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A Fresh Look at End-of-Life Care

Joe Cantlupe, for HealthLeaders Media, September 16, 2013

"The cost of healthcare in the country is bankrupting the country, and we've got to get our minds around the cost of care," says Chris Van Gorder, FACHE, president and CEO of the 1,323-bed Scripps Health in San Diego. "We need to manage costs much more effectively. The question we always have is, 'Is what we are doing at the end of life the most appropriate thing to do, and the most compassionate thing to do?'

"From an economic and clinical standpoint, the most money spent is in the first five years of life and the last five years of life," Van Gorder adds. Expenses also mount with overtreatment, readmission, and unusually extensive lengths of stay, he says.

End-of-life care also is widely variable in terms of cost. A Dartmouth Atlas study of nearly 3,000 hospitals found significant differences in spending on patients who died between 2001 and 2005 after receiving care. While the Mayo Clinic had the lowest cost at $53,432 per patient, UCLA and New York University had costs of between $90,000 and $100,000. High cost centers also had greater lengths of stay and more procedures, such as doctor visits and consultations.

Although palliative care is seen as cost-effective, the benefit derives not from how much a healthcare institution generates in revenues, but from how it avoids expenses, Van Gorder says. Reimbursements are lagging in palliative care, prompting hospitals to be innovative with their programs, such as taking steps to team up with hospice programs or nursing facilities to curtail costs and reduce 30-day readmissions.

Care alternatives

To alleviate the most heart-wrenching and costly aspects of end-of-life care, healthcare executives are increasingly implementing palliative and hospice care programs for chronically ill patients or those nearing death. Palliative care has been shown to both extend life for patients and reduce healthcare expenses. Palliative care programs focus on the chronically—but not necessarily terminally—ill.

Such efforts are growing in popularity as hospitals form multidisciplinary teams who work to care for patients to relieve the suffering, pain, depression, and stress that often accompany chronic illness. Those teams include physicians, nurses, psychologists, spiritual counselors, and social workers. Unlike palliative care, hospice care is focused on improving quality of life for terminally ill patients with a prognosis of less than six months to live.

As many as 90% of major hospitals with more than 300 beds have palliative care programs, says R. Sean Morrison, MD, director of the Hertzberg Palliative Care Institute at the 1,171-bed Mount Sinai Hospital in New York City and director of the National Palliative Care Research Center.

Morrison is a longtime advocate of palliative care and has been one of the most prolific researchers into its impact on healthcare. He has focused on studies of the economic impact of patients facing serious illnesses that he says account for a disproportionately large share of Medicare spending.

In one of his most significant studies, Morrison examined four New York hospitals between 2004 and 2007 and found that the average patient who received palliative care incurred $6,900 less in hospital costs during a given admission than a matched group of patients who received usual care. The reduced costs included $4,098 less in hospital expenses per admission for patients discharged alive compared to non-palliative care, and $7,563 less for patients in palliative care who died in the hospital.

"Every study has shown people survive long or longer when they receive palliative care. It doesn't shorten life; it extends life," Morrison says. "By matching patient goals to treatment and essentially ensuring patient-centered care, we eliminate misutilization and waste."

The number of palliative care programs in American hospitals has grown substantially over the past decade, according to an analysis by the Center to Advance Palliative Care, which advocates more palliative care programs. Between 2000 and 2008, the number of palliative care programs in hospitals with 50 or more beds increased from 658 to 1,486, for a total increase of 125.8%, the center reports.

For hospitals, palliative care is relatively inexpensive, has a relatively low start-up investment, and has increasing ROI potential because of anticipation that more patients—the elderly and those with chronic conditions—may be suited to such care, the CAPC states. Such programs can have an immediate impact on overall resource usage, including ICU utilization, when patients in palliative care decide to steer away from expensive procedures, according to the center.

Program development

While the trend for such programs clearly is underway, there still is confusion among physicians, hospital leaders, and patients as they struggle to define exactly what palliative care and hospice care is. Some complain bluntly that there are physicians who don't know the difference and have made little attempt to understand the meaning behind the terms. Some healthcare leaders are describing their elevated care for the chronically ill and dying patients as "advance care planning," which is an emphasis on improved coordination including involvement of the patient and his or her family.

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1 comments on "A Fresh Look at End-of-Life Care"


Carol J. Eblen (9/20/2013 at 8:32 PM)
In 1991, The Congress, at the request Of Medicare, passed the Patient Self Determination Act (PSDA) which together with the 1986 Hospice/Palliative Entitlement, was intended to solve or stem the problems of overtreatment of the elderly that produced the fiscal problem of expensive end-of-life care in the nation's ICUs and CCUs that was covered by Medicare and private insurance. Elderly patients might spend weeks in ICU and finally die [INVALID]or survive to go home, or to a nursing home [INVALID]-and then return to ICU to die in the last year of their lives. It was envisioned that The PSDA would permit elderly patients to elect to shorten their lives to shorten their suffering, even if the refused life-saving or life-extending treatments weren't deemed "medically futile" by the physician/hospital. Unfortunately, the AMA lobbied against physicians/clinics being placed under the mandate of the 1991 PSDA. While Congress and Medicare [INVALID]d two distinct standards of care that would be reimbursed by Medicare/Hospice, the physicians (primarily the specialists) didn't want the legal burden and expense of SEEKING INFORMED CONSENT from their elderly patients for one standard of care as opposed to the other. Because the for-profit incorporated clinics and physicians' specialist practices were not covered under the PSDA, and because clinics/physicians (the specialists) were reimbursed up to the Diagnosis Group Cap for treatment of life threatening cancers/diseases no matter the age and co-morbidities of the elderly patients (because of the Age Discrimination Statute) they had/have no incentive or legal duty to discuss the other legal standard of care [INVALID]d and reimbursed by Medicare, i.e. Hospice/palliative care, with their elderly patients with life threatening diseases/cancers. (In the past few years, some of the states have passed new laws that do impose a legal obligation on the physicians to inform their elderly (and all) patients about Palliative Care/transition to Hospice. Unfortunately, there has been no clarification of the PSDA at the federal level, even though there has been much "noise" and a few proposed bills concerning end-of-life conversations and treatments. In this age of specialization, the Primary Physicians, in keeping with their oaths, refer their very ill and threatened patients to specialists. The primary physicians didn't think it was their responsibility to talk to the specialists' patients about the two different standards of care. Elderly patients on Tricare-for-Life and other Insurance can self-refer to specialists, etc., and bypass their primary physicians. When both the specialist and the primary physician rejected any responsibility to have these end-of-life conversations, the Acute Care Hospitals then were put in the position of promoting hospitalists/palliative care teams, etc. who would consult within the hospital with inpatients with life-threatening diseases about end-of-life choices and the two standards of care. Even this, however, was not terribly successful because physicians were still over treating with chemo and radiation in the outpatient setting. Patients were not referred to palliative care/transition to Hospice in a timely manner and were often unaware that the treatment they were getting was merely palliative and that, in reality, there was no chance of cure. (We see lately that the Department of Justice is moving against Oncologists who have been over treating for profit) Palliative care which has become a board certified specialty (outside of pain clinics) since the 1991 PSDA was passed into law is practiced within the hospital inpatient setting. The hospitals have to contribute as much as 50% (more or less) of the operating expenses of in-house palliative teams and do so with the view that the palliative teams will refer more patients to Hospice earlier in the course of their diseases/cancers. It was envisioned that the Palliative Teams within hospitals would produce earlier voluntary entrance by patients into Hospice but, of course, the requirement of physician certification of 6 months or less to live worked against this vision. NOW, we see that a TRIAL is planned by Medicare wherein elderly/disabled and all patients will be entitled to be on BOTH the Medicare and the Hospice entitlement at the same time. With Obama Care, over treatment of the elderly/disabled on Medicare/Medicaid will be a problem of the past because already and for the past ten years or more, under both political parties, CMS and its private partners in BIG Insurance have NOT been reimbursing physicians/hospitals for over treatment, mistake, error, and the complications thereof, and the hospitals have had to eat these costs. This has produced a very hostile environment for the elderly/disabled who have exceeded DRG caps or who are the victims of over treatment, or mistakes/errors, and the complications thereof. Unilateral DNRs are being misused to shorten the lives of elderly patients without their informed consent when Hospitals/physicians KNOW that there will be no further reimbursement from CMS and the private insurers. It appears, however, that the solution [INVALID]-if Hospice Care, after the trials, will no longer be a separate entitlement where curative care is abandoned and merely part of Medicare, etc. [INVALID]-that the specialists will still not have to SEEK informed consent from elderly Medicare/Medicaid patients for curative treatment, as opposed to doing nothing and accepting palliative care and transition to Hospice. What do you think?