There is no billing code for compassion

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?

Paul Levy is the former President and CEO of Beth Israel Deaconess Medical Center in Boston and blogs at Not Running a Hospital. He is the author of Goal Play!: Leadership Lessons from the Soccer Field and How a Blog Held Off the Most Powerful Union in America.

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  • http://www.practitionersolutions.com Niamh van Meines

    Great food for thought! Money cannot be the reward system for an inherent value when people’s lives & health are at stake. We all bear witness to the decisions and practices from practitioners who valued money and fame over patient care and felt the anger and shame for our respective disciplines…..the oncologist who would never prescribe PO chemotherapy because he can’t bill for it, the narcissistic nurse who put her own needs first over the needs of her patient…etc. Compassion is up there with honesty and integrity, a basic expectation in any patient / practitioner relationship. Clinicians who lack this characteristic (which cannot be acquired through education) need NOT to be in positions where interactions with patients and patient relationships are required. Compassion is one of the variables that result in safe, quality healthcare services & I believe should be a requirement for licensure. Perhaps a tiered rating system or limited licensure might be a better option for rewarding clinicians who provide the best compassionate services. I can imagine if there was a billing code, the level of suspicion of authenticity would be raised and from a patient perspective….there would be no possibility that I would trust that the compassionate display would be genuine! How might it be measured? The clinician had a compassionate facial expression? They cried when they heard my story? They showed their emotions? They held my hand? We would probably need clarity about what constitutes compassion and I’m quite sure, like love and integrity….it cannot be measured on a scale or in a mechanistic way! Pandora’s box..best leave that one alone! Thanks for the article though…..an interesting journey!

  • http://strangelydiabetic.com Scott Strange

    This raises an interesting point, as a patient I would like to see compassion be a component of every billing code.  The term “billing code” makes seem so sterile, though.  I certainly don’t want to be referred to as 250.1

    Maybe a more fundamental problem is in play here.  Are doctors able to allocate enough time per patient visit to establish the type of rapport needed to be compassionate?

    • http://www.facebook.com/people/Tammy-Marie-Ruiz/722525419 Tammy Marie Ruiz

      Scott… compassion is a virtue.  It encompasses empathy and sympathy and is shown as love.  Not everyone is capable of providing compassionate care as it is not in everyone’s nature to be this way.  You provided a good statement by asking if doctors have enough time to be compassionate.  It has nothing to do with time, it has to do with the person providing the care.  If they are indeed a good person, they will express compassion in their work.  I am a registered nurse and am extremely compassionate.  The appreciation shown to me by my patients is a reward like no other.  I believe that compassion is part of a nurses role.  To answer the original questions in this debate, NO – Compassion should not have a billing code as it would go against every ethical rule of nursing.   

      • Keisa Bennett

        I have to say that I agree with you both in certain ways.  While a person can show compassion in every action, regardless of time, time actually has a lot to do with a health provider’s ability to demonstrate and cultivate relationship, and that’s really what we’re talking about here.  
        If you are a healthy person who gets a sprained ankle or a bad sinus infection, perhaps you value the quickest possible visit with a concise but compassionate acute-care doctor. Relationship is not something you’re looking for.  That makes sense.  But most of my patients have multiple chronic care issues or interest in cultivating wellness across the family and lifespan, and I’m here to help them.  That requires relationship and it requires a lot of time.I don’t want compassion to be a billing code, and I don’t really even want just time to be a billing code.  But when I am rushed (which is most of the time, psychologically) I don’t provide the same quality of care, and I’m afraid that my stress blunts my compassion as well.  Like most primary care docs, I just want the complexity of chronic care, prevention, patient education, and care coordination to be valued as much as procedures so that we could be incentivized to spend more time with patients who need it and find other ways to serve patients with simple issues like colds, INR checks, subconjunctival hemorrhages and other things for which people don’t really need to see a doctor.

        • Anonymous

          So you assume that those with simple issues don’t need compassion?

          I see now why when it seemed I had a cold, I didn’t receive any compassion from my PCP. 

  • http://www.facebook.com/people/Dennis-Pacl/1485063654 Dennis Pacl

    There is pay for compassion… it’s called gratitude. 
     
    On a more mundane note, the prolonged service codes are easy to use (99356 - 99357). The problem with these codes is they require prolonged service at least 30 minutes longer than the time component for the highest level of E&M service.
     
    Under the current CPT system, you are rewarded for quantity not quality. Since it’s inception in 1966, CPT has been influential in transforming the nature of the Doctor-Patient relationship. In my opinion, “managed care”, capitalizing on increasing the volume of services(and reimbursement), accelerated the diffusion of responsibility for the patient experience, as there is little incentive for commitment to that relationship beyond the the time that can be billed for! 
     
    The CPT system in a sense punishes Doc’s who take extra time with a patient. For example, a pain specialist can perform 3 epidural steroid injections in the time it takes to see a patient with Fibromyalgia. Do the math.
    You lose money seeing patients who need a lot of compassion. 

  • http://www.facebook.com/people/Dennis-Pacl/1485063654 Dennis Pacl

    There is pay for compassion… it’s called gratitude.

    On a more mundane note, the prolonged service codes are easy to use (99356 – 99357). The problem with these codes is they require prolonged service at least 30 minutes longer than the time component for the highest level of E&M service.

    Under the current CPT system, you are rewarded for quantity not quality. Since it’s inception in 1966, CPT has been influential in transforming the nature of the Doctor-Patient relationship. In my opinion, “managed care”, capitalizing on increasing the volume of services(and reimbursement), accelerated the diffusion of responsibility for the patient experience, as there is little incentive for commitment to that relationship beyond the the time that can be billed for!

    The CPT system in a sense punishes Doc’s who take extra time with a patient. For example, a pain specialist can perform 3 epidural steroid injections in the time it takes to see a patient with Fibromyalgia. Do the math.
    You lose money seeing patients who need a lot of compassion.

  • http://www.facebook.com/people/Pat-Northrup/1500527958 Pat Northrup

    After being a patient twice this summer for bilateral TKR, I will now have  much more empathy  for my patients.  I now understand what I am teaching and suggesting is not as easy I thought,  I  have always considered my self a very compassionate person, now I will make an effort to be more so,
    I will now totally change my approach to teachig pts post op, due to my first hand experience.
    I have been a RN for 37 years, and have seen compassion decrease sadly in the hospital setting, due to under staffing, and the insurance companies directing medical care.  The recquirements to discharge, are ridicilious.
    If a patient can walk 15 feet and climb 4 stairs they are ready to go home.  Most elderly do not live in homes with 4 stairs, and the bathrooms are on the second floor.   Something has to change, we are putting people at risk, and this is why the rehospitalzation rate among the elderly is so high.  
    Patricia Northrup RN CHN

  • Anonymous

    No, compassion should not be used to determine how much a health-care provider is paid, but what if patients got the chance to rate their doctors after each visit/surgery/lengthy treatment experience on compassion and other non-tangible aspects of healthcare that can make all the difference in the patient’s experience?   My clients fill out a feedback form after every project I complete, rating my coworkers and me in areas such as how well we met their expectations, how useful our product is, how well we met their objectives, and how responsive we were to their needs.  As others have already pointed out, compassion isn’t about time, it’s about attitude and approach.  So many doctors, nurses, and others in the healthcare system do practice compassion and are doubtless the sought-after HCPs who get recommended by their patients.  Others surely practice good clinical medicine but might benefit from a little patient feedback about the degree of personal caring they show.

  • http://twitter.com/PatientCommando Patient Commando

    I’ve had a chronic illness for over 30 years. Measuring “compassion” isn’t about what the patient feels they get from a provider. I can’t imagine there’s many doctors/nurses/social workers that go into the profession for money alone. Strip technology and drugs and hospital buildings out of the equation, and all you’re left with is the human component. Its not a quality that you’re going to be able to measure in time, money, or a specimen collection.

    Compassion for patients is the intersection of medicine and humanity. Compassion is part of the process. Developing skills that improve practice will not only connect practitioners with their inherent compassion but result in improved outcomes in patient safety, disease prevention, and early detection.

    Better listening, empathy and reflection skills don’t need any technology but will help practitioners reconnect with the motivation for choosing their career path.  I’m sure that Dr Amy Ship would agree with Dr Rita Charon, Executive Director of the Program in Narrative Medicine, College of Physicians & Surgeons of Columbia University, a renowned expert in the application of illness narratives in the practice of medicine, when she described the experience in this way:
     
    “Its about suffering. It’s also about joy. When we make contact with ill persons, with persons in pain, or persons in fear, we open ourselves to suffering because we’re allowing ourselves to come close. And we will suffer more with more contact. We grieve, we mourn, we cry, we worry. As we make that contact we also open ourselves to the joy and the reward and the realization that our human equipment is being used to benefit another human. We also become better ourselves. The recognition that I give to a patient, if I can, causes that patient to then recognize me. You become a better self by virtue of first recognizing that patient and then being recognized as one who can do that. So the entire thing is profoundly elevating and as you go through the day you are elevated by the process. It does hurt more and it gives you great joy. If you want to do without the hurt you do without the joy.”

    Listen to our (patients’) voices and you’ll have not only enthusiastic particpants in the management of our healthcare but you’ll also have a guide to change your practice to the way you wanted it to always be.

    Zal Press
    http://www.patientcommando.com

  • http://twitter.com/DoctorPullen Edward Pullen

    In communities where there is competition for patients the financial advantage of compassion is a full schedule of patients.  Less malpractice suits may also be a financial advantage.  Most of all positive long term patient relationships is priceless.  The CPT code idea is silly.  

  • http://www.facebook.com/LeslieAnnFraser Leslie Fraser

    Compassion fatigue is real.  It grows every time staff is asked to do more with less…less of everything.  The CPT for Compassion is obviously “tongue in cheek” but it raises a great point.  The payer and provider want great care and for the smiling nurse/MD, etc to be a part of the marketing program.  Patients need and deserve basic kindness, friendliness, courtesy, respect, information, a FULL visit from the MD (not a fly-by).  Health care employees do NOT lack compassion, the system and employers have sucked it out of them.  The margins of corporate America are not sustainable.  In my city a nurse on average is earning $60k – $75k and still has difficulty making ends meet due to soaring costs of everything.  The expectation is that as a professional they could live with less financial stress.  This is no longer the case.  Most nurses I know moonlight to pay their school loans back, driver older cares, don’t take vacations and don’t have cushioned bank accounts.  The same is true for teacher…the HCAHPS and surveys are rolling in 2013 and while the compa$$ion formula isn’t in the CPT, there will certainly be a formula based on patient customer service surveys.  Is your health institution ready?  How will you get ready?  Can you institution afford to lose more due to poor customer service?  Teachers have the pay for student performance…marketers are rated o how much business they attract…now health care employees will have the same type of expectation.  Patient centered care, culture shift…Star Rating Systems…
    …so get your staff to plaster that smile onto their faces whether they like to or not…maybe they will be transformed by the smile…and remember the reason they entered health care.  Maybe institutions need to point the fingers at themselves and not at the line staff.   Do our institutions demonstrate adequate compassion to the people who make everything possible everyday?  The trickle down effect (ripple) is quite amazing….We live in interesting times when a person really has to be conscious about so much more than avoiding a needle stick or med error…back to basics… DId you love your patient(s) today?