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Outpatient Practice

Your Hospital Needs Palliative Care Telemedicine

One of the good things to come out of the COVID pandemic was the expanded use of telemedicine. It allowed us to provide on-going care to our patients during lock-down periods early in the pandemic and later allowed us to care for patients who were uncomfortable coming into a place where they could potentially become infected. It became clear from the beginning that some specialties were more amenable to telemedicine than others. Telemedicine was less useful for those visits that require a more detailed physical exam or required in-office procedures. Telemedicine was more useful for those visits that were mainly for counseling. A recent study in JAMA demonstrated the value of telemedicine in palliative care for non-cancer diseases.

The study involved 306 patients two Veteran’s Administration health systems between October 2016 and April 2020. Patients all had either COPD, interstitial lung disease, or heart failure. Patients were randomly assigned to either usual care or a telehealth group that received 6 phone calls from a nurse and 6 phone calls from a social worker. Patients were evaluated with a multi-domain quality of life survey (the FACT-G score) and disease-specific quality of life scores. After 6-months, the telehealth group reported significantly better quality of life than the usual care group. There are several important conclusions we can make about palliative medicine telehealth based on this study:

  1. It does not require expensive specialists. The RN and social worker who performed the telephone calls had 10 hours of training. Physicians who have completed palliative medicine fellowships are in short supply and there are not enough of them to provide telehealth services for all hospitals. Registered nurses and social workers are much more widely available (and less expensive) than board-certified palliative medicine physicians. This study shows that at least some of palliative care telehealth can be provided by RNs and social workers with a minimum of training. This would free up palliative medicine physicians (and nurse practitioners) to provide programatic oversight and to provide selective telehealth encounters when the RN or social worker identified need for advanced care and decision-making.
  2. It works for patients with non-cancer diagnoses. In many hospitals, palliative medicine is largely relegated to the care of patients with cancer. Furthermore, palliative medicine is often funded by the hospital’s cancer program. This study shows that the quality of life of patients with COPD, interstitial lung disease, and heart failure improve with palliative medicine telehealth.
  3. It overcomes transportation and mobility barriers. Patients with advanced COPD, interstitial lung disease, or heart failure generally have limiting dyspnea with exertion and are often on supplemental oxygen. This creates a barrier to traveling to an outpatient clinic site with the result that many patients who could benefit by palliative medicine do not receive it. This is especially true of patients who live a great distance from the palliative medicine clinic location.
  4. It did not affect hospitalization rates. The total number of patients in the study was small with only 154 patients randomized to palliative care telehealth and 152 patients randomized to usual care. The primary outcome for which the study was powered was for quality of life scores and a secondary outcome was hospitalization. At the end of 1 year, 109 of the palliative care group and 119 of the usual care group had been hospitalized, a difference that was not statistically significant. There was also no statistical difference in mortality at 1 year: 6 patients in the palliative care group and 5 patients in the usual care group died. Healthcare utilization, in terms of annual total healthcare costs, was not reported so it is unknown if palliative care telehealth reduced healthcare expenditures.
  5. The population studied was limited to Veterans Administration patients. Care at VA medical centers is very different than care at other healthcare facilities. There is easy access to inpatient and outpatient care. Co-pays and deductibles for medical care are relatively low or waived. Additionally, medications are free or available with a relatively low co-pay. In this study, most patients were male and Hispanic. It is unknown if the results can be extrapolated to a more diverse group of patients or patients at non-VA hospitals.

Advantages of palliative medicine telehealth

Any physician who has ever performed a home visit will tell you that you get important information by seeing the patient in their own home environment that you cannot get when seeing the patient in a clinic exam room. During a video-telehealth visit, you can often get a good idea of the patient’s environment that can clue you into home health needs. Assessment of entry ways, stairs, and bathrooms can indicate measures that can be taken to reduce falls. Assessment of home oxygen equipment can ensure adequate (and safe) oxygenation. The need for durable medical equipment can be identified.

The advantages of using telehealth to reach patients who have mobility, transportation, or geographic distance barriers cannot be overstated. Some physicians will argue that in-person visits for palliative care are superior to telemedicine visits; however, a telemedicine visit is vastly superior to no visit if the patient is unable to come to the physician’s office. This is particularly true for patients with conditions such as end-stage renal disease who are bound to their locality three days a week for dialysis, those who are wheelchair-dependent, and those who have limiting dyspnea on exertion.

During COVID, it quickly became clear that telemedicine was more effective for some specialties than others. Diseases that require the patient to undergo regular testing (blood tests, EKGs, pulmonary function tests, etc.) are not as amenable to telemedicine since the patient must come to the clinic for the tests, anyway. Similarly, diseases that require an in-person physical examination for regular assessment are not as amenable to telemedicine compared to those diseases that only require counseling. Palliative medicine is primarily counseling and generally does not require regular testing or procedures. Thus, palliative medicine is in many ways the ideal specialty to utilize telemedicine.

Telehealth has the potential to reduce palliative medicine outpatient no-show rates. When a patient cancels an outpatient appointment on short notice, there is no bill generated and no income to cover the overhead expense of the clinic or the physician’s salary for that period of time. Even if a patient is feeling too unwell to travel on the day of their office appointment or if their transportation is unexpectedly unavailable, that patient can still have a billable telehealth visit which can reduce or eliminate the financial loss of a late cancellation or no-show.

Paying for it

The recent study does not address cost of care. A disadvantage of using a registered nurse to perform palliative care telehealth is that those encounters are generally not billable. Thus, the funding must come from other sources. Alternatively, telehealth can be performed by a physician, nurse practitioner, or physician assistant who can generate revenue by making it a billable telemedicine encounter. Future studies are needed to determine if per-person annual healthcare costs are lowered by palliative medicine telehealth in non-cancer diseases. If so, then managed care programs and insurance companies could be approached for funding. Similarly, health systems participating in value-based-purchasing models and bundled-care payment models could internally fund palliative care telehealth if it is shown to be reduce hospitalizations or annual cost of care.

Palliative medicine is rarely financially self-sufficient. In most hospitals, palliative care is heavily subsidized by the hospital since it is not possible to cover the salary of palliative medicine physicians or advance practice providers on professional revenue billing alone. This study has shown that palliative medicine telehealth improves patient quality of life. However, the current U.S. healthcare system does not pay hospitals to improve quality of life. Hospitals get paid by outpatient testing, surgeries, and inpatient admissions. They use the profits from these services to cover the cost of services that they lose money on. Palliative care has to compete with a myriad other hospital services for funding. In deciding which of these services to monetarily support, hospital leaders rely on clinical research studies and publications to guide them. This recent study will help to provide needed justification for expansion of palliative care telemedicine services. Indeed, palliative medicine and telemedicine are perfect for each other.

March 8, 2024

By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital