Key Findings

Despite the myriad benefits of palliative care, as well as its recent growth, more progress is needed. Availability varies considerably by region and by state. The 2011 State-by-State Report Card updates the 2008 Report Card.

The study, America′s Care of Serious Illness: A State-by-State Report Card on Access to Palliative Care in Our Nation′s Hospitals, conducted by the Center to Advance Palliative Care (CAPC) and National Palliative Care Research Center (NPCRC), examines variation in access to palliative care at the state level in order to help both the public and policymakers increase the availability of these services for all Americans in need.

What Are the Key Predictors of Access to Palliative Care?

As we have seen in other areas of our health care system, we found wide geographic variation in access to palliative care services. Factors predicting the presence of a hospital palliative care team have not changed markedly since the 2008 Report Card.

Large hospitals with 300 or more beds are more likely to report a palliative care team (85 percent).
Public hospitals (54 percent), for-profit hospitals (26 percent), and sole community provider hospitals (37 percent) are less likely to report a palliative care team.
On average, midsize (50–300 beds) and large hospitals (over 300 beds) are more likely to be not-for-profit.

Where You Live Matters

As the Dartmouth Atlas^[1] researchers have often pointed out, “geography is destiny.” The same holds true when speaking of access to hospitals offering palliative care. If you′re living in the South, for example, you′re much less likely to find a hospital with a palliative care program. If you′re living in a region where there are only small hospitals (fewer than fifty beds), for example, your chances of having access to palliative care are extremely limited.

In 2008, our nation received an overall grade of C. In 2011, the country receives an overall grade of B. Seven states plus the District of Columbia now receive a grade of A, with more than 80 percent of hospitals reporting palliative care services. More than half of the fifty states receive a grade of B. Fewer than 25 percent of states now need significant improvement (C). Approximately 12 percent receive nonpassing grades of D or F.

Top performers (programs in 81% to 100% of hospitals):

States receiving an A grade

District of Columbia (100%); Maryland (90%); Minnesota (89%); Nebraska (93%); Oregon (88%) Rhode Island (88%); Vermont (100%); Washington (83%)

On their way (programs in 61% to 80% of hospitals):

States receiving a B grade

Arizona (69%); California (67%); Colorado (73%); Connecticut (72%); Florida (62%); Idaho (63%); Illinois (67%); Indiana (63%); Iowa (61%); Maine (71%); Massachusetts (67%); Michigan (76%); Missouri (75%); Montana (67%); Nevada (69%); New Hampshire (77%); New Jersey (80%); New York (75%); North Carolina (75%); North Dakota (67%); Ohio (80%); Pennsylvania (67%); South Dakota (78%); Virginia (78%); Wisconsin (74%)

States in the middle (programs in 42% to 60% of hospitals):

States receiving a C grade

Georgia (43%); Hawaii (58%) ; Kansas (47%); Kentucky (55%); Louisiana (43%); New Mexico (44%) South Carolina (51%); Tennessee (52%); Texas (42%); Utah (60%); West Virginia (55%); Wyoming (50%)

States that need significant improvement (programs in 28% to 38% of hospitals):

States receiving a D grade

Alabama (28%); Alaska (29%); Arkansas (38%); Oklahoma (30%)

States with little or no access (programs in 0% to 20% of hospitals):

States receiving an F grade

Delaware (20%); Mississippi (20%)

Improvements Since the 2008 Report Card

In 2008, the eleven states with the lowest prevalence rates were: Mississippi (10 percent), Alabama (16 percent), and Oklahoma (19 percent), Nevada (23 percent), Wyoming (25 percent), Louisiana (27 percent), South Carolina (30 percent), Texas (33 percent), New Mexico (33 percent), Kentucky (37 percent) and Georgia (38 percent). Today, only Delaware and Mississippi get an F (20 percent). However, Mississippi demonstrated substantial improvement since 2008, doubling its prevalence from 10 to 20 percent.

The prevalence of hospital palliative care in Alabama increased from 16 to 28 percent. Oklahoma increased from 19 to 30 percent. Seven states improved their grades from a D to a C: Georgia, Kentucky, New Mexico, Texas, South Carolina, Louisiana and Wyoming. Nevada saw dramatic gains, rising from a D to a B grade.

States getting an A nearly tripled from three in the 2008 Report Card to seven plus the District of Columbia in 2011.

Size Matters

The 2011 Report Card shows that the national prevalence rate for palliative care services in small hospitals is 22 percent.

The highest prevalence rates for small hospitals are found in New Hampshire (62 percent) and Maine (58 percent).
The lowest prevalence rates in small hospitals are found in Louisiana (0 percent), Mississippi (0 percent) and Alabama (4 percent).

Underserved Populations Have Less Access to Palliative Care

In addition to marked disparities in geographic availability, we observed low rates of access to palliative care in public and sole community provider hospitals. Public and sole community provider hospitals often serve as the only option for medical care for the forty-seven million Americans lacking health care coverage or living in geographically isolated communities:

Only 54 percent of public hospitals provide their patients access to palliative care.
Fewer than 40 percent of sole community provider hospitals offer their patients access to palliative care.

Lack of Board-Certified Palliative Medicine Physicians

A major barrier facing the expansion of palliative care services is the lack of palliative medicine physicians. Where there is approximately one cardiologist for every 71 persons experiencing a heart attack and one oncologist for every 141 newly diagnosed cancer patients, there is only one palliative medicine physician for every 1,200 persons living with a serious or life-threatening illness.

Improving access to palliative care for America’s patients and families requires a workforce highly trained in the fundamentals of palliative medicine. Today in the United States there are 2,887 physicians board-certified in palliative medicine. Prevalence of board-certified palliative care physicians varies across states:

The highest rates are to be found in Hawaii (1 per 154 Medicare deaths), New Mexico (1 per 222 Medicare deaths) and Colorado (1 per 244 Medicare deaths).
The lowest rates are in Mississippi (1 per 1,698 Medicare deaths), Rhode Island (1 per 1,267 Medicare deaths), Montana (1 per 1,218 Medicare deaths), Delaware (1 per 1,060 Medicare deaths) and South Dakota (1 per 1,037 Medicare deaths).

Conclusion

Although access to palliative care in the hospital setting is improving year-by-year, people living with a serious illness will still find significant disparities in their access to a hospital that provides palliative care. Focused efforts by hospital administration, the health care community, and policymakers are required to promote the development of quality palliative care programs in all hospitals, with special attention needed in small, rural, public and for-profit hospitals (see Recommendations for Action section of this report). This will result in a more efficient and effective use of hospital resources, and will enhance the quality of care delivered to our nation′s most seriously ill patients and their families.

View the 2008 National Rankings

[1] The Dartmouth Institute for Health Policy and Clinical Practice. The Dartmouth Atlas of Health Care website, www.dartmouthatlas.org. Accessed January 13, 2011.