The first Duke Margolis team that I started working with just had one of our big projects get published in the Journal of Pain and Symptom Management.** We examined a demonstration project in Western North Carolina that attempted to offer pre-hospice palliative care to individuals outside of the typical end of life spectrum. Our big finding is that control groups are awesome especially when the patient population is extremely morbid as propensity matching techniques don’t work well on a population that is inherently outliers. But that is not the point I want to expand on.
We need to talk about cost attribution and the need for clarity about savings as we stated in this paragraph:
Despite widely cited studies supporting the cost-saving potential of palliative care literature, the inability to consistently detect cost savings in the post period in this demonstration may be explained by both Medicare payment mechanisms and the inability to identify a credible comparison group.11, 12 Hospital internal cost information has demonstrated that some aggressive therapies and associated costs can be avoided via palliative care; however, for hospital care, Medicare often pays a prospective amount based on diagnosis. As a result, any savings in cost reduction accrue to the institution, not to Medicare. As alternative payment models proliferate, the studies intending to detect cost savings of palliative care will be less fruitful because reimbursement is increasingly disconnected from resource use in value based payment models.
Monetary savings can be seen from two perspectives; total payer (CMS) perspective for Medicare and clinician/provider perspective. When we operated on a pure fee for service model, these two things were mostly linked. Fewer services produced fewer billing opportunities which produced fewer total payer costs. A service provider would be profitable if they could offer an incremental service at below reimbursement. If the service provider had a great ability to negotiate a good deal on a saline bag, they made money by offering one more saline bag to the patient.
Hospital care for Medicare is mostly driven by the perspective payment system where CMS cuts a hospital a check that is determined by the diagnosis codes and a few other claims based attributes for that particular hospital. The hospital gets a big chunk of money to care care of a patient and if they can spend less money than the chunk, the hospital profits while the hospital loses money if they spend above the chunk of care. This is a long standing bundle. Hospice payments have always been per-diem rates with a 2016 change altering early care and the last week of life payment levels.
Studies can look at total costs and potential savings of early palliative care from multiple perspectives. If an individual enters the hospital for an inpatient stay, there is very little savings that CMS and broader society will accrue from palliative care. CMS saves money if palliative care prevents an inpatient admission but conditional on an admission, there is very little juice for CMS to squeeze. Conditional on an admission, the hospital can control costs and pocket the difference. A palliative care intervention that leads to the patient and/or their family deciding to not engage in last ditch/low hope/high cost interventions will save the hospital money without changing what CMS pays.
This is important as studies that claim large care savings from a palliative care intervention can come from either perspective. There is way more potential swingable costs from the provider perspective in any given episode than from the CMS perspective. Both perspectives are asking valid questions but they are asking and answering different questions.
As we move towards even more bundled payments, and population capitated payments and/or global budget models that disconnect the payment from service intensity, we just need to be even more aware of exactly what question and from which perspective cost savings or increases are being viewed from.
** https://doi.org/10.1016/j.jpainsymman.2019.06.019 Taylor et al. 2019
Zinsky
I hope that any honest evaluation of the alternative modes of palliative care for terminally ill patients includes cannabis and cannabis concentrates.
David Anderson
@Zinsky: That can be a viable research question. It is not the project that we assessed.
Ella in New Mexico
I did a 50hr Palliative Care rotation with a really great non-profit hospital system in Albuquerque for my Family NP degree at UNM. My program also really emphasizes Palliative Care concepts throughout our coursework, particularly in Geriatrics and in our complex chronic conditions patients.
I think Palliative Care is the future for chronic, debilitating and life limiting conditions. People we saw included all kinds of diagnoses, from end-stage (but not meeting the qualifications to move to Hospice Care) COPD, CHF, Renal Disease, advanced, painful degenerative joint disease. We individualized treatment plans to limit unnecessary or non-beneficial medical tests, procedures and hospital admissions, taking into consideration the patient’s personal choices about how they wanted to function and their life expectancy.
We used a Palliative Care Team approach for both in and outpatients that included specially trained MD’s, NP’s, RN’s, Case Managers, Clergy, and home health services, as well as novel pain management, Physical/Occupation/Speech therapists and and home health services. We often sent NP’s to the patient’s homes for checkups, and could order limited blood or x-ray tests to be done there.
Maybe we’re having trouble showing Palliative Care to be “cost effective” because of a couple of issues.
One, as long as it’s been a thing, Palliative Care is still not fully developed in this country as a consistent, cohesive type of health care with standardized services offered for predictable reimbursements. The best programs are often like the one I worked in–run by patient centered non-profit or public institutions who care more about outcomes and reducing hospital admissions. Too many other, profit-making hospitals and home health services are calling the stuff they do “Palliative Care” without providing the comprehensive services needed to fully maximize the benefit of this approach. They can’t do the full “spectrum” of care, people drop out or don’t follow up aand so they get fewer positive outcomes including increased in-patient admission costs.
We–the health care profession– also confuse Palliative Care with Hospice care, so we get fewer referrals for the very type of patient that would benefit and be most likely to save money for the healthcare system. Many people who are not going to die in the immediate future don’t want to have to cease all treatment for their conditions, as Hospice requires, they just want the most effective and least limiting treatments that enhance their ability to function.
@Zinsky: I SO agree. I have done quite a bit of work learning evidence-based use of both cannabis and non-THC CBD in my patients, particularly so as to avoid the use of far riskier medications such as opioids and benzidiazapines–and they respond well to these options.
Fortunately, in New Mexico, medical cannabis is becoming more accepted and recommended by health-care professionals for patient’s with chronic conditions of all types, from pain to PTSD to addiction treatment. Not just oncological patients.
Barbara
The problem isn’t the DRG payment methodology, it’s the resort to hospitalization even in situations where everyone has accepted that the case is terminal. It will take a huge paradigm shift to keep people needing end of life care out of hospitals.
I would note that problem isn’t always that people are unwilling to use other resources, but those other resources are not always available, or not easily available. When my brother was dying he could not manage his care at home, not even with hospice support. He needed an “intermediate” institution, but that kind of institution requires you to pay room and board and to qualify for additional kinds of assistance. So even though we all understood that every bit of treatment he would receive was palliative, all of it was provided in a hospital setting for lack of any alternative. “At home” hospice is a boondoggle (sorry, I have just seen it too many times). If the patient can be managed at home hospice isn’t really necessary, and if they can’t, the normal hospice arrangement is totally useless. Maybe it seemed like a great idea 30 years ago but it really hasn’t changed much and doesn’t even really keep people out of hospitals. Among other things it is invoked too late to do much good for saving money.
I don’t have anything against cannabis (well, I do for me and anyone I am close to, but not for others) but I really wish people would stop talking as if cannabis is going to solve every kind of complex socio-medical need, like chronic pain or end of life suffering. It is not going to prove to be the equivalent solution to medical problems that vinegar is to common household cleaning needs.
laura
Cannabis was of great help to me and my brothers as we cared for our dad at home in his last week of life. YMMV.
If we’d had a do-over, I’d never agree to subjecting him to Keytruda infusion for his melanoma metastasized to brain. It felt like his doctor was insisting on further treatment for the benefit of research and not for improving his terminal condition or minimizing his suffering.
Any/every improvement in options for end and not immediate end of life is worth the efforts for all concerned.
CatFacts
The folks commenting here already know this, but for any random lurkers out there who have family members in nursing home/assisted living situations, palliative/hospice care can also be provided there. It was a godsend to a relative of mine.
Ella in New Mexico
@Barbara:
Actually, we don’t have a full understanding of the role of cannabis–particularly medicinal products–can have right now in the US due to lack of evidence-based research conclusions. That’s going to change over the next few years. We can rely on good information from Europe and Israel, who have been doing scientific studies on it’s use, and by all indications, cannabis has a broad range of potential, from immune system enhancement/anti-inflammation effects, improving insulin response in diabetes, to helping neuropathic pain, anxiety, depression and sleep disorders. Many of the pharmaceutical options for these disorders have serious side effects or addiction/safety implications for patients. I’d rather they try something safer first, if possible and medically appropriate.
Cannabis for medical use has to be used purposefully prescribed, with strains/preparations tailored by THC/CBD ratios to those diagnoses–you can’t just smoke a tone of recreational marijuana to cure your PTSD or your crushing neuropathic back pain, because you’ll likely become too intoxicated to function at a healthy level and not get the full benefits of the CBD aspects of the substance.
So stay open minded and hopeful, like me. I’m at the “Start low, go slow, use purposefully” phase here and hoping the science catches up. :-)
elliott.gorelick
The ethical framework for end of life care in theory is weak at best. In practice, it’s a f***ing disaster involving unreasonable/unconscious patients, family tension, and timid/bullying doctors. Add into the mix the economic incentives and studies are useless because there is no consistency.
cckids
@Barbara:
I have to disagree, from my own experience. My adult son was in palliative care, then hospice at home, throughout 2014 until he passed in late 2015. Both were absolute sanity savers for my husband and me, and added a level of comfort and peace to our son’s final months that was priceless, but most likely less expensive to Medicaid than the previous stitched-together arrangement of doctors and other providers we had.
And as to level of care, my son had a tracheostomy with a respirator, a feeding tube, colostomy and catheter. He was quadraplegic, non-verbal and needed complete care. And we did it at home; with a nurse coming in once a week, and an aide twice a week. Much, much better and easier than having him in hospital.
Having a family member who cannot advocate for themselves in the hospital is a draining, stressful nightmare. The last few times my son was hospitalized we had to sign paperwork acknowledging that one of us had to be with him at all times because he couldn’t call for help, and it wasn’t the hospital’s responsibility to look out for him.
Barbara
@Ella in New Mexico: I am open minded but there are a lot of “assertive” claims being made about cannabis by people whose main interest is making recreational use legal or profiting from that use. Mind you, I have no real issue with legal recreational use but there is a lot of eliding of claims going on out there. Yes, I understand that the lack of research has created a vacuum in which such claims can proliferate, but the reality is that the future for medical uses of cannabis is much more likely to be like supplements than medications proved through randomized double blind studies. The emerging research on using cannabis for chronic pain is just getting started but has not been very promising.
Barbara
@cckids: All I can say is that hospice has been around for 30 years and it hasn’t reduced the average use of intensive resources at the end of life. Whatever value it has for individuals in their own personal situation is not necessarily an endorsement of its supposed mission to provide less expensive, palliative end of life care.
StringOnAStick
The mixed results about hospice being reported in this thread has to do with the same core problem of our entire health care system: very fragmented, a mix of for-profit as non-profit providers and no national standards other than what each large hospital/provider group has created for themselves. Medical care and courses of treatment are not entirely a series of “if, then” software commands, there always needs to be some flexibility instead of strict rules, and then it comes down to how ethical/egotistical the professional giving orders are. Example: my mom died last year of perforated bowel from diverticulitis; by the time it was clear she would not survive she was too fragile to transport to a hospice facility. Hard and fixed rules to cut care costs would have forced transport.
The discussion about reducing costs here always seems to revolve around cutting or reducing the use of care, not the fees charged by the high end providers like hospitals and doctors, probably because these are powerful targets with lots of lobbying money.
As for medical marijuana and CBD, research on either was so onerous to undertake due to federal rules that most institutions wouldn’t bother until very recently; luckily the Europeans were less ridiculous. I agree that CBD is being marketed in many places as a miracle for every possible condition. I have some anecdotal evidence regarding it’s use based on European studies about CBD and cancer. My husband was diagnosed with CLL 2 years ago, very early stage. He was told his WBC count would slowly creep upwards; he uses CBD now and his WBC continues to decline for the last 18 months to the point that it is just 2 points above the normal range, his oncologist shook his head in amazement last time and bumped my husband down to just seeing the PA now for his biannual blood test visits. The once a day drug to treat this form of leukemia once your WBC gets to 200 is $5,000/month. The longer we can put off his needing that drug, the better.
cckids
@Barbara: My answer to that would be to educate people better; to attempt to start changing the culture in our country that living an extra week, no matter what the pain, loss of dignity, or cost, is always worth it. I don’t understand it, myself, but maybe that’s because I’ve spent way too much time in hospitals already.
I’m always struck by how terrified so many are of death; especially religious people. Don’t they profess to believe in an afterlife? And yet, they will fight tooth & nail, damn the torpedos, damn the expense, to exist for another day.
Ella in New Mexico
@StringOnAStick: OMG so good to hear! Hang in there!
Barbara
@StringOnAStick: Yes, our system is too fragmented and the “friction” and expense of having to create the medical equivalent of a complex a la carte gourmet meal drags down even the best intentioned among us. Yes, per unit costs are too high. My brother lived with CLL for more than three years and it never accelerated or became worse. Something altogether different killed him. He never used CBD. Highly skeptical about cannabis the same way I am about nutraceuticals or supplements.
@cckids: Education would be a good thing, but it won’t ameliorate the instinct to use all resources that are on the table.
cckids
@Barbara:
Why not?? People can come to understand the reality that life ends, and that there are better ways to meet that end than in a cold, impersonal hospital room. Trying to “bring someone back” when their heart has stopped naturally is a rather violent, physical process. TV and movies have done the public a real disservice by making it look easy and/or gentle. It’s not.
I’m old enough to remember when people wouldn’t wear seat belts; when a much higher percentage of the public smoked EVERYWHERE, when child or spousal abuse was overlooked. Those things have all changed. Attitudes can and do evolve, but people need accurate, real information.
StringOnAStick
@cckids: One of the core tenants of Stoicism is the live each day with the knowledge that it could be your last, so you end up mentally prepared for your end. It sounds like a depressing approach to life but it’s actually quite liberating.
My late mom desperately grabbed for every last minute, even though her last years were nothing but hard drinking and anger with ever increasing senility. As long as she could keep ordering more and more stuff from catalogs she was some approximation of “happy” though angry she couldn’t order everything; she blamed my dad for that, which was a big chunk of her anger that she wasn’t as rich as she thought she deserved to be though they were firmly middle class. More and more “stuff” is not happiness but she was positive it was so of course facing your death means no more “stuff,” Their house is packed to the rafters with ” stuff “, but it was never enough and you can’t live long enough to fill that kind of a hole in your soul. Our materialist culture has a lot to do with the desperation to cling to every last moment.
StringOnAStick
@cckids: Exactly! I’ve been involved in two back country accidents where we kept up CPR until SAR got there even though the person was quite plainly dead; it’s nothing like on TV. It’s awful and traumatic for everyone involved.
Life ends for all of us sooner or later. I swear Tv culture makes us think it can always be put off if you try the one long shot treatment or have Dr House or whatever that parade of medical oddities was called
Barbara
@cckids: Because in these situations any person who objects to withdrawing care typically has veto power over withdrawal of care, just as, unless it is TOTALLY clear that the individual does not want the care, they will receive the care. The ONLY way to avoid it is NOT TO GO TO A HOSPITAL. Don’t call the ambulance. Let the person die. It’s harder than it sounds. Seriously, I could write a tome on the ways people default into the overuse of resources at the end of life. It does not have to be that way. It wasn’t for my parents or my in-laws but their experience was not typical.
CatFacts
@Barbara: I think I’m with cckids here. If it doesn’t *have* to be that people default to overuse of resources at the end of life, then education should help some. It won’t totally solve the problem, but if it can help people gain peace and dignity at the end of their lives plus possibly save money, it’s worth trying.
Also, it’s not necessarily a binary choice between “try everything at a hospital” and “don’t call an ambulance while patient is actively dying”. Anecdotes aren’t data, but my relative was residing in long-term care when they chose hospice, and education was critical for that decision. I’m eternally grateful to the LPN who sat us all down and talked us through the alternatives while my relative was still able to consent. Made a world of difference in terms of pain control and care. For people who have COPD, congestive heart failure, or certain types of cancer, a relatively early decision to go with palliative care can really help their last several months of life. Without if, my family wouldn’t have known hospice was available to a patient who was not going to get better but wasn’t dying at that moment.
Barbara
@CatFacts: Better outcomes are possible but everything has to fall in place correctly because the default is to call the ambulance and once that happens, the rest is practically autopilot.
Brad F
David
You note above, ” Conditional on an admission, the hospital can control costs and pocket the difference. A palliative care intervention that leads to the patient and/or their family deciding to not engage in last ditch/low hope/high cost interventions will save the hospital money without changing what CMS pays”
HOspitals can deliver higher acuity care by treating the renal, respiratory, or cardiac failure. Sepsis can worsen and CMIs can increase. Why would you think CMS cannot save? Same episode but different DRG. Difficult to suss out the counterfactual of a fully functional palli care world, but Dartmouth atlas does a nice job, as you know, of hospitals pushing the throttle on more intense care. That is revenue.
Brad