The Affordable Care Act was designed to address healthcare spending by eliminating waste and focusing on value. But Obamacare did little to impact one of our major healthcare cost drivers: disproportionate spending on the care of dying patients. Often this involves applying curative approaches to incurable conditions without regard to the patient's dignity or emotional and social needs.
With 30 percent of Medicare dollars being spent during the last 12 months of life, doesn't it make more dollars and sense to rethink how we are spending our limited resources?
The concept of palliative care not only saves healthcare dollars, it also has a tremendous impact on patients' well-being. A 2010 study in The New England Journal of Medicine reveals that lung cancer patients receiving early palliative care experienced less depression, increased quality of life and survived 2.7 months longer than those receiving standard oncologic care. However, research programs, palliative care fellowships and mandatory rotations for oncology fellows are still uncommon.
Curative medicine versus comfort and quality of life: that is the question. And palliative care may hold the answer.
When you read the words "palliative care," what comes to mind? Instead of thinking of an area of healthcare that focuses on relieving and preventing the suffering of patients, most people immediately think of the hospice care concept.
First, let's understand the basics of hospice care, which in turn will help us better understand the concepts of palliative medicine.
Hospice care is a type and philosophy of care that focuses terminally ill patients' pain and symptoms as well as attending to their emotional and spiritual needs. The modern concept of hospice includes palliative (symptom-relief) care for the incurably ill. Hospice care is delivered in hospitals and nursing homes and is also provided to those who would rather spend their last months and days of life in their own homes.
The biggest difference between hospice and palliative care is the patient: where they are in their illness related to prognosis and their goals/wishes regarding curative treatment. While hospice care is reserved for people with life-limiting illness, palliative care services can be offered to any patient without restriction as to disease or prognosis. It may be appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time or to experience disease progression.
Another key difference between the two: hospice care is covered by most insurance plans while palliative care is not. For example, the Medicare Hospice Benefit (MHB) requires that two physicians certify that a patient has less than six months to live if the disease follows its usual course. (However, this does not mean that if a patient is still living after six months he or she will be discharged from hospice.) Under MHB, a patient signs off their Medicare Part B (acute hospital benefit) and enrolls in hospice through Medicare Part B. From that point on, direct care is provided by a Medicare-certified hospice agency.
Under terms of the MHB, the hospice agency is responsible for the plan of care and may not bill the patient for services. The hospice agency, together with the patient's primary care physician, is responsible for determining the plan of care. All costs related to the terminal illness are paid from a per diem rate that the hospice agency receives from Medicare. This per diem rate includes all drugs and equipment, nursing, social service, chaplain visits and other services deemed appropriate by the hospice agency.
So now let's take a closer look at palliative care, whose name comes from the Latin word palliare (to cloak). Palliative care is appropriate for patients of any age and in all disease stages, including those undergoing treatment for curable illnesses, those living with chronic diseases and those who are nearing the end of life.
Palliative medicine utilizes a multidisciplinary team approach to patient care to improve the quality of life of the patients and their families. Relying on input from physicians, pharmacists, nurses, chaplains, social workers, psychologists and other allied health professionals, a plan of care is formulated to relieve anxiety and suffering in all areas of a patient's life. This multidisciplinary team approach allows the palliative care team to address physical, emotional, spiritual and social concerns that arise with advanced illness.
Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease or cause. Palliative care focuses on symptoms such as pain, shortness of breath, fatigue, constipation, nausea, loss of appetite, difficulty sleeping and depression. It also helps patients gain the strength to carry on with daily life and tolerate medical treatments. In addition, it helps them to have more control over their care by improving communication so that they can better understand their choices for treatment.
Palliative care is a relatively new medical specialty that has recently emerged. Traditionally, most physicians have concentrated on trying to cure patients. By contrast, palliative care focuses on improving life and providing comfort to people of all ages who have serious, chronic and life-threatening illnesses. These diseases may include cancer, congestive heart failure, kidney failure, chronic obstructive pulmonary disease, HIV/AIDS and Alzheimer's disease, among others. "It's the whole spectrum, really," said Joseph Chan, MD, a palliative care physician, in a 2011 interview with WebMD.
Medical education is also catching on to the palliative care concept. "The vast majorities of America's medical schools have palliative care programs and are teaching medical students and residents about palliative care. That didn't occur 10 years ago. There was literally no education occurring on the topic," said Diane Meier, MD, director of the Center to Advance Palliative Care, in the same WebMD interview.
Over the past twenty years, focus on patients' quality of life has increased. According to Dr. Meier, there are now more than 1,400 hospital palliative care programs in the United States. About 80 percent of hospitals with more than 300 beds offer palliative care. And among hospitals with more than 50 beds, about 55 percent have programs.
So how can hospitals get involved? In building a palliative care program, the following should be taking into consideration:
- Indications for palliative care
- Provision of services
- Who will be involved
- Sources of funding
- Education/acceptance of a palliative care concept.
UPMC and Mayo Clinic have developed palliative care program best practices that can be accessed from their websites, and the Center to Advance Palliative Care offers a comprehensive starter tool kit.
In building a palliative are program, funding (or lack thereof) is often the most difficult aspect. In the United States, palliative care services are paid for by philanthropy, fee-for service arrangements or from direct hospital support (unlike hospice care, which is covered by Medicare, Medicaid and most private health insurers). The Center to Advance Palliative Care is a good resource for hospitals that want to learn more about funding options.
Acceptance is another frequent stumbling block to palliative care. Physicians practicing non-curative medicine do not always receive support from patients, family members, healthcare professionals or their social peers for their work to reduce suffering and follow patients' wishes for end-of-life care. Physician education is therefore a key part of any program.
Finally, acceptance by patients and families is another vital piece of the puzzle. This means education about the purpose and benefits of palliative care. It also means keeping the patient and family informed so that they can be active participants in the plan of care. Understanding and accepting the prognosis early on is the key, because patients generally get the most benefit from palliative care when they enter the program early.