The Business Case for Integrating Palliative Care into Oncology Practice
By Kathy Boltz, PhD
Oncology treatments are increasingly becoming outpatient-based, yet patients have unmet needs in managing the symptom burden, pain, and stress that they experience. Today, a model is emerging that provides palliative care throughout the trajectory of any cancer that is metastatic or has high symptom burden. This type of palliative care emphasizes medically appropriate goal setting, communication with patients and their families that is honest and open, and assessing and controlling symptoms meticulously.
Defining Palliative Care Today
The American Society for Clinical Oncology (ASCO) recently published a provisional clinical opinion that defines palliative care as being “focused on the relief of suffering, throughout the course of a patient’s illness.”1 Though palliative care is often misconstrued as being the same as end-of-life care, ASCO suggests combining standard oncology care with palliative care early in the course of illness for any patient with a serious illness. The opinion notes that, while more evidence on the optimal delivery of palliative care is needed, no trials to date have found excessive costs or harm to patients or caregivers from the early involvement of palliative care.
The arguments for palliative care are many. A compelling study published in 2010 found that early palliative care for patients with metastatic non-small cell lung cancer improved quality of life and reduced depressive symptoms compared with patients receiving standard care.2 Further, the median survival of the patients receiving palliative care was 2.7 months longer than those receiving standard therapy, despite fewer of the palliative care patients receiving aggressive end-of-life care.
A recent follow-up study found that the patients who received early palliative care had a mean cost savings of $2,282 in total health care expenditures in the final month of life compared with the standard care group.3 Most of the difference was accounted for by reduced costs for hospitalizations (mean of $3,110/patient) and chemotherapy administration (mean of $640/patient), though the patients receiving early palliative care did have longer lengths of hospice stays and higher hospice costs (mean of $1,125/patient).3
Better integration of palliative care has been identified in an editorial in the New England Journal of Medicine as a key change to bend the cancer-cost curve downward.4 The current trend of increasing costs for cancer care are not sustainable and some medical oncologists are considering changing practice attitudes to integrate palliative care, which will help decrease cancer care costs while also improving patient outcomes.
Moving the discussion of palliative care away from the misunderstandings and debates regarding “death panels” is supported by evidence that shows palliative care gives patients equivalent or improved survival and improved satisfaction, while reducing costs. The NEJM editorial argues that combining usual care with palliative care will improve both quality and quantity of life, while yielding meaningful cost savings.
Outpatient Palliative Care
To meet ASCO’s goal of providing palliative care for patients with metastatic cancer or high symptom burdens, the care will need to be integrated into the outpatient clinic, since most oncology care is provided on an outpatient basis, and the increasing numbers of patients with cancer as a chronic condition is leading to more patients in community settings needing palliative care.5
Most outpatient palliative care practices are associated with cancer practices and are generally small in scope, seeing about 500 patients each year.6 The staffing models for these practices are varied, but often include physicians and advanced practice nurses. The support for these practices comes primarily through an even mix of billing revenues and institutional support.