Thursday, October 1, 2009

What if palliative care doesn't save money?


15 years ago, Drs. Zeke and Linda Emanuel wrote an article in the New England Journal of Medicine titled, "The Economics of Dying - The Illusion of Cost Savings at the End of Life." They present the potential cost savings if all persons who died in a particular year executed an advance directive, chose hospice, and refused in-hospital treatment at the end of life. Savings? 3% of health care spending, max. Max. Their conclusion:
The unlikeliness of substantial savings in health care costs does not mean, however, that there are no good reasons to use advance directives, fund hospice care, and employ less aggressive life-sustaining treatments for dying patients. Respecting patients' wishes, reducing pain and suffering, and providing compassionate and dignified care at the end of life have overwhelming merit. But the hope of cutting the amount of money spent on life-sustaining interventions for the dying in order to reduce overall health care costs is probably vain. Our alternatives for achieving substantial savings seem limited to major changes in the financing and delivery of health care, difficult choices in the allocation of services, or both. Whatever we choose, we must stop deluding ourselves that advance directives and less aggressive care at the end of life will solve the financial problems of our health care system.
I am reminded of this article for two reasons. First, the vituperative reaction to proposed health care legislation that would compensate physicians for advance care planning. The argument against the legislation runs something like this, "Advance care planning is a way of saving money by killing patients. Bureaucrats in Washington want to decide who is worth saving and who should die. Don't let this happen to your grandma!" This is all utter nonsense, of course, but cleverly done. The argument plays into a suspicion that the real motivation behind hospice and palliative care is limiting or denying care and reducing end of life costs. In the years since Drs. Emanuel and Emanuel published their paper, researchers have established the cost savings of inpatient palliative care, primarily through reduced lengths of stay. This research has been misconstrued to play into the fear that the real motivation behind hospice and palliative care is to save money. Well...that's why I trained in palliative medicine. To save money. Right? Wrong. Here is an excerpt from a grant I wrote recently about my commitment to the field of palliative medicine:
During medical school my father was diagnosed with brain cancer and died. I cannot, nor would I wish to, separate the indelible impact of my father’s dying from my lasting interest in palliative care. Anecdotally, I have found that many in palliative care have been wounded in a way that shaped their choice of profession. Over the years, I have also come to appreciate the ways in which palliative care privileges me to focus on aspects of care that brought me to medicine in the first place: attention to the whole person, helping others, and constant discovery. On a daily basis, I feel honored and privileged to care for these patients and their families.
Did you spot the bit about cost savings? Nope. Admittedly, cost savings are a nice bonus. Hospitals have "bought in" to inpatient palliative care because they believe in the reduced length of stay data. The cost savings argument is responsible for the boom in hospital-based palliative care programs across the country, in contrast to geriatrics, which has yet to establish itself outside of academic centers. But cost savings have nothing to do with the core reasons why we believe in what we do.

The Emanuels' paper came up again in the context of today's palliative care journal club at UCSF, a RCT of a nurse-drive palliative care intervention published in JAMA. (Pallimed has an interesting discussion of the article). Advanced practice nurses called patients newly diagnosed with advanced cancer and coached them in goal-directed problem solving around social, communication, and symptom issues. The remarkably comprehensive handbook nurses used can be found here. Compared to usual care, the intervention arm had better scores for quality of life and mood, but no difference was found in hospital, ICU, or ED use. Costs were not measured directly, but you get the sense that this is not a cost savings intervention. You also get the sense that it wasn't terribly expensive.

Should we fund interventions like this "merely" because they improve quality of life for patients living with life-threatening illness? How about "yes." We should fund these palliative care interventions not because they will save money, much less rescue our costly health care system, but because they are fundamentally the right thing to do. The origins of hospice and palliative medicine are rooted in a desire to improve quality of life, in cherishing the value of life, "live everyday as best as you can," -- not in limiting or denying care to save money. We need to be clear about how we promote ourselves to others, before we are labled as standing for something we do not.

Time to fight for our image.

10 comments:

Chrissy Kistler said...

Amen, brother!

Ron Walent said...

In terms of the cost versus quality dilemma, I'm with you 100%, i.e., firmly planted in the importance of the quality of life camp. In the end as a society we are faced with the very real need (and thorny problem) of developing systems to pay for care as well as to provide it. We need to develop models, methods and measures that can capture the value of palliative care. This may require looking at palliative care as a family or social unit phenomenon, and evaluating the benefit to immediate family and extended social unit, as well as the individual at end of life. In the end improving quality of life is the right thing to do. Making a case for palliative care to the broader world and financial powers-that-be may require looking beyond the individual death event to benefits that accrue to a patient's remaining social network.

Christian Sinclair, MD said...

I totally agree with your post and know that many in the palliative care field have echoed the "it is not about cost savings" mantra for a long time in many different ways. I agree with your wounded clinician premise for how people find hospice and palliative care whether it be nurses, social workers or doctors.

bj miller said...

It isn't surprising, after all, that our field finds its self vulnerable, and just when we might have guessed HPM would be held up as the clear way through the healthcare debate. There is a risk of our strengths becoming weaknesses on this new center stage we've fought hard to come to. I don't think we can stay as fuzzy anymore. It's a shame we haven't taken proper time to articulate ourselves to the audience. Or, better yet, as Alex frames for us, we would do well to articulate ourselves to the community we serve (and work with, for that matter!).

Gail C said...

"Time to fight for our image"!! Congratulations on making an important point - NOW is the time to educate people. Palliative medicine is all about improving quality of life and we need to remind the world!

ken covinsky said...

Wonderfully said Alex. I think this illustrates that the discipline needs to really think about how it presents itself. The central raison d'etre for palliative care has been that it improves quality of life and reduces suffering. To the extent that it saves money, it is because it sometimes replaces care that is ineffective, bad for patients, and costly. I am not sure the public fully appreciates that some of the care given to seriously ill patients makes them worse, not better. This is the reason for avoiding such care. The dollar savings is not the motivation, but the fact that harmful care is also expensive just adds to pain. And perhaps the public needs to better understand that the palliative care that may replace other care does not come cheap. Good palliative care is highly labor intensive and requires good highly skilled providers. But it is worth paying for.

Tim Cousounis said...

The fact of the matter is that the fee-for-service reimbursement system encourages uncoordinated futile care. I don't believe it is a coincidence that many of the exemplar palliative care communities in the nation are characterized by highly intergrated medical groups whose incomes are not inextricably linked to performing more procedures. While palliative care should, of course, be promoted based upon improving quality of life, we cannot ignore the fact that there is a great deal of physician revenue generated during late-life care.

Dan Matlock said...

Great post Alex! We definitely need to manage the message. I heard a talk recently where the lecturer specifically used the words "unwanted costs" at the end-of-life meaning that if people really understood what they were getting, they wouldn't want many of these interventions (as Ken Convinsky alluded to).

James Tulsky said...

Alex - nice post! I have two thought about this. First, if this is true, are we to worry about the funding of palliative care in 5 years? Many programs (including our own) are seeing huge infusions of dollars expressly because our health systems think that we will save money and reduce readmission rates. If this doesn't pan out, will the plug be pulled and we find that we overreached?
The second point counters this. There are countries, such as Australia, where palliative care gained huge traction for reasons not related to cost savings. Now, palliative care is such a part of the landscape that it could never go away there. That is the scenario I hope we can create here. If we build it well, the public won't let it get taken away (for the reasons you articulate).

Alex Smith said...

Thanks James, appreciate the comment. I think the cost savings of inpatient palliative care are pretty clear. My major concern is with outpatient programs, like the one by Bakitas in the JAMA paper above. The financial model for outpatient palliative care is not well established. I'm hopeful that health care reform, with the increased focus on packaging inpatient and outpatient care, will result in greater attention to the potential cost savings associated with outpatient care.

That said, that's not why we should do it. Like Australia, we should do it because it's best for patients and families. This being a country that doesn't generally do the right thing unless it aligns with private interests, however, reducing admissions will probably be the mechanism that drive growth of outpatient palliative care. But it's not the best reason.