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.
The Business Case for Integrating Palliative Care into Oncology Practice (continued)
Michael Rabow, MD, Director of the Symptom Management Service at the Helen Diller Family Comprehensive Cancer Center and Professor of Clinical Medicine at UCSF explains that, “Palliative care practices must be aligned with and supported by a larger institution to be sustainable financially. Cancer centers must commit to providing palliative care to all patients who need it, as ASCO now calls for.”
According to a study published in 2010, the benefits of providing outpatient palliative care services are quantifiable for both patients and oncologists.7 In the study, patients had their symptom burden reduced by an average of 21%, according to the Edmonton Symptom Assessment System survey.Each palliative care referral saved about 170 minutes of time for the referring oncologist. This led to the oncology practice saving just over 4 weeks of time (162 hours) during the second year of having the palliative care clinic embedded into an office-based oncology practice.
This time savings meant that oncologists could focus on evaluating new patients, test results, and treatment options. Moreover, the respondents reported high levels of satisfaction with the palliative care, and the number of patients that they referred increased over time.
Embedding the palliative care practice into the oncology practice meant that the shared physical space and close contact allowed the practices to integrate efficiently. According to Dr. Rabow, benefits for offering palliative care practices affiliated with cancer practices include:
- Co-management frees up oncologists’ time from managing pain and depression and from such tasks as running family meetings.
- The positive public perception of palliative care and the ASCO consensus on the subject mean that offering palliative care may be a competitive advantage among local competitors who do not offer this state-of-the art cancer care.
- Depending on the practice and its involvement in a shared risk network, the larger institution may benefit from an expected decrease in hospitalizations and chemotherapy at the end of life.
Lynn Hill Spragens, MBA, of Spragens & Associates and of the Center to Advance Palliative Care (CAPC), says “The model of palliative care embedded in the cancer center, with co-management capability, has the following operational advantage: by utilizing existing space and support functions, overhead is minimized, and costs are limited to direct costs for team members and billing functions.”
Notably, the availability of outpatient palliative care services is not yet widespread. A survey of cancer center executives in 2010 found that less than half offered outpatient palliative care services. While 54% of National Cancer Institute (NCI) cancer centers had palliative care clinics in place, only 20% of non-NCI cancer centers had dedicated outpatient palliative care clinics.8 The executives surveyed cited financial constraints as the major obstacle to effectively delivering palliative care.
Financial and Personnel Challenges
Sustaining a palliative care program can be a financial challenge, since the current business model for palliative care is unusual.9 The current model is based on avoiding costs by reducing unwanted and unnecessary utilization, rather than on generating revenue. Successfully employing this model requires forethought about measurement methods to integrate palliative care into the operating metrics of hospitals.
“The financial case for palliative care is relevant to the bigger picture of health system costs or total costs of care,” explained Spragens. “For complex patients, adding the costs of palliative care can be more than offset by savings on admissions, emergency expenses, or redundant or ineffective tests and treatments. Programs will need to examine the alignment issues at the system level.”
The Business Case for Integrating Palliative Care into Oncology Practice (continued)
When Kaiser Permanente conducted a trial with 298 homebound, terminally ill patients randomized to usual or in-home palliative care plus usual care, the patients receiving in-home palliative care had increased patient satisfaction and reduced use of medical services and costs of medical care at the end of life.10 The patients enrolled in the palliative care group had an adjusted mean cost of $12,670 ± $12,523, while those receiving only usual care had costs of $20,222 ± $30,026. The palliative care patients had an average cost per day of $95.30, which was significantly lower than the $212.80 average daily cost for the usual care patients.
The Center to Advance Palliative Care (CAPC) indicates that $6 billion per year could be saved if palliative care was fully penetrated into the nation’s hospitals; however, providing palliative care for all the patients who would benefit is difficult due to the lack of personnel trained in palliative care. CAPC reports that there is only one palliative medicine physician for every 1,200 patients who have a serious or life-threatening illness.9 To fill the estimated demand for physicians trained in hospice and palliative medicine, an estimated 6,000-18,000 individual physicians are needed in the area.11
Spragens had several suggestions to overcome the shortage of personnel trained in palliative care. First, she said, “Think hard about roles. Often a social worker can be effective in some of the time-consuming roles and follow-up.” Further, she explained that existing professionally trained staff can build on skills by utilizing existing training such as End-of-Life Nursing Education Consortium (ELNEC) and Education in Palliative and End-of-Life Care (EPEC).
Four factors were described by Spragens as keys to sustaining outpatient palliative care programs. First, be clear about role and goals, anticipate patient use patterns and set aligned expectations, and do not attempt to fill all unmet social needs and structural supports for patients. It is critical to have good skills to collaborate to find solutions instead of taking on all problems. Second, manage to maximize patient convenience and minimize “no show” rates. Third, manage time and schedules. Finally, have reliable and effective billing functions.
Palliative care offers time savings and financial benefits, and improves patient outcomes. It must be integrated carefully into an oncology practice, but its addition will benefit the quality of life for patients and their families, along with freeing time and saving money for practicing oncologists. Palliative care provides an extra layer of support that can improve the quality of life for both patients and their families.12
- Smith TJ, Temin S, Alesi ER, et al. American Society of Clinical Oncology Provisional Clinical Opinion: The Integration of Palliative Care Into Standard Oncology Care. J Clin Oncol. 2012;30(8):880-887.
- Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
- Greer J, McMahon P, Tramontano A, et al. Effect of early palliative care on health care costs in patients with metastatic NSCLC. J Clin Oncol. 2012;30(suppl; abstr 6004).
- Smith TJ, Hillner BE. Bending the cost curve in cancer care. N Engl J Med. 2011;364(21):2060-2065.
- Kamal AH, Bull J, Kavalieratos D, Taylor DH, Jr., Downey W, Abernethy AP. Palliative care needs of patients with cancer living in the community. J Oncol Pract. 2011;7(6):382-388.
- Rabow MW, Smith AK, Braun JL, Weissman DE. Outpatient palliative care practices. Arch Intern Med. 2010;170(7):654-655.
- Muir JC, Daly F, Davis MS, et al. Integrating palliative care into the outpatient, private practice oncology setting. J Pain Symptom Manage. 2010;40(1):126-135.
- Hui D, Elsayem A, De la Cruz M, et al. Availability and integration of palliative care at US cancer centers. JAMA. 2010;303(11):1054-1061.
- Center to Advance Palliative Care. Report Card: America’s Care of Serious Illness. 2011. http://reportcard-live.capc.stackop.com/pdf/state-by-state-report-card.pdf. Accessed June 5, 2012.
- Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J Am Geriatr Soc. 2007;55(7):993-1000.
- Lupu D, American Academy of H, Palliative Medicine Workforce Task F. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
- Kirch RA, Brawley O. Palliative Care: A Lifeline to Quality of Life. J Oncol Practice. 2012;8(2):128-129.