Too often, palliative care, which was officially recognized as a medical specialty in 2006, is mistakenly thought to be synonymous with hospice care. Although palliative care includes the coordination of care for patients at the end of their lives, it more broadly aims to reduce patient suffering and is available to all patients with serious disease. It is designed to be given alongside active care, and certain chemotherapies have important palliative properties, including reduction in pain and nausea and improved quality of life (QOL) by the use of more tolerable dosing mechanisms.
A provisional clinical opinion published by the American Society of Clinical Oncology (ASCO) in February 2012 recommends integrating palliative care services into standard oncology practice at the time a person is diagnosed with metastatic cancer.1
Payers have taken notice. Based on recent survey data from Reimbursement Intelligence (RI), payers see an opportunity to assist physicians in promoting palliative care via new tools, mainly evidence-based clinical pathways. Payers also see an opportunity to change compensation incentives so that providers are not financially penalized for offering patients palliative care options when appropriate.
The high cost associated with end-of-life care is a major driver in healthcare spending in oncology, with an estimated 20% to 35% of cancer patients receiving chemotherapy in the last 14 days of life.2,3
Numerous randomized clinical trials show that when palliative care services are encouraged alongside standard oncology care, patient QOL (including overall mood and symptoms) improves, while treatment costs decline by as much as $4900 per patient.4 Indeed, a 2011 study by Temel and colleagues showed that palliative care, in addition to standard cancer care, allowed patients to live almost 3 months longer than patients who received usual care.5
In addition to advancing a provisional clinical opinion on palliative care, ASCO has taken an important step in supporting the practice through its Quality Oncology Practice Initiative (QOPI) and by its participation in the Choosing Wisely campaign. An oncology practice–based quality improvement program, QOPI aims to improve cancer care by creating a culture of self-examination through chart review and benchmarking against peers. Such feedback is extremely effective in promoting the use of palliative care. When physicians at the University of Michigan were given feedback about their use of chemotherapy to treat patients with 2 weeks or less to live, the use of active therapy during this interval dropped from 50% to 20% in one quarter.6
Payers, meantime, are eager to find politically acceptable ways to improve the management of end-of-life cancer care and reduce costs. When RI surveyed 49 payer executives representing 100 million US lives about their oncology management strategies in late summer 2012, 95% stated that they would use evidence-based clinical pathways to promote palliative care.
Actual implementation remains a crucial question, however, with payers split on how strongly these pathways would emphasize such practices. Nevertheless, 47% of executives surveyed noted that pathways language would include concrete direction for the appropriate transition to palliative care (Figure 1).
It is important to recognize that many of these programs are still in pilot mode and have yet to be broadly adopted by community oncologists. Moreover, there are significant adoption hurdles to overcome since oncologists are trained not to give up on patients and will default to recommending additional lines of therapy. Indeed, at ASCO’s inaugural Quality Care Symposium in December 2012, Hui and colleagues reported that even at top-tier cancer centers like M.D. Anderson, palliative care is significantly underutilized, with a majority of patients (55%) not accessing palliative care services before death.7
Based on the recent RI survey, payers believe that new care delivery structures such as accountable care organizations (ACOs) and oncology medical homes can assist in changing provider treatment patterns. When payers were asked to rank on a scale of 1 (minimal impact) to 5 (strong impact) where ACOs would have the greatest influence on oncology care, greater utilization of palliative care was among the top-rated categories, alongside pathways, coordination of care, and a reduced need for supportive care therapies (Figure 2).
This suggests that the adoption of ACOs and pathways will mutually reinforce the emphasis on palliative care. As providers standardize practice patterns via clinical pathways that create direct prompts to transition patients to palliative care, the highly coordinated care teams working in ACOs enable the transition from active treatment to palliation to occur.
Although pathway adoption and care coordination are good first steps, payers who want to lead in this arena must also create new reimbursement schemes to compensate physicians for the time spent on educating patients and family members about palliative care options. Such strategies move physicians away from the fee-for-service paradigm that rewards doctors for prescribing costly medicines and puts greater emphasis on compensating for cognition rather than script-writing.
In 2010, UnitedHealthcare, working with 5 community oncology offices, instituted an episode-of-care–based program in 19 discrete tumor types.8 (It has since expanded the program to include an additional oncology practice.) The resulting changes in practice patterns have yet to be published in a peer-reviewed journal.
However, participating practices clearly see a link between such changed incentives and increased use of palliative care. “Where it is most helpful is in enabling tough decisions regarding palliative care,” says John Hennessy, executive director of the Kansas City Cancer Center. “It allows us to be economically indifferent to the patient’s choice, whether that is to continue therapy, take a treatment holiday, or enter hospice. In a traditional fee-for-service environment, our economics prioritize continuing therapy.”
Initiatives such as UnitedHealthcare’s (and smaller pilots by the likes of Michigan’s Priority Health) are far from mainstream. Some 60% of payers surveyed by RI report that they do not currently provide financial incentives for providers that adhere to cost-management principles. Still, we are cautiously optimistic that payers are revamping their administrative and information technology systems to process claims via episode or bundled mechanisms.
Indeed, based on RI’s survey data, 25% of plans already link financial incentives to increased use of generics, and 10% incentivize earlier palliative care counseling (Figure 3). Of note, national plans, as opposed to smaller, regional payers, are more likely to adopt this approach (Figure 4). Payers believe that drug manufacturers can also assist in driving palliative care use. Based on our survey, 73% of payers believe that manufacturers could support specific provider education efforts tied to the palliative properties of the drugs they manufacture. More than 60% believe manufacturers can play a role in broader palliative awareness-building initiatives (data not shown).
The current political climate and the use of polarizing terminology such as “death panels” highlights the breadth of the misunderstanding of what palliative care is—and what it is not. Payers can assist nonprofit organizations such as ASCO and the National Comprehensive Cancer Network in prioritizing palliative care, by encouraging providers to adopt evidence-based clinical pathways that support such services.
New reimbursement schemes that do not penalize physicians for providing earlier palliative care are also essential. Our survey data suggest payers are eager to work with forward-thinking providers to institute such programs, because they offer an important means of holding the line on rapidly rising oncology costs while offering high- quality—if not superior—care to patients.
