The Case for Palliative Care

"What turns out to be a better patient experience and a better family experience can end up having a positive outcome both from a public policy point of view in healthcare expenditures as well as from a hospital's bottom-line point of view," Nicholson says.

Dollars and cents
Massachusetts General's parent system, Partners Healthcare, is one of a growing number of large healthcare systems that have implemented palliative medicine systemwide. But the need for palliative medicine isn't restricted to large systems. "I think every single hospital has a population that's appropriate for consideration for palliative care," Nicholson says.

Currently, 30% of all hospitals—and 70% of hospitals with more than 200 beds—offer some type of palliative care, according to the Center to Advance Palliative Care. The main obstacle to adding a palliative care program is reimbursement—or lack thereof. Medicare and private insurance don't yet reimburse for all palliative care services, Byock explains. However, physician and advanced practice nurses are covered, and, at Dartmouth-Hitchcock (as with most organizations offering palliative care), nonreimbursable costs like chaplaincy, social work, and specialized therapy are supported by philanthropy and hospital overhead.

"A good palliative care program can recoup a substantial fraction of its salary costs just on billing if it's billing accurately for the level of complexity of the cases," Meier says.

Palliative care proponents say the financial benefits of such a program far outweigh the costs. "It's true that CEOs and CFOs have almost a parade of people coming to them saying our new program saves you money, but the fact is that ours really does," Byock says.

To support this, the Center to Advance Palliative Care's Web site provides an impact calculator to help leaders estimate costs saved and incurred. By entering length of stay, cost, and occupancy data, organizations can estimate the volume and financial impact of adding a palliative care program.

Although the resources needed to support a palliative care program vary greatly depending on hospital size and patient mix, most programs require the same basic components.

1. Good leadership: "The major barrier to the establishment of palliative care programs in hospitals is the slow rate of production of palliative care leaders," says Diane Meier, director of the Center to Advance Palliative Care. Because palliative care is a newer specialty (the American Board of Medical Specialties recognized it as a subspecialty in 2006), there are only about 60 postgraduate training programs in the country. Senior leaders should look at their own physician and nurse staff to determine whether someone has the commitment, interest, and leadership capacity to head a palliative care program, she says.

2. 24-7 staffing: Regardless of a palliative care program's size, it must include coverage for weekends, vacations, and out-of-office events. So for a program with three full-time people, the staffing need might be more like 4.5 full-time employees, Meier says.

3. Dedicated office space. Palliative medicine typically requires a different level of activity and furnishings than other areas of the hospital because more emphasis is put on team meetings and family activities, says Massachusetts General Hospital's Britain Nicholson, MD.

4. Administrative support: Organizations need some level of secretarial support to oversee their palliative care program, as well as financial expertise to bill appropriately for services and run data on the impact of service, Nicholson says.