La Jolla National University Palliative Care Presentation

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The business case for palliative care VIEWS & REVIEWS
Palliative care and neurology
Time for a paradigm shift
Isabel Boersma, MS
Janis Miyasaki, MEd,
FRCPC, MD
Jean Kutner, MD, MSPH
Benzi Kluger, MD, MS
Correspondence to
Dr. Kluger:
benzi.kluger@ucdenver.edu
ABSTRACT
Palliative care is an approach to the care of patients and families facing progressive and chronic
illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues,
and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting,
and disabling conditions, it is important that they understand and learn to apply the principles
of palliative medicine. In this article, we aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is
hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? We cover several fundamental palliative care skills relevant to neurologists,
including communication of bad news, symptom assessment and management, advance care
planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. We conclude by suggesting areas for future educational efforts and research. Neurology®
2014;83:561–567
GLOSSARY
MS 5 multiple sclerosis; PD 5 Parkinson disease.
In a 1996 review, the American Academy of Neurology Ethics and Humanities Subcommittee
stated: “Many patients with neurologic disease die after long illnesses during which a neurologist
acts as the principal or consulting physician. Therefore, it is imperative that neurologists understand, and learn to apply, the principles of palliative medicine.”1 Similarly, the Accreditation
Council for Graduate Medical Education requires neurology residents to receive instruction in
end-of-life and palliative care.2 However, research suggests that there are major gaps in the
education of neurology resident physicians in these topics and low levels among neurologists of
referrals for palliative care services.3,4 While palliative care emerged in the treatment of patients
with terminal cancer, more recent developments in this field suggest that palliative care may be
appropriate for any patient living with advanced, progressive illness or multiple comorbidities.
As examples, palliative care been successfully applied to chronic illnesses such as heart failure,5
chronic pulmonary disease,6 and end-stage renal disease.7 There is also an emerging interest, in
both research and clinical care, to apply these principles in neurology.8–10 Our goal in this article
is to provide a starting point for neurologists to become more knowledgeable and comfortable
with the principles of palliative medicine.
Supplemental data
at Neurology.org
WHAT IS PALLIATIVE CARE AND WHAT IS HOSPICE CARE? Many health care professionals, including
neurologists, hold misconceptions about palliative care.11 The most common misconception is that palliative
care is synonymous with hospice. The lack of clarity regarding the similarities and differences between palliative
care and hospice likely influences the view that only patients nearing the end of life are suitable candidates for
palliative care.12 Similarly, some health care professionals believe palliative care is “giving up on patients” or “no
care”; however, research efforts suggest that early palliative care interventions may positively affect both quality
of life and survival.13 Notably, palliative care can be used alongside curative treatments.14–16
From the Departments of Neurology and Psychiatry (I.B., B.K.) and Internal Medicine (J.K.), University of Colorado Anschutz Medical Campus,
Aurora; and Department of Neurology (J.M.), University of Alberta, Edmonton, Canada.
Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
© 2014 American Academy of Neurology
561
Table
Hospice guidelines for neurologic disorderse18
Dementia
1. Stage 7C or higher on the FAST scalee19 AND
2. One or more of the following in the past year: aspiration pneumonia, pyelonephritis, septicemia, stage 3 or 4 pressure
ulcers, recurrent fevers, other conditions suggesting limited prognosis, or inability to maintain sufficient fluid/caloric
intake in past 6 months (10% weight loss or albumin ,2.5 g/dL)
1. Palliative Performance Scalee20 score #40% AND
Stroke or coma
2. Poor nutritional status with inability to maintain sufficient fluid/caloric intake (10% weight loss in 6 months, 7.5%
weight loss in 3 months, serum albumin #2.5 g/dL, or pulmonary aspiration resistant to speech therapy interventions)
Other neurologic disease including ALS,
PD, MD, MG, or MS
1. Critically impaired breathing including dyspnea at rest, vital capacity ,30%, O2 need at rest, AND refusal of artificial
ventilation, OR
2. Rapid disease progression (to bed-bound status, unintelligible speech, need for pureed diet, and/or major assistance
needed for ADLs) with either:
A. Critical nutrition impairment in the prior year (inability to maintain sufficient fluid/caloric intake, continuing weight loss,
dehydration, AND refusal of artificial feeding methods) OR
B. Life-threatening complications in the prior year (recurrent aspiration pneumonia, pyelonephritis, sepsis, recurrent
fever, OR stage 3 or 4 pressure ulcers)
Generic criteria
1. Terminal condition (can be multiple conditions) AND
2. Rapid decline over past 3–6 months as evidenced by progression of disease signs, symptoms and test results, decline in
PPS #40%, and involuntary weight loss .10%, and/or albumin ,2.5 g/dL
Abbreviations: ADL 5 activities of daily living; ALS 5 amyotrophic lateral sclerosis; FAST 5 Functional Assessment Staging Test; MD 5 muscular dystrophy; MG 5 myasthenia gravis; MS 5 multiple sclerosis; PD 5 Parkinson disease; PPS 5 Palliative Performance Scale.
The Center to Advance Palliative Care defines palliative care as “specialized medical care for people with
serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain,
and stress of a serious illness—whatever the diagnosis.
The goal is to improve quality of life for both the
patient and the family. Palliative care is provided by
a team of doctors, nurses, and other specialists who
work with a patient’s other doctors to provide an extra
layer of support. Palliative care is appropriate at any
age and at any stage in a serious illness, and can be
provided together with curative treatment.”17 Notably, palliative care may be applicable early in the
course of illness, including the time of diagnosis, to
help the patient adjust to the many changes in their
life and life plans.18,19 Similarly, palliative care may
complement life-prolonging therapies, such as chemotherapy or radiation therapy, and investigations
needed to better understand and manage distressing
clinical complications.15
Palliative care describes an approach to patient care
available from the time of diagnosis through bereavement and may be delivered in conjunction with standard care or through specialized services including
hospice care, inpatient palliative care, outpatient palliative care clinics, and home palliative care. Hospice
care refers specifically to palliative care for the end of
life. In the United States, the Medicare hospice benefit
is available to patients certified by 2 physicians to have
a prognosis of 6 months or less if their disease runs its
natural course and who have chosen directly or
through surrogates to focus medical care on comfort.20,21 It is offered when disease-directed treatments
are no longer wanted or beneficial. The table provides
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August 5, 2014
hospice eligibility guidelines for specific neurologic
conditions. However, it should be noted that patients
with poor prognoses may be eligible for hospice without meeting these specific guidelines.
The palliative care approach augments traditional
care for neurology patients in several ways. While traditional approaches emphasize the preservation of
function and prolongation of life, palliative care draws
additional attention to the relief of suffering and places importance on planning for decline and death as
an expected and natural outcome rather than as a failure of medical treatment.22 Palliative care transcends
the historical patient-physician dyad by addressing
caregiver strain and offering supportive services to
family members such as respite care and counseling.22,23 Finally, palliative care assesses and treats medical, psychosocial, and spiritual issues including not
only pathologic diagnoses but other sources of distress, including normal reactions to living with a
life-threatening, progressive, and/or disabling illness.
WHAT ARE THE PALLIATIVE CARE NEEDS OF
NEUROLOGY PATIENTS? This question can be bro-
ken down into related questions: Would neurology
patients and family members benefit from palliative
services? Are neurology patients receiving adequate
care in these areas? On the basis of both questions,
we believe there is a substantial and growing need
for neurologists to apply the principles of palliative
medicine to the care of patients with progressive,
chronic illnesses.1,9 Regarding the question of benefit,
neurologic diseases are largely incurable, reduce life
expectancy,24 and are associated with pain, depression,
and other symptoms that are difficult to control.25
Miyasaki et al.26 showed that symptom burden in
advanced Parkinson disease (PD) is similar to that in
metastatic cancer. Caregivers of neurology patients
also have similar, if not higher, rates of distress and
burnout as caregivers of patients with cancer.27
Regarding the question of adequacy of current palliative services, place of death and documentation of
advance directives offer objective measures of physician performance. Hospital deaths among patients
with chronic neurologic disorders are high: 43% for
PD and 56% for multiple sclerosis (MS).28 However,
hospice deaths are extremely uncommon in PD and
MS: 0.6% and 2.5%, respectively.28 Only 9% of
patients with idiopathic PD die in their own home
compared with 17% of the general elderly population.29 These are striking statistics because research
overwhelmingly indicates that the majority of patients
prefer to die at home.30 Furthermore, although neurologists broach advance care planning late in the disease course if at all, patient surveys suggest that at least
50% of patients with PD want to discuss advance care
documents with their physician early in their disease
course.31 Even in patients with advanced dementia,
less than 20% have advanced directives documented.32,33 Regarding symptom management, multiple studies show that neurologists frequently fail to
adequately assess and treat many symptoms associated
with quality of life including depression, fatigue, pain,
and sleep.34–36
DO NEUROLOGY PATIENTS HAVE UNIQUE
PALLIATIVE CARE NEEDS? We propose that tradi-
tional models of palliative care do not sufficiently
address the unique needs of patients and family members living with a neurologic diagnosis. Moreover,
palliative physicians who are largely trained in internal
medicine may have less comfort with neurologic illness
than cancer or other medicine diagnoses.37 Patients with
a life-limiting neurologic illness often have a long and
variable disease progression punctuated by cognitive
impairment, behavioral issues, and communication
problems, in addition to motor symptoms.38 This
trajectory differs from the sharp decline seen in many
patients with cancer.39 Fortunately, palliative care
services are increasingly recognizing the needs of
noncancer patients, particularly in rapidly progressing
neurologic conditions such as motor neuron disease.38
Differences between neurology and other patients
include symptom profiles, psychosocial issues, caregiver needs, and effects on spiritual well-being. As
examples, patients with motor neuron disease experience more demoralization, hopelessness, and suicidal
ideation than patients with metastatic cancer40; patients with brain cancer have distinct symptom profiles including more cognitive problems, seizures, and
communication deficits than patients living with
other types of cancers41; and patients with Huntington disease have distinctive social work needs as the
result of combined behavioral, psychiatric, movement, and cognitive issues.42 Notably, young patients
with Huntington disease can be particularly challenging to place in nursing homes, and social workers
experienced in caring for these patients are necessary
to provide the highest quality of care.43 In our clinical
experience regarding spiritual well-being, neurology
patients experience their disease as something intrinsic to their person, which clearly differs from patients
with cancer who see “the cancer” as something outside of themselves. The physical and cognitive disabilities associated with neurologic illness also
contribute to feelings of being “useless” or a “burden”
and may contribute to higher rates of demoralization.40 Neurologic diseases are associated with caregiver distress and reduced quality of life related to
caregiving,44 well-being, depression, and demoralization.45,46 Caregivers of patients with dementia are
more adversely affected by their role, have unique
psychological issues compared with cancer caregivers
(e.g., losing parts of their spouse one day at a time,
delusions of infidelity),47 and are at high risk of complicated bereavement.48
WHAT
PALLIATIVE
CARE
SKILLS
DO
NEUROLOGISTS NEED? All physicians, including
neurologists, should have familiarity and comfort
with several fundamental palliative care skills including communicating bad news, nonmotor symptom
assessment and management, advance care planning,
and caregiver assessment. For more complex or
advanced patients, referral to palliative care specialty
teams may be appropriate, including inpatient palliative care consultation, outpatient palliative care
clinics, home palliative care, or hospice.
COMMUNICATION AT THE TIME OF DIAGNOSIS
Data from patients with heart failure have shown that
palliative care should start at the time of diagnosis,49
yet research suggests that physician communication is often inadequate or ineffective, particularly
for new diagnoses.50,51 This impression was reinforced at a round-table discussion at a continuing
medical education event where patients with PD
and caregivers discussed their experience of being
diagnosed, including not having enough time for
questions, not understanding what their diagnosis
actually meant, not knowing where to go for
support, and feeling abandoned by their doctor
after being given bad news.
Regarding ways to communicate bad news, there
are a number of tools physicians can utilize including
SPIKES (Setting up the interview, assessing patient’s
Perception, obtaining patient’s Invitation, giving
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August 5, 2014
563
Knowledge, address Emotions, Strategy and Summary)52 or the Vital Talk Web site and smartphone
application.53 When delivering a serious diagnosis,
physicians must bring their full attention to the patient
and figure out what they know about the diagnosis.
Obtaining an invitation before sharing sensitive information such as prognosis and other potentially distressing information refers to finding out how much the
patient wants to know and is especially important in
the initial interview. Using open-ended questions and
assessing emotions and feelings are critical to optimally
support the patient. It is crucial that neurologists finalize the meeting with a follow-up including what to do
when the patient has had a chance to process the information and now has more specific questions. This
practice is particularly helpful to support the patient
and minimize feelings of abandonment.52
SYMPTOM ASSESSMENT AND MANAGEMENT
Neurologists need to carefully assess and treat nonmotor symptoms such as pain, depression, anxiety,
fatigue, sleep, constipation, urinary urgency, and sexual
dysfunction. Multiple studies in several populations
have shown that nonmotor symptoms over time are
among the most function-limiting for patients, and
affect caregiver burden and overall quality of life
more than motor symptoms.54–56 The management
of these debilitating symptoms depends on their
recognition by physicians.57 Research suggests that
as many as 50% of patients with PD who have
depression are not treated, despite evidence that
treatment parallels that of the general population
(e.g., selective serotonin reuptake inhibitors for
depression and anxiety).58,59 Some issues may not
be readily treatable, but should still be closely followed
(e.g., dementia, dysphagia, and weight loss/nutritional
status) because they may require additional support or
affect advance care planning.
ADVANCE CARE PLANNING All neurologists
should be knowledgeable about and feel comfortable
discussing advance care planning with their patients
while the patient is cognitively able. Many patients
have never heard of advance care planning, and
30% of patients with advance care plans do not share
these with their physicians.60 Contrary to the common clinical perception that patients do not want to
discuss advance directives, patients often cite their
expectation for physicians to initiate this discussion
when asked about barriers to planning for the future,
and patients who engage in end-of-life conversations
with their doctors report greater satisfaction with their
care.e1,e2 Notably, having conversations about death and
dying with patients lowers the risk of aggressive
treatment at the end of life.e2 Advance care planning
includes topics such as medical durable power of
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August 5, 2014
attorney, financial power of attorney, living will, and
cardiopulmonary resuscitation directive. Physicians
may also want to less formally discuss overall goals of
care including understanding important life goals and
patient and caregiver fears. Health care professionals
who care for neurology patients should have regionspecific information regarding these topics readily
available for patients and keep an updated copy of
completed forms with patient records. Patients should
also be informed to keep these documents on their
refrigerator and distribute copies to family members.
CAREGIVER ASSESSMENT Caregivers are at risk of
chronic illness,e3 impaired sleep,e4 depression,e5 and
cardiovascular disease,e6,e7 and can have up to a
60% increased mortality rate compared with agematched controls that are not caregivers.e8 The
increase in caregiver mortality rates is related to
both providing care and strain,e8 which in caregivers
of patients with PD, has been shown to increase with
disease progression.e9 It has also been shown that
caregivers of patients residing in nursing homes and
caregivers who are well supported and do not report
feeling distress have lower mortality rates.e8 Caregiver
quality of life is also associated with patient quality of
life—thus, when patients spend their last months of
life in the intensive care unit or die a traumatic death,
it affects caregivers.e10
Caregiver support from neurologists begins by
adequately assessing their needs. The very act of asking caregivers how they are doing is often met with
gratitude and may relieve caregiver concerns that their
only role in the patient’s illness is supportive. Caregiver assessments should include questions relating to
their ability to provide adequate care to the patient
and also to self-care.e11 Assistance with providing care
may include home safety evaluations, information
regarding the illness, understanding the role of medications, and knowing who to contact and how to
handle complications or emergencies including
backup plans for caregiver incapacity. The following
are example questions neurologists can use to assess
caregiver well-being: Are you feeling overwhelmed?
How is your health? What are you doing to take care
of yourself? Do you feel isolated? Do you have time to
meet your financial, work, parental, or other obligations? With these simple questions, neurologists can
provide caregivers with important validation and may
be able to address issues directly or refer caregivers for
further counseling or other necessary support (e.g.,
respite or home health services).
APPROPRIATE REFERRAL FOR SPECIALIZED
PALLIATIVE CARE SERVICES AND HOSPICE
There are many barriers preventing neurologists from
appropriately referring patients to specialized palliative
care services and hospice. Unsatisfactory prognostic
predictors for specific illnesses, fear of diminishing
hope in patients, and physicians’ lack of fundamental
palliative care skills are examples of obstacles that contribute to the underutilization of these services. Limitations of Medicare hospice guidelines for neurologic
illnesses (see table) also present a potential obstacle,
including being overly conservative for patients with
amyotrophic lateral sclerosis and dementia compared
with newer empiric criteriae12,e13 and nonspecific or
nonexistent for patients living with PD, MS, and other
less common conditions.21
Referral to specialist palliative care services are warranted if patients or family members have needs going
beyond their physicians’ ability to manage and may
include the following: end-of-life care, feeding tube
discussions or other complex interventions, spiritual
concerns, distressing psychological issues, lack of caregiver or need for additional caregiver support, difficult
to control physical symptoms, need for capacity assessment or power of attorney disputes, home safety issues,
or communication issues within a family. Red flags
such as frequent hospital admissions (e.g., pneumonia,
falls, and urinary tract infection), unexplained weight
loss, dysphagia, restricted activities of daily living,
increased somnolence, or a rapid decline in function
may signify the need for referral to hospice. Research
suggests that patients are referred to hospice too infrequently or too late. Thirty percent of patients with
advanced dementia go to hospice, and 25% of hospice
stays are 3 days or less.e14
The benefits of referral to palliative care services
are becoming increasingly well-documented, including in neurologic populations.26 A well-publicized
randomized controlled trial of palliative care vs standard oncology care for 151 patients with metastatic
lung cancer found improvements in not only quality
of life and depression but also median survival (11.6
vs 8.9 months).13,26 Similarly, a well-performed randomized controlled trial of 52 patients with advanced
MS showed that outpatient palliative care improved
caregiver burden and reduced the cost of care, including less inpatient care.e15
WHAT RESOURCES ARE NEEDED TO SET UP A
PALLIATIVE CARE TEAM IN MY PRACTICE? The
following is an outline of resources needed to set up
a palliative care team in a neurology practice and is
based on the University of Colorado Hospital Outpatient Neurology Supportive & Palliative Care Clinic
and the University of Toronto Palliative Program for
Parkinson Disease and Related Disorders. Part of our
impetus for setting up these clinics was the need for an
interdisciplinary team to adequately address the full
breadth of palliative care issues facing our patients.
Ideally, a palliative care team should consist of a
physician, social worker, and counselor with some spiritual training. Notably, spiritual support services are
associated with higher quality of life across multiple
studiese16; however, having spiritual support from the
community, but not from a medical team, may be
associated with more aggressive treatment.e17
More important than the specific makeup of the
team is the commitment of its members. The University of Toronto team includes a neurologist, palliative
care physician, and a spiritual advisor, whereas the
University of Colorado Hospital team includes a
neurologist, a nurse with prior hospice experience,
a social worker, a chaplain, and an acupuncturist.
We strongly encourage all team members to pursue
palliative-specific readings and workshops if they
do not have a background in this area.10 The American Academy of Neurology and many subspecialty
meetings now have neurology-specific palliative care
offerings.
The logistics of palliative care may differ from
standard patient visits. Our initial visits may last more
than 2 hours, and we encourage family members and
informal caregivers to attend palliative care appointments. Both clinics were started with volunteer help
and are partially dependent on philanthropy to maintain their full operation. Local disease-specific organizations may be interested in providing social work or
other support for clinics. We find that on-site and
integrated consultations do make a difference regarding both access and quality of care.
RESEARCH AND EDUCATIONAL PRIORITIES
Interest in palliative care within the neurologic community is increasing, but there are several research gaps
that need to be addressed, including:
1. Development and validation of more accurate
prognostic predictors, particularly for 6-month
survival to alert physicians for potentially appropriate hospice referrals.
2. Better identification of high-risk patients and caregivers for palliative care referrals.
3. Clinical trials including implementation studies to
improve management of nonmotor symptoms.
4. Patient-centered studies to identify and characterize palliative care needs in neurology and patient
preferences for addressing these needs.
5. Cost-effectiveness and outcome studies of palliative care interventions.
Despite recent efforts to improve the palliative
care training of neurology resident physicians, only
52% of programs offer a didactic experience in endof-life and/or palliative care, and less than 8% provide
a clinical rotation.3 These data support the continuing
need for enhanced palliative care training of neurology resident physicians. Neurologists and primary
Neurology 83
August 5, 2014
565
care physicians may benefit from further training
regarding primary palliative care skills through meetings, journals, and other continuing medical education opportunities. Palliative care teams may also
need specialized training for managing neurology patients. Finally, patients and caregivers need more/better information about palliative care and hospice and
may benefit from talks given in the community and
online resources.
13.
14.
15.
16.
17.
AUTHOR CONTRIBUTIONS
I.B.: writing of the first draft and revision of subsequent drafts. J.M.:
assistance with conceptualization of the manuscript and revision of subsequent drafts. J.K.: assistance with response to reviewers and final revision. B.K.: design and conceptualization of the manuscript.
18.
STUDY FUNDING
Supported by the NIH (1 K07 Ag030337-01A2), Veterans Administration Medical Center–Colorado Research to Improve Care Coordination
(CRICC) Pilot Grant Program, and the University of Colorado Hospital
Clinical Effectiveness and Patient Safety Program.
DISCLOSURE
19.
20.
21.
The authors report no disclosures relevant to the manuscript. Go to
Neurology.org for full disclosures.
Received January 31, 2014. Accepted in final form April 27, 2014.
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Top 10 Things Palliative Care Clinicians Wished Everyone Knew About Palliative Care
Strand, Jacob J, MD;Kamdar, Mihir M, MD;Carey, Elise C, MD
Mayo Clinic Proceedings; Aug 2013; 88, 8; ProQuest Central
pg. 859
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.
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Vol. 50 No. 6 December 2015
Journal of Pain and Symptom Management 741
Special Article
The Business Case for Palliative Care: Translating Research
Into Program Development in the U.S.
J. Brian Cassel, PhD, Kathleen M. Kerr, BA, Noah S. Kalman, MD, MBA, and
Thomas J. Smith, MD, FACP, FASCO, FAAHPM
Massey Cancer Center (J.B.C., N.S.K.), Virginia Commonwealth University, Richmond, Virginia; Kerr Healthcare Analytics (K.M.K.), Mill
Valley, California; and Johns Hopkins University (T.J.S.), Baltimore, Maryland, USA
Abstract
Specialist palliative care (PC) often embraces a ‘‘less is more’’ philosophy that runs counter to the revenue-centric nature of most health care financing in
the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable
clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together
form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based
PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative
payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships
that allow for greater access to and funding of community-based PC. J Pain Symptom Manage 2015;50:741e749. Ó 2015 The Authors.
Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Key Words
Palliative care, finance, health economics, payment reform, policy
Introduction
In his famous ‘‘Escape Fire’’ speech, Dr. Donald Berwick diagnosed the foundational problems with the
U.S. health care system and articulated a vision for
its transformation. He stated that for a comprehensive
solution to succeed and be broadly adopted today, it
must make sense from four distinct perspectives:
Whatever ‘‘escape fire’’ [revolutionary innovation] we
create has to make sense in the world of science and
professionalism, in the world of the patient and family,
in the world of the business and finance of health care,
and in the world of the good, kind people who do the
work of caring. I think the toughest part of this may be
in terms of the business and financing of care. There is
a tendency to assume that financial successde.g.,
thriving organizationsdand great care are mutually
exclusive. However, we will not make progress unless
and until these goals become aligned with each
other.’’1
Address correspondence to: J. Brian Cassel, PhD, 1101 E
Marshall Street, Box 980230, Richmond, VA 23298, USA.
E-mail: JBCassel@VCU.edu
Ó 2015 The Authors. Published by Elsevier Inc. on behalf of American
Academy of Hospice and Palliative Medicine. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
This is certainly true of the field of palliative care
(PC). The clinical-moral imperative that has driven
innovators and practitioners in the field is necessary
but insufficient for catalyzing and sustaining widespread investment in PC programs. Unless and until
stakeholdersdhealth system administrators, physicians, and payersdperceive a clear path to the financial viability of specialist PC programs, they will not
support fully the development of such services.2,3
Clinical leaders who have struggled for years to
garner support for PC services can attest to the
degree to which the misalignment of clinical and
financial incentives has stymied the creation and
expansion of specialist PC services. This phenomenon has been explored in at least one national study:
in a survey of cancer centers in the U.S., financial issues were the most-often perceived barrier to PC program implementation.4
Accepted for publication: July 7, 2015.
0885-3924
http://dx.doi.org/10.1016/j.jpainsymman.2015.06.013
742
Cassel et al.
The Clinical-Financial Disconnect
Why is there such misalignment between clinical
and financial interests? The U.S. health care system
is fundamentally rooted in a fee-for-service (FFS)
model, where third parties compensate providers
for each service delivered to patients. In such a system, there is a direct correlation between the quantity and intensity of health care provided and the
amount of revenues collected by systems and individual providersdmore activity (procedures, tests, and
hospitalizations) results in more revenue. In contrast,
the field of PC uses a ‘‘less is more’’ philosophy,
where attention to patient and family needs and clarification of care goals often lead to reduced use of
the most expensive health care services (such as inpatient admissions and emergency department [ED]
visits) and increased use of less expensive services
(such as home-based services).
With hospice, insurers cut through this obstacle by
offering an entirely separate benefit that is mutually
exclusive with continuation of disease-focused health
care. The business case for specialist PC outside of
hospice is more complex and more subtle, in part
because PC needs to be provided concurrently with
disease-focused therapies, rather than in the ‘‘either/
or’’ forced choice inherent in the current regulations
of the Medicare Hospice Benefit.
From the perspective of a hospital entrenched in the
FFS reimbursement model, shifting activity away from
hospital care does not make much financial sense. In a
description of the Advanced Illness Management Program developed by SutterHealth, a program leader
noted that although the intervention was successful in
increasing hospice utilization, reducing hospitalizations
and lowering costs of care, the misalignment of quality
and financial incentives posed a serious challenge:
‘‘The current reimbursement system does not pay for
Advanced Illness Management-type services, such as
care coordination and hospital-to-home transition.
Reduced hospitalizations cost Sutter hospitals more in
lost revenue than they gain from dollar savings.’’5
The goal of this article is to help insurance and hospital executives, PC leaders, and policy makers to understand the extent to which the clinical/moral and
financial imperatives for PC are actually aligned and
the congruence between positive clinical and financial
outcomes. Although numerous studies have documented the impact of PC on costs,6e9 no prior article
has presented a comprehensive assessment of the
financial or business imperative for PC and how it
could be aligned with the clinical/moral imperative.
Drawing on the published literature and our technical
assistance work with hundreds of PC programs over
the past 15 years, we articulate the 10 principles that
together create the economic rationale for specialist
Vol. 50 No. 6 December 2015
teams to provide an additional layer of support for patients (and families) facing progressive life-limiting
diseases. These principles also refer to and reflect
the increasing importance of the pay-for-quality movement that is slowing supplanting the FFS model.
The 10 Principles of the Business Case for PC
Principle 1: Persons with serious illness, especially
those with progressive life-limiting diseases [and their
families] are at risk for pain and suffering from multiple sources; PC helps prevent or improve those
outcomes.
The business case for specialist palliative care (SPC)
begins with the clinical case. Without a clinical imperative, there would be no need for a financial model;
recall that the national Medicare Hospice Benefit followed (by eight years) the founding of the first hospice in the U.S. Voluminous evidence speaks to the
extent to which patients with serious illness and their
families suffer; there is equally strong and abundant
evidence of how SPC services help to mitigate or
even prevent that suffering.10e16
Principle 2: Persons with progressive life-limiting diseases often have heavy utilization of expensive health
care services (e.g., ED visits, frequent and lengthy hospital admissions), some of which are avoidable. These
utilization patterns are often evident in the last months
of life but may occur earlier in the disease course.
The literature on this, too, has become voluminous;
three studies are worth highlighting. A recent study
showed that one-half of older Americans go to a hospital ED in the last month of life; once there, threequarters are hospitalized; and of those hospitalized,
more than two-thirds die in the hospital.17 For three
major diseases, Medicare patients are increasingly
receiving intensive care unit (ICU) care in the last
month of life, and more than one-quarter of those
dying in hospice care have received hospice for less
than three days.18 This utilization of hospital services
at the very end of life would be acceptable if such
care was aligned with patient and family preferences.
Unfortunately, this is not the case: studies continue
to show that the proportion of people who die in hospitals and nursing homes exceeds the proportion of
those who identify these sites as their preferred location of death.19 Worldwide, more than 80% of people
want to die at home.20
Principle 3: Hospitalizations toward the end of life
tend to be lengthy and costly; these can result in negative fiscal outcomes for hospitals and payers, in both
FFS and risk-based revenue models.
Published studies have documented the duration
and cost of hospitalizations near the end of life, which
Vol. 50 No. 6 December 2015
Business Case for Specialist Palliative Care
have clear implications for payers.6,7,21,22 But studies
on either hospital costs or on payer expenditures do
not in themselves describe whether the reimbursement from payers to hospitals results in positive or
negative financial outcomes for the hospitalsdare
they breaking even or experiencing positive or negative margins? One needs to know both parts of the
equation, but such results are not usually published.
To understand the magnitude of financial risk for
both payers and providers, we present below some
data from the Virginia Commonwealth University
(VCU) Health System, which contrasts hospital costs
and reimbursements (payer expenditures) across
three groups of Medicare beneficiaries: those who
died in the hospital, those with very serious illness
and high mortality risk, and all other admissions
(Fig. 1).
Reimbursement for the cases in the first two groups
(deaths and high-risk survivors) is around three times
greater than that seen in the ‘‘all other’’ group, representing the burden on Medicare; but even more striking is that Medicare’s reimbursement falls short of the
actual costs incurred by the hospital. The net loss for
hospitalizations of Medicare patients at this hospital
for that year was driven entirely by the 16% of cases
that ended in death or had high risk of deathdcases
that may be PC relevant.
Another analysis of VCU data depicts the worsening
net margin among cancer and congestive heart failure
(CHF) admissions in the six months before death
(Fig. 2). As this graph indicates, the FFS reimbursement model for inpatient care does not guarantee a
positive net margin. With the inpatient prospective
payment system that Medicare uses (and which is
emulated by many other payers), the amount of reimbursement per case is predetermined by the clinical
and utilization characteristics that are used in the
diagnosis-related group (DRG) classification system.
Within any given DRG, a hospital may have a positive
net margin if their costs are low but a negative margin
if their costs exceed the predetermined payment.
Fig. 1. Inpatient admissions of Medicare patients at Virginia
Commonwealth University hospital in Fiscal Year 2011, stratified by their disposition at discharge: deaths, survivors with
high risk of mortality, and all others. aHigh-risk survivors
defined as discharged to hospice or those with all patient
refinedediagnosis-related group risk of mortality score of 4
combined with severity of illness score of 3 or 4. bNet margin
represents revenues less total costs.
743
Hospitals may be unaware of the extent to which
end-of-life care is driving such losses; in our experience, most hospitals conduct their financial analyses
by major disease groups (e.g., cancer, cardiology,
neurological) and not in terms of disease course. As
pay-for-performance and shared savings programs
become more prevalent, financial analytics will have
to adopt this population health management
perspective.
Analyses such as these may reveal previously underappreciated financial risks for hospitals regarding the
unprofitability of near-end-of-life hospitalizations (i.e.,
those ending in death or that occur in the last few
months of life). It may be that some hospitals would
rather examine contribution margin (reimbursement
minus direct costs) rather than net margin (reimbursement minus total costs), but the principle is
the samedlong resource-intensive admissions toward
the end of life may not be generating the kind of positive net margin that hospitals see for the bulk of their
admissions. Further research is certainly warranted on
this issue of the net margin for hospitalizations near
the end of life, taking into account both hospital costs
incurred and payer expenditures.
Principle 4: Hospitals are penalized by payers,
notably the Centers for Medicare and Medicaid
Services (CMS), for high 30-day readmission rates,
30-day mortality rates, and similar measures; a significant portion of this is driven by care at the end of life.
In a major shift, CMS is now penalizing hospitals for
excessive rates of hospitalizations associated with poor
coordination of care (high readmission rates) and
poor quality (high 30-day mortality rates). Medicare
has two separate programs in effect. In the Readmission Reduction Program at issue is the rate of readmissions within 30 days for initial hospitalization for
specific conditions or procedures.23 When the program started in federal fiscal year (FFY) 2013, the penalties were as much as a 1% reduction in DRG
payments, and penalties have increased to up to 3%
for FFY 2015. It is important to note that the penalty
affects all Medicare hospitalizations for a given hospital, not just the conditions used to measure performance. The Kaiser Foundation reports that 2610
hospitals are being fined in 2014 and that 39 hospitals
are receiving the highest penalty of 3% of payments.24
In Maryland, the last state in which Medicare pays for
hospitalizations without DRGs, reimbursement is now
fixed per hospital per year so that Medicare will not
pay for any additional hospitalizations, thus having
the same effect.25
The second program is the Value-Based Purchasing
Program, which increases or reduces payments to
acute-care hospitalsdup to 1.25% currently,
increasing to a maximum of 2.0% by FFY 2017.26 An
744
Cassel et al.
$2,00,000
$1,00,000
$-
Vol. 50 No. 6 December 2015
Annual net margin by month for cancer and heart failure inpaƟent
admissions of Medicare paƟents in final 6 months of life
$1,04,660
$13,624
$4,587
$(14,745)
$(7,956)
$(17,810)
$(46,798)
$(67,749)
$(1,00,000)
$(93,668)
$(98,622)
$(2,00,000)
Cancer Annual
CHF Annual
$(3,00,000)
$(3,44,533)
$(3,73,002)
$(4,00,000)
6 mo
5 mo
4 mo
3 mo
2 mo
1 mo
Fig. 2. Virginia Commonwealth University hospital data Fiscal Year 2010 to Fiscal Year 2012. X-axis is the month before death, ascertained from inpatient deaths and by querying data from the Social Security Death Master File to identify patients who died in
other settings. The Y-axis is the net margin for this hospital (reimbursement minus total costs). CHF ¼ congestive heart failure.
overall score for a hospital is based on its performance
on process measures, outcome measures (including
30-day mortality rates for three conditions), and patient experience (satisfaction); outcome measures
recently increased to 40% of the total score. Like the
readmission program, Value-Based Purchasing affects
all acute care payments from Medicare for a given hospital, not just payments for the conditions used in the
metrics.
From a hospital finance perspective, a single end-oflife hospitalization can have all three unwanted characteristics: it can produce a negative net margin, it
can be a readmission from a prior hospitalization,
and it can be associated with death within 30 days.27
Led by CMS, the largest health care payer in the
U.S., payers are slowly shifting from paying for quantity to paying for quality; CMS has announced that by
the end of 2018, 50% of Medicare payments will be
tied to quality or value28 through alternative payment
models or value-based payments. The implications
for hospitals are clear: business as usual is beginning
to shift, opening up greater alignment between the
clinical and nonclinical outcomes for the field of
PC (although some of the metrics used by CMS to
date focus on sudden conditions such as acute
myocardial infarction for which PC is not involved).
PC has always been associated with quality and has
been shown to have a mitigating effect on overutilization of some types of health services. Indeed, many
measures of quality, such as those endorsed for
cancer end-of-life care by the National Quality
Forum,29 make an explicit link between quality and
overutilization of some types of health care services
(hospitalizations, ICU stays, and ED visits) and underutilization of other services (such as hospice and
PC). The attention that payers are giving to measures
of overutilization presents a clear opportunity to the
PC field, which can demonstrate that some of these
admissions and readmissions near death could be
avoided through better outpatient and home-based
care. This represents a different interpretation of
what kind of quality the 30-day mortality measure
purports to be monitoring.30 A high rate of 30-day
mortality for CHF admissions may not represent
poor quality of inpatient CHF care; but it could very
well represent poor quality of ambulatory CHF care
or inadequate access to early PC.
Principle 5: Community-based PC (CBPC) improves
symptoms, coordinates care, and reduces ED visits
and hospitalizations in the months before death.
Hospice care is being used very close to the time of
death,18,31 and inpatient PC can only be provided
once patients are hospitalized. Thus, there is a profound need for nonhospice PC to be provided in
the weeks and months before death, in settings
outside the inpatient hospitaldwhat is being termed
CBPC. Rabow et al.32 summarized the evidence that
CBPC reduces hospital utilization while improving
patient-reported outcomes, such as distress, symptom
management, and satisfaction with health care. Dramatic growth and interest in CBPC in the past few
years is driven by the recognition that inpatient PC
alone is insufficient and by the compelling evidence
from randomized controlled trials of home-based
Vol. 50 No. 6 December 2015
Business Case for Specialist Palliative Care
PC33 and of outpatient clinic-based PC.34 We discuss
the financial implications of CBPC in Principle 9.
Principle 6: Inpatient PC improves symptoms, coordinates care, and reduces the cost of hospital admissions
that do occur.
Numerous studies provide evidence that inpatient
PC consultation services and units improve
symptoms10e13,35 and reduce hospital costs6e9,36 in
the days after consultation, and this finding is not
limited to decedents.37 The key to understanding
the business case for inpatient PC is to understand
whose costs are saveddare hospital cost savings passed
on to payers? Largely, nodbecause of the payer mix,
payers’ reimbursement structures for inpatient care,
and the timing of PC involvement within a
hospitalization.9
 Payer mix. According to one multisite study,
the payer mix for inpatient PC is about 70% Medicare, 11% Medicaid, and less than 20% all
otherdcommercial, health maintenance organizations, preferred provider organization, Tricare,
self-pay, indigent, and so on.38
 Structure of reimbursement for the predominant payers.
Medicare and most states’ Medicaid reimbursement for hospital care is paid through DRGs or
similar per-case mechanisms.39
 Timing. Extended lengths of stay are often a
trigger for PC consultation,40,41 and several articles have described a significant proportion of
PC referrals occurring only after a week or more
of hospitalization has passed.38,42e45
Consider a scenario in which a patient was admitted
to the ICU from the ED and remained in that unit until
the PC team was consulted on hospital day 8. The PC
intervention could reduce costs in the days after consultation but could not affect the costs of procedures or
ICU use that occurred during the first eight days: and
it is very likely that the patient’s diagnosis and the
utilization that occurred in hospital days 1e8 would
determine the DRG designation and, therefore, reimbursementdthese would not be changed by a PC intervention that began on day 8. If the PC intervention
results in clarification of goals and alteration of treatment plans such that the patient is transferred out of
the ICU and into a less expensive unit, the cost savings
that the hospital sees are real, because the payment is
already fixed (set) regardless of actual costs. Conversely,
in such a scenario, cost savings would not be passed on
too payers who use a DRG-based fixed payment system
because their payment or expenditure was prospectively determined and is not linked to the details of
the services rendered.
There is some evidence that inpatient PC indirectly
helps to influence postdischarge utilization to the
745
extent that it increases access to CBPC or hospice,42,46
and such changes would reduce payer costs. Similarly,
it is possible that PC involvement early in a hospitalization could affect what procedures are done, thus
affecting the DRG assignment and payer expenditures. But overall, there is a strong incentive for hospitals, but no incentive or only a weak one for payers, to
invest in inpatient PC.
Principle 7: In the usual FFS model, third-party revenue for PC services covers only a portion of the full
cost of a multidisciplinary PC team, so subsidies or
new contractual approaches are needed.
Services that are provided to patients with progressive diseases often generate substantial clinical revenues (e.g., chemotherapy for cancer; surgery and
implanted devices for cardiac care), whereas revenues
for PC are quite modest. CMS and most commercial
plans do not offer any supplemental payments or special benefit packages to health systems for providing
PC. Specialists who can bill for their services are reimbursed at modest rates for evaluation and management visits, but such billings are typically insufficient
to cover the entirety of salary and benefit costs of
the multidisciplinary team.47 This is the case for
both inpatient and community-based services. Moreover, some core PC team membersdregistered nurses,
many hospital-based social workers, and chaplainsd
cannot bill third parties despite their central role in
providing interdisciplinary PC. The inadequacy of
clinical revenue may be exacerbated by poor billing
practices48 and/or the increasingly competitive salaries required for recruiting and retaining PC specialists. Therefore, specialist PC programs often need a
funding source other than (traditionally structured
and priced) clinical revenue to support the full costs
of their interdisciplinary teams.47
It is important that PC programs be able to describe
or project the cost of delivering care, as well as the
direct cost savings and indirect financial contributions
the program will make.43 Understanding the full cost
of the PC intervention and the full spectrum of
expected (or actual) benefits is a prerequisite to
securing program support from a health system or a
service contract from a payer. Tools are available to
help institutions estimate their costs and benefit.49,50
Principle 8: For hospitals, the combined value of
lower costs and operational impacts from inpatient
PC almost always exceed the cost of staffing the service
(positive return on investment); this would be applicable in both FFS and risk-based revenue models.
Because inpatient PC reduces costs in the context of
case-rate payments (see Principles 3 and 6), and the
relative ease with which the cost reduction can be
measured and attributed to SPC involvement,7 it is
fairly easy for inpatient PC programs to demonstrate
746
Cassel et al.
that they produce cost savings greater than the subsidies needed for the multidisciplinary team. An
example in a published article was provided by
Morrison et al.,43 in which financial impact was
estimated at greater than four times more than the investment for program personnel. Similar estimates at
VCU have resulted in a return on investment of
greater than five times the investment. All that is
required is a quantification of two thingsdcost savings
caused by SPC involvement, and the annual amount of
PC program funding that is not covered directly by
third-party reimbursement.
Principle 9: The return on investment for CBPC depends on the degree to which fiscal and quality incentives are aligned; in general, entities that are at risk for
high cost care at the end of life have the greatest
incentive to invest in CBPC.
Although the return-on-investment analyses for
inpatient PC are relatively straightforward, the issue
is a bit more complex for CBPC. As shown in Principle
5, early engagement of PC may help to prevent hospitalizations by making them unnecessarydthrough better symptom management and care coordination, for
example. From a payer perspective, the cost savings
may be real and significant, a circumstance that has fueled a number of payer-provider partnerships to
deliver CBPC.51e54
Why would a health system or hospital invest in
such a CBPC program? One scenario is that the hospital realizes that the status quo for end-of-life care is
resulting in negative net margins and that it is being
penalized for readmissions and 30-day mortality admissions; even in a traditional FFS context, that hospital may recognize that the clinical and financial
incentives for CBPC are already aligned (see Principles 3 and 5). Alignment is much more likely in hospitals that are part of alternative payment
methodologies, such as health maintenance organizations, shared savings programs, and accountable
care organizations (ACOs), in which there is a stronger and more explicit reward for minimizing overutilization of the costliest health care services.55 Indeed
the push to overcome barriers can come from health
plans, which have a strong interest in controlling
their expenditures, and providers.56e58
Although the primary purpose of CBPC is to proactively manage symptoms, prevent and alleviate distress,
and coordinate care more effectively, there is a strong
need to align these patient-centered outcomes to an entity’s financial interests to get programmatic supportd
budgetary, political, and operational. This must include
quantification of the costs and revenues associated with
reducing some forms of health care, such as hospitalizations; increased costs and revenues associated with
increasing other forms of health care (e.g., CBPC,
Vol. 50 No. 6 December 2015
home health, hospice); reductions in unwanted penalties from overutilization (e.g., 30-day morality admissions); and, where relevant, the financial rewards of
more efficient care, for example, when entities have
risk-bearing contracts, or are part of an ACO.
Health care reimbursement is a moving target. As
payers and providers continue to coevolve in the context
of their changing symbiotic relationships, we will continue
to see new structures for sharing savings and sharing risk,
which create incentives for bending the cost curve while
maintaining quality and patient-centered outcomes.
Understanding the role of CBPC in this, and quantifying
projected and actual impacts, is not a one-time event; it is a
process that must be done continually.
Principle 10: All types of health care organizations
can evaluate opportunities for and impact of PC.
Although much of the evidence cited here has come
from studies and systematic reviews conducted at academic centers, we believe that the essential pieces of
data could be analyzed by any community hospital, integrated health system, or insurer. Many of the analyses
regarding inpatient PC are well established and have
been translated to inpatient SPC programs of all sizes
nationwide through the ‘‘Palliative Care Leadership Center’’ technical assistance program, operated by the Center to Advance Palliative Care since 2004.59 Emerging
data-based approaches to planning and evaluating
CBPC programs have been made available as well.49,50
Use of These Principles
There are several ways that these principles can be
put to use. First, we would encourage researchers to
note that there are some principles for which the published empirical evidence is rather thin. Three areas
stand out: the impact of CBPC in noncancer populations; how much of a PC program’s budget is covered
by clinical revenue (in the context of third-party reimbursement); and the worsening financial margin for
hospitalizations closer to the date of death (in the
context of third-party reimbursement). An obstacle
to research on the latter two is that health systems
treat their revenue data, and their net margin, with
greater secrecy than their cost data alone. But in the
FFS environment, knowing the costs of care relative to
revenue is a key issue in understanding the sustainability of the status quo or of innovations.
Second, these principles can provide the framework for program-specific business plans. Each
component of this model can draw on institutional
dataddescribing the clinical need for new or
expanded SPC services; the potential or actual
impact of inpatient and/or community-based SPC;
the anticipated or existing gap between third-party
Vol. 50 No. 6 December 2015
Business Case for Specialist Palliative Care
revenues and the program budget; the intensity and
cost of various kinds of inpatient hospitalizations
and the use of hospital care in the months leading
up to death for various disease groups. These components can then be pulled together into a cohesive
plan that makes a compelling argument for administrators to consider. It is important for SPC leaders to
understand these principles to make their case in a
clear and internally coherent way and equally important to know where their institution stands in the
shifting health care reimbursement landscape. Is it
entrenched in the FFS model or transitioning to
the population health management and pay-forquality model? The answer will have significant implications for how much traction one can expect for
various pieces of the business case. It may be most
difficult to get traction for CBPC in an institution
that is firmly entrenched in the FFS modeldfor
example, not participating in ACOs or other payer
initiatives that would welcome more efficient
patient-centered health care.
Third, we have found repeatedly that neither researchers nor hospital administrators necessarily
believe that research findings produced at another
institution are valid and relevant at one’s own. Local
data are almost always needed to make the business
case for such programs, and then published data are
used to validate and support the local findings. However, any health system that uses this or a similar framework should recognize that producing local evidence
for some of these principles (e.g., ED visits and hospitalizations increase in frequency and cost toward the
end of life) will demand some sophisticated financial
analyses. Technical assistance materials are now available from a variety of sources including the Center
to Advance Palliative care (https://www.capc.org),
the California State University Institute for Palliative
Care (csupalliativecare.org), and the California Coalition for Compassionate Care (http://coaliti
onccc.org/tools-resources/palliative-care/).
747
Conclusions
In the U.S., health care is often performed as a set
of business transactions, and the health system is
both revenue centric and hospital centric. In that
context, the easiest innovations for providers (physicians and hospitals) to implement are those that
generate more revenue from payers than the costs
the providers incur. A special business case for PC is
necessary because the specialist teams cost more
than they produce directly in revenue, and in fact
PC involvement may reduce hospitalizations, which
are the primary source of revenue for hospitals.
The U.S. health care system may be unique in the
extent to which it applies capitalistic principles to
health care, but the development of PC is a global
phenomenon. Some of the principles are universaldsuch as the clinical imperativedwhereas others
may be uniquely relevant in the FFS context that underlies so much of the U.S. health care system.
The business case for inpatient SPC is well established and is reflected in the rapid growth of SPC programs in more than 60% of U.S. hospitals.65 The
business case for community-based SPC is emerging
and is most relevant where health systems are partnering with payers to deliver more efficient patientcentered high-quality care.
Disclosures and Acknowledgments
This work was supported in part by NCI Cancer Center Support Grant P30CA016059 to VCU Massey Cancer
Center; National Center for Advancing Translational
Science grant UL1TR000058 to VCU Center for Clinical
and Translational Research; and grants 17686 and
17373 from the California HealthCare Foundation. Funders did not play any role in the content of this article.
The authors declare no conflicts of interest.
The authors thank Diane Meier, Lynn Spragens,
Egidio Del Fabbro, Irene Higginson, and Michael
Rabow for their contributions.
Limitations
Beyond the paucity of evidence of some principles
as described earlier, the major limitation of this synthetic review is that the findings cited are largely
from nonexperimental studies and thus subject to
the weaknesses inherent in observational research,
such as the potential for selection bias.60 Researchers
using nonexperimental methods have used several
techniques including the use of an instrument variable and using propensity scores to control or select
matched comparison cases.61e64 A recent article that
used a large number of clinical and demographic
characteristics in its propensity-based matching found
a significant effect of PC involvement on cost reduction among hospitalized cancer patients.41
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