Palliative care as a win-win

Palliative care offers multiple benefits. Pain can slow the healing process. It extends hospital stays, prolongs needless suffering and erodes a patient’s capacity to adhere to prescribed treatment.

A 2008 Journal of Palliative Medicine study measured the impact of palliative care on patient satisfaction, clinical outcomes and cost of care for six months after being released from the hospital. Patient satisfaction was higher, more advance directives were completed, fewer ICU admissions were necessary and overall medical costs were lower compared to patients with life-limiting illnesses not in palliative care. Patient satisfaction stems primarily from palliative care’s patient-centered approach, which incorporates personal values and preferences.

This is in contrast to the usual intensive care many patients receive regardless of their preferences. More than half of Medicare spending on beneficiaries in their last two years is for hospital costs. About 25 percent of total Medicare costs is spent for patients in the last year of life. Most of those expenses are for hospitalizations, including readmissions and ICU stays. One out of 5 cancer patients are still receiving chemotherapy in the last two weeks of life.

Patient satisfaction with hospital care is inversely related to intensity of care. It falls in direct proportion to higher spending, greater use of resources and intrusive care.

Early palliative care can actually extend life. A 2010 study found that people with lung cancer who received the care lived three months longer, compared with those receiving standard care. Those with lung cancer can expect to get only two or three additional months of life at most from chemotherapy.

Despite its advantages, there are several barriers to widespread use of palliative care. Physicians are trained to save lives, even if it requires aggressive measures. It is often not clear at what point a condition becomes inevitably terminal. For many physicians and their patients, palliative care represents a surrender of sorts. Aggressiveness is the default approach to end-of-life care in the U.S.

An intensive battery of procedures and tests is paid for by Medicare and private insurers without questions. Reimbursement for palliative care is less certain. Medicare and private insurers pay for some palliative care, but the billing can be less comprehensive and more complicated than for standard hospital care, and physicians may consider this too burdensome. Customarily, most health plans do not pay for time-consuming care coordination and shared decision-making.

To counter these barriers, in 2010 Gov. David A. Paterson signed into law the New York Palliative Care Information Act, which requires physicians to offer terminal patients and their families information about prognosis and options for end-of-life care. New York State’s medical society opposed the law because they believed the government was intruding on the physician-patient relationship.

Palliative care is not necessarily intended to be less expensive care, but that often is the result. A hospitalized palliative-care patient costs $279 to $374 less a day. There are significant reductions in pharmacy, laboratory and ICU costs. The average annual savings of a palliative-care program is $1.3 million for a 300-bed community hospital and $2.5 million for an average academic medical center.

In a study of Medicaid patients in four hospitals in New York state, patients who received palliative care cost $6,900 less during a hospital stay compared with those who received standard care.

In Spain, a 2006 study found that a shift to palliative and at-home care and away from traditional hospitalization saved 61 percent.