Saving Money while Helping Patients: Palliative Care Teams in Hospitals

With nearly one-third of US healthcare spending going to hospital care, it's natural that people would be looking for ways to trim spending on hospital services. A new study just published in the journal Health Affairs reports that seriously ill hospital patients receiving consultations from palliative care teams can incur lower costs. For this study's population - Medicaid patients facing serious or life-threatening illnesses admitted to four New York State hospitals - the authors found that patients who received palliative care consultations incurred costs that averaged $6,900 less than those for comparable patients receiving usual care. Wider use of these teams could be good for payers and for patients, who can receive help with pain and related quality-of-life issues.

Here's the description from R. Sean Morrison and his coauthors of what palliative care is and how palliative care teams work (references omitted):

Palliative care aims to relieve suffering and improve quality of life for patients with advanced illness and for their families. It does so through assessing and treating pain and other symptoms; communicating about care goals and providing support for complex medical decision making; providing practical, spiritual, and psychosocial support; coordinating care; and offering bereavement services.

Palliative care is provided in conjunction with all other appropriate medical treatments, including curative and life-prolonging therapies. It is optimally delivered through an interdisciplinary team consisting of appropriately trained physicians, nurses, and social workers, with support and contributions from other professionals as indicated.

... Although palliative care can be delivered by specialists through a range of clinical models, the predominant delivery model in the United States (outside of hospice) is the hospital palliative care consultation team. Palliative care consultation, like other specialist consultation, is typically initiated at the request of the treating physician. Consultation teams communicate their recommendations back to the referring physician for implementation. Additionally, palliative teams focus on clarifying diagnoses and treatment options, helping patients and family members identify goals of care, and helping them select--in conjunction with their treating physicians--the treatments and hospital discharge options that meet those goals.

Palliative care isn't just for dying patients, although patients nearing the end of life can benefit greatly from palliative care consultations. As one of the study's authors, Diane E. Meier, explains in a book chapter about palliative care, "In hospitalized and seriously ill patients, pain has been associated with increased length of stay, longer recovery time, and poorer patient outcomes, all of which have implications for health care quality and cost." It seems likely that palliative-care team members' assistance with communications and decisionmaking support might also help reduce patients' stress, which could also interfere with recovery.

For this study, Morrison et al focused on adult patients with Medicaid as their sole insurer who had been diagnosed with at least one of these conditions, which researchers and clinicians generally consider appropriate for palliative care:

metastatic solid tumor malignancies; central nervous system malignancies; metastatic melanoma; locally advanced head and neck cancer; locally advanced pancreatic cancer; HIV/AIDS (with at least one of the following secondary diagnoses: hepatoma, cirrhosis, cachexia, lymphoma, or other cancer); congestive heart failure or chronic obstructive pulmonary disease, with either two or more hospitalizations in any six months of the study period or one or more intensive care unit admissions during the study period; and advanced liver disease with evidence of cirrhosis. Also included were people who had been in an intensive care unit for more than five days, regardless of diagnosis.

All of the subjects had been admitted to one of four urban New York State hospitals - a community hospital, two academic medical centers, and a safety-net hospital located in one large and two midsize cities. Each hospital had an interdisciplinary palliative care team that had existed for more than five years; each team included at least one physician and one nurse practitioner, and three of the four included social workers. The sample included 1,717 patients who were discharged from the hospital alive and 495 who died while hospitalized.

Using hospital administrative data, the researchers used propensity scores to match patients receiving palliative care consultations with patients receiving usual care, and compared hospital costs for the two groups. They found that among patients who were discharged alive, those receiving palliative care consultations incurred an average of $4,098 less in hospital costs per admission than those receiving usual care; for those who died in the hospital, the difference was $7,563. Among the patients discharged alive, those receiving consultations had lower intensive-care costs; among patients who died in the hospital, those receiving consultations spent fewer days in intensive care and had lower average pharmacy costs.

The authors note that previous studies on palliative care consultations have found that palliative care can improve quality of life for patients and reduce hospital costs, but these studies have not focused specifically on patients enrolled in Medicaid. They point out that state Medicaid programs are facing budget cuts at the same time they are projecting a jump in enrollment due to the Affordable Care Act, so interventions that can reduce Medicaid costs are especially important right now. (In 2014, Medicaid eligibility will be extended to those earning less than 133% of the federal poverty level; states will receive 100% federal funding for this expanded coverage for three years, and the federal share will then decline to 90% in subsequent years.)

One thing I'm curious about is why the researchers were able to find so many patients who didn't get palliative care consultations at hospitals that had well-established palliative care teams. Among the patients discharged alive, 1,427 received usual care and just 290 got palliative care.

The authors note that hospital recognition of palliative care's benefits has led to growth in the number of US hospitals with palliative care programs - fewer than 10% of American Hospital Association member hospitals reported having them in 2000, and that number climbed to 60% in 2010. Evidently, though, having a palliative care program doesn't mean that every patient with a disease considered appropriate for palliative care will receive a consultation. In some cases, physicians might not be referring these patients for consultations; in others, patients might be offered consultations but refuse them. It appears that expanding the use of palliative care for seriously ill hospital patients - an intervention that can improve patients' quality of life while saving money - will require establishing more hospital palliative care programs and encouraging them to be used more consistently.

Morrison RS, Dietrich J, Ladwig S, Quill T, Sacco J, Tangeman J, Meier DE. Palliative care consultation teams cut hospital costs for medicaid beneficiaries. Health Aff (Millwood). 2011 Mar;30(3):454-63.