La Jolla National University Palliative Care Presentation

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  • Strand JJ, et al: Top 10 Things Palliative Care Clinicians Wished Everyone Knew about Palliative Care – PDF Document (1.08 MB)
  • Boersma I, et al: Palliative care and neurology – PDF Document (265.5 KB)
  • Cassel JB, et al: The Business Case for Palliative Care: Translating Research into Program Development in the U.S. – PDF Document (418.7 KB)
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  • Key concepts in palliative care delivery
  • Appropriate utilization of palliative care
  • Utilization of palliative care in the treatment of neurology patients
  • Compare and contrast palliative care and hospice care
  • The business case for palliative care VIEWS & REVIEWS
    Palliative care and neurology
    Time for a paradigm shift
    Isabel Boersma, MS
    Janis Miyasaki, MEd,
    Jean Kutner, MD, MSPH
    Benzi Kluger, MD, MS
    Correspondence to
    Dr. Kluger:
    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®
    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
    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 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
    Hospice guidelines for neurologic disorderse18
    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
    Neurology 83
    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.
    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
    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
    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.
    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
    Neurology 83
    August 5, 2014
    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
    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
    Neurology 83
    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).
    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
    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
    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.
    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
    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.
    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.
    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.
    The authors report no disclosures relevant to the manuscript. Go to for full disclosures.
    Received January 31, 2014. Accepted in final form April 27, 2014.
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    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.
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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
    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 (
    Key Words
    Palliative care, finance, health economics, payment reform, policy
    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
    Address correspondence to: J. Brian Cassel, PhD, 1101 E
    Marshall Street, Box 980230, Richmond, VA 23298, USA.
    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 (
    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.
    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
    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.
    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
    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
    Cassel et al.
    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
    Cancer Annual
    CHF Annual
    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
    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
     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
    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
    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 (,
    the California State University Institute for Palliative
    Care (, and the California Coalition for Compassionate Care (http://coaliti
    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.
    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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