why you went into medicine in the first place. Don't we all aspire to that?
nonlocal
On first read liked this idea, but then I realized: shouldn't compassionate care be the default, i.e. not an add-on?
ReplyDeleteThe concept of paying a doctor to be compassionate makes as much sense as paying the ocean to make waves or paying the sky to be blue, pink or black. It is axiomatic that being a physician or a nurse or any health care provider is to be compassionate. We should encourage, coax, model and nurture it. If we need to pay for compassion, we are more lost than I previously assumed.
ReplyDeleteFrom Facebook:
ReplyDeleteThis note is very timely for me as I have sat with my father in the hospital for the last 9 days. He speaks very, very little English and as a result, he is often ignored or marginalized. As a result, I am his patient advocate nearly 14 hours each day. Not only is compassion lacking, the delta between when should be done because of rules and regs and what actually is done is quite wide.
Just in the past week alone, I've been asked to sign forms they backdated and his transfer from the ICU to the step-down unit was delayed because the chest tube they inserted never actually had an order written for it (among other JC violations that make me cringe).
So, while I would love a P4P for compassionate care, I believe it would be as flawed as the current clinical financial incentives in place. The bare minimum necessary to be compliant would be done, and likely in the same CYA spirit that I've seen pervade in daily hospital operations. And I totally agree with you, philosophically, paying staff to be compassionate towards patients seems fundamentally wrong.
From Twitter:
ReplyDeleteU can bill 4 compassion. It's a palliative medicine consult. Its reimbursement compared to procedures says a lot about values.
We just need to pilot documentation and QI systems that take standards regarding patient wishes as seriously as standards for recording and responding to serious allergies.
ReplyDeleteI just looked up the definition of "compassionate." It is:
ReplyDelete"Deep awareness of the suffering of another coupled with the wish to relieve it"
This is what should be a prerequisite for anyone who wants to be in the health care field. Billing for it seems at odds, not right. It should be part of the package.
Perhaps the bigger question should be, how do we get compassionate people to be accepted to medical school? How can it be made to be as important as test scores or a thick CV?
Suzanne Salamon
"No one can serve two masters. Either he will hate the one and love the other, or he will be devoted to the one and despise the other. You cannot serve both God and Money." - Luke (he was a physician)
ReplyDeleteFrom Twitter:
ReplyDeleteYes, but not if the compassionate care code is abused for financial gain. Medicare is looking ahead to the boomer cost.
Of course monetizing compassionate care would work;look at used car sales. Sincerity is monetized there and look how much of it there is, and so affordable.
ReplyDeleteI would not advocate for a compassionate care modifier. However, we should also consider that the value-based purchasing movement has the real potential of reducing compassion further and making healthcare a more and more transactional business. At the very least, we should consider the inpact of proposed performance measures on compassion. For example, the recently endorsed NQF measures on mortality for ICU patients has the potential for reducing exposure to palliative care services.
ReplyDeleteA provider fills out his fee sheet and checks off codes for services provided and then he will check off a code for compassionate care? All other codes can be supported by the medical record. How would a compassionate care code be supported? That is highly subjective. The provider may have given compassionate care in their mind but it could still be lacking in compassion especially from the patient's perspective.
ReplyDeleteAnd health care professionals should be providing compassionate care as a matter of practice. That should be a built in item for all charge codes.
I have been in primary care practice for 29 years and for the past 14 years have served as the medical director of a large academic primary care practice. Over that period the key ingredient of care that has been squeezed the most is time with the patient doing actual doctoring. The "doctoring time" can be face-to-face, over the phone or electronic (e.g., email). Primary care providers have been pressed to grow panels to unrealistic size and to provide higher volume -- e.g., see more patients in less time -- all the while being held accountable for innumerable lists of tasks -- preventive services, prior authorizations, documentation of home services, medication reconciliation, tracking test results, etc. All of these functions are vital to safe, quality care but the existing "system" is generally not configured to allow sufficient time for all of this to happen while fostering an environment that allows, let alone promotes humane interactions with patients. (A second reality is the fact that managing all these lists spills over into late nights at home, reducing compassionate interactions with families.) One can be compassionate in short time aliquots with patients -- even 5-10 minutes -- but the pressure to keep up with the lists often sabotages the best intentions of a group of individuals who went into primary care in large part in the first place because they are compassionate. It's those human interactions with patients -- sitting on the bed and talking with a dying patient, calling the anxious patient at home at 8 PM to reassure him/her of a test result, spending the extra time in the office learning about the challenge of a single parent with a rebellious adolescent that add richness to what I and we do. Of course, none of these activities are reimbursed but are fundamental to what we are about. We need to be freed up from the non-doctoring part of care to put this level of interaction closer to the center of our universe. The move toward the advanced medical home offers some promise here, but there will need to be a fundamental restructuring of resources.
ReplyDeleteI believe that like quality, compassion should be an expectation for our patients. I also believe that like quality in the end providers who are compassionate will be the most successful both in their own personal satisfaction and their business success.
ReplyDeleteKen Schwartz believed strongly that compassionate care helped to heal the body and nourish the soul, yet even 15 years ago, he was worried that the changes
ReplyDeletetaking place in our healthcare system would strain the patient-caregiver relationship and make it more difficult for caregivers to provide compassionate care. Before his death, he wrote: "In such a cost-conscious world, with its inevitable reductions in staff and morale, can any hospital continue to nurture those precious moments of engagement between patient and caregiver that provide hope to the patient and vital support to the healing process?"
As our survey (http://www.slideshare.net/schwartzcenter/survey-the-state-of-compassionate-healthcare-in-the-us) found, Americans believe strongly in the value of compassionate care, but only a third believe that doctors and nurses - because of their dedication and professionalism - will be able to continue to provide
compassionate care as our healthcare system changes. Only slightly more than half characterized the current U.S. healthcare system as a compassionate one.
Some insurers are beginning to tier payments to providers based on how well they score on various quality and safety measures. Why shouldn't patients'experiences of care, including their perceptions of the effectiveness of communications, emotional support and responsiveness be included in this calculation?
Julie Rosen
Executive Director
The Schwartz Center for Compassionate Healthcare
Ah Julie, now we're talkin'!
ReplyDeleteYep, Paul: add the patient voice to the reimbursement equation. Top o' me head thought: but not on a visit by visit basis, rather on a yearlong basis. Find some incentive for patients to do an assessment (insurance discount). High scores somehow reward the doc. Any legs on this? If so, how might it play out?