Palliative Care and Hospitals' Bottom Line

If there are such things as universal truths, then one of them is almost certainly this: nobody likes to be in pain (okay, maybe masochists). This simple assumption is the key principle behind palliative care, which focuses on reducing the severity of pain and managing symptoms of patients with advanced illness—instead of relentlessly concentrating on trying to cure a condition. As many have put it before, palliative care is about caring, not curing—helping patients feel better, sometimes through medication and sometimes through communication and personal support.

Palliative care seems like a practice that would be somewhat at odds with American-style medicine, which centers on maxing out detection efforts and treatment interventions. The reasons for this tendency are two-fold: in our warped reimbursement system, doctors get paid more to do more procedures, and our medical culture is very much focused on ‘beating’ sickness instead of treating people.

Yet palliative care has been on the upswing in American medicine over the past few years. According to the American Hospital Association, as of 2005, 30 percent of U.S. hospitals and 70 percent of hospitals with more than 250 beds had a palliative care program—an increase of 96 percent from 2000. What’s behind this surge?

One hopes that hospitals are increasingly recognizing the value of palliative care to patients. Palliative care is not just about hospice care—that is, care for the dying—though it’s a big part of helping sick patients pass on in comfort. It’s also, as Dr. Diane Meier, the Director of the Center to Advance Palliative Care and member of The Century Foundation’s Medicare Working Group, has noted, an important part of helping all people with advanced illness have a higher quality of life. If we ignore palliative care, we end up with patients who might be getting ‘treatment,’ but who are miserable and in pain during the process. “Forcing a choice between cure and comfort until the end-of-life predictably results in preventable suffering during all other stages of a serious illness,” Meier pointed out in a 2007 commentary for Medscape.

But it would be foolish to ignore the elephant in the room when it comes health care: money. In the newest Archives of Internal Medicine, Meier and a collection of co-authors from the Palliative Care Leadership Center offer another possible explanation as to why palliative care is catching on: it saves hospitals money.

Meier and co. looked at more than 5,000 palliative care patients and 20,551 patients who only received “usual care” (i.e. care focused on curing rather than caring) across eight hospitals. After controlling for age, gender, condition, and even insurance coverage within the sample group, the research team found that, for patients discharged alive, “palliative care consultation was associated with adjusted net savings in total costs of $2,642 per admission compared with usual care.” For patients who died in the hospital, “palliative care consultation was associated with adjusted net savings in total costs of $6,896 per admission and $549 per day.”  In other words: “hospital palliative care consultation teams are associated with significant hospital cost savings.”

This is important stuff, because any and all savings make a difference to hospitals. The authors point out that hospitals have a median operating margin—that is, the profit made on patient care—of just 2 percent, which breaks down to about $27-$40 per day. That’s not a lot. So why does palliative care save money? Simple: “discontinuing costly non-beneficial interventions among seriously ill patients reduces hospital costs.” In other words, consultation from palliative care teams appears to make patients and doctors think twice about undergoing costly, unproven treatments intended to “prolong life and avert death at all costs.”

It’s hard to over-estimate the importance of any sort of consultation that influences this decision-making process surrounding issues of what kind, and how much, intensive or invasive care seriously ill patients receive, particularly for end-of-life care. As the famous annual Dartmouth Atlas research project has shown again and again, spending more time and money on severely ill patients doesn’t necessarily make them healthier. In fact, regions of the U.S. that spend more on Medicare patients over the course of their last two years of life have slightly worse mortality outcomes.

Unfortunately, it’s generally difficult to get physicians to rethink the do-everything-you-can-because-you-can-do-it logic that results in bombarding patients with painful, and sometimes inhumane, care. In May, Maggie reported on a harrowing story that Meier recounted to an audience of medical students about a man who was literally tied to his bed so that doctors could install a feeding tube he didn’t want in order to ‘save’ him. A 1995 JAMA study confirms that such stubbornness amongst doctors isn’t as rare as you might hope. This study looked at 9,105 patients over two years who had life-threatening illnesses, and split the sample roughly evenly into two groups. Patients in the first group had access to a specifically trained nurse to have “multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication.” In other words, these patients had a special go-between representing their preferences and palliative care priorities to doctors. The second group did not, and received usual care. 

Unfortunately, the JAMA found that the addition of a specialized nurse didn’t make much of a difference. Patients in the first group “continue[ed] to receive low-yield, burdensome, and high-cost tests and treatments including prolonged ICU stays—a probable result of highly ingrained physician and hospital practice patterns and prevailing hospital culture.” Sadly, according to the JAMA authors, it seems that “enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices.”

It’s tough to convince doctors that they should be prioritizing palliative care—at least when it’s only a nurse and a patient discussing things. But it seems that full-on palliative care consultation—intervention by an interdisciplinary consultation team that can include any range of medical experts from fields like oncology, internal medicine, psychiatry, and other disciplines as needed—does make a difference. Maybe doctors will only listen to other doctors, or maybe there’s strength in numbers; whatever the reason, it seems that “palliative care consultation fundamentally shifts the course of care off the usual hospital pathway and in doing so, significantly reduces costs.” It looks like a lot fewer patients want to be poked, prodded, cut open, or irradiated than the medical establishment usually assumes—they just need a critical mass of experts valuing their comfort in order for these preferences to be made reality.

As palliative care becomes more common in the U.S., it will undoubtedly face many of the same difficulties that surround so many other health care issues, such as compensation and equity. As Meier told Maggie earlier this year, reimbursement for palliative care consultations is abysmally low: “When a three-person palliative care team made up of a doctor, a nurse and a psychologist spends 90 minutes in a meeting with a family, Medicare would probably pay $130 to $140—for all three people.” Just as concerning is the fact that hospice care, which is a large part of palliative care, is also unevenly distributed in the U.S.: though African-Americans make up 13 percent of the total U.S. population, the Robert Wood Johnson Foundation reports that they make up only 8 percent of hospice patients—while whites make up 83 percent of patients who receive end-of-life hospice care.

Still, whatever challenges may lie ahead for efforts to better integrate palliative care with American health care, evidence that it saves money—and helps to divert doctors from a medical methodology that has proven to be much more expensive than its benefits warrant—is an important start.

Comments

[cheap jerseys]

)Is interdisciplinary in that teams of physicians, psychologists, sociologists,theologians, ethicists and others thus delivering integrated "Holistic Care" to the dying patient

[palliative care]

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[Tim Cousounis,MDvantage Palliative Care Group]

Niko, you're right on the mark with your post about the merits of palliative medicine and its merits. I've been working professionally for more than 20 years to improve end-of-life care, and aside from a few communities and institutions, I've not yet seen the promise of palliative medicine realize its potential. Two parts accomplishment for three parts potential is how I put it. Why is this the case? Several reasons come to mind. Most prominently, I've concluded, is that health care professionals and executives are not particularly adept at spreading innovation (in the form of ideas) unless that innovation is housed in "technology". And the way that most palliative care programs are managed, and reimbursed, in this country will not lend themselves to adopting new ideas.

[Panacea]

I'm happy to see hospitals embrace palliative care. It's win-win.

I'm seeing more doctors take hospice and palliative care seriously. While I still occasionally see the doc who doesn't want to give narcs because "it might kill the patient," generally I see them as more open to comfort measures and stopping painful treatments that have no benefit.

While some docs may still need more education, so does the community. Too many people I know view hospice and palliative care as "giving up." We need to educate families that we are not giving up, merely changing the focus of care to quality of life, not its length.

Last week, one of my nursing students was caring for a dying woman. Her sats were in the 60's, so the doctor had ordered a non-rebreather mask. It was clearly irritating her, but the family kept putting it back on her. When she stopped breathing, my student went to remove the mask. Her grandson, a paramedic, started yelling at her, "She still has a pulse! She still has a pulse!" I came into the room at that point, listened to her chest, and pronounced her. Then I was able to remove the mask.

My student wondered about the grandson's behavior. I explained that, for many people, death does not come until the heart stops, regardless of what happens to the brain.

A trained hospice nurse in the hospital would have been a wonderful asset to support the family and explain the dying process.

[mike]

Great post. It's about time society started talking about these things more often.

-mike
--http://www.funeral-tips.com

[HCBerkowitz]

I'm having a battle, thankfully with mediation, with a homeopath at Citizendium. Now, I'm reasonably certain that I have some palliative care structure, if needed, but I will discuss it again with my primary physician.

The homeopath, however, made me think about it again. I made an offhand comment that if I were in end-stage disease, or rapidly developing dementia, I'd want palliative care. A palliative care team, I suspect, is more willing to comply with my instructions for no antibiotics should I develop pneumonia with end-stage dementia.

Something that gets into the loop, and hasn't been discussed here, is rather than closing one's life gracefully, is a search from quack to quack. I don't mean considering Phase I trials. I mean the false home of "cures promised".

To put it poetically, there is a difference between not going gentle into that good night, and recognizing that it's time for tbe Birkenhead Drill.

[drricklippin]

I am a huge fan of Pallitative Medicine. It mere existance has provided me some hope for the future of organized medicine in the US. I believe it is actually a model of all medical specialties for the following reasons. Palliative Medicine-

1)Recognizes the miracles of medical technology but by definition also recognizes technologies limits.

2)Is interdisciplinary in that teams of physicians, psychologists, sociologists,theologians, ethicists and others thus delivering integrated "Holistic Care" to the dying patient

3)Actively invites and involves the patient and the family in health care decisions and delivery

4)Invites a dialogue of the importance of spiritual and ethical issues in Medicine

5)Requires a discussion on confronting the limits of health care expenditures

6)Respects and promotes the concept of quality of life and death and the inherent dignity that all patients deserve during any interaction with the Health Care System at any stage in the human life cycle.

Thanks

Dr. Rick Lippin
Southampton,Pa
ralippin@aol.com