Palliative care treats the pain and other debilitating symptoms of serious and chronic illness. By efficiently improving quality of care geared to our sickest, most vulnerable patients, it is emerging as a critical component of health reform.
Recent public opinion research by the national polling firm Public Opinion Strategies has shown that once informed about palliative care, 92 percent of the American public are highly likely to consider palliative care for themselves or their families if they have a serious illness. Ninety-two percent also said it is important that palliative care services be made available at all hospitals for patients with serious illness and their families throughout the United States. The data also show a positive response to palliative care regardless of party affiliation.
Despite the considerable growth in the number of palliative care programs across the United States, barriers in three key areas—workforce, research and access—currently prevent full availability of palliative care for all patients and families facing serious or life-threatening illness. Specifically, three key policy initiatives are needed:
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.
There are two principal reasons for the shortage of palliative medicine providers. First, palliative medicine is a new specialty, formally recognized in 2007. Thus, although the number of training programs is increasing, as of 2010 there were only 73 accredited allopathic subspecialty training fellowship programs in the United States, collectively producing approximately 86 new palliative medicine physicians per year. Second, Medicare funding, which currently supports the majority of post–medical school residency training for physician specialties in the United States, does not support palliative medicine specialty training. This is a consequence of the 1997 Balanced Budget Act’s cap on Medicare-funded graduate medical education (GME) slots. The majority of academic medical centers—the site of training for medical students, residents and fellows—currently are at or exceed their GME residency cap. As a result, Medicare dollars are unavailable for training palliative medicine physicians, and current palliative medicine fellowship training programs are inadequately supported by scarce philanthropic dollars.
Three initiatives are necessary to ensure that Americans with serious illness and their families have access to quality palliative care. First, future generations of palliative medicine specialists require support and expansion of palliative medicine fellowship training programs. Demand for this training is high, as palliative medicine is the fastest-growing medical subspecialty in the United States and expansion and support of fellowship programs is needed. Second, a substantial number of midcareer physicians are seeking training in order to transition from their current field of practice into palliative medicine. Third, all physicians who care for patients with serious illness should be trained in the core principles of palliative medicine to ensure that they know how to communicate with seriously ill patients and treat pain and other distressing symptoms.
Several policy initiatives are likely to have a major impact on increasing the current number of palliative care clinicians, including proposals to:
Increased funding for palliative care research is needed to strengthen clinical practice and improve health care delivery that will maximize quality of life for patients and families facing serious and chronic illnesses.
The National Institutes of Health (NIH) and the Institute of Medicine have repeatedly called for substantial investments in palliative care research. Yet, as of 2009, there were only 114 active awarded NIH grants supporting palliative care research. While the growth of the palliative care field has been remarkable, there is a need to strengthen the knowledge base that supports basic elements of clinical practice in pain and symptom management, communication skills and care coordination. To that end, specific focus areas and funding mechanisms for palliative care research should be developed in all NIH institutes, the Agency for Healthcare Research and Quality (AHRQ) as well as the Veterans Administration.
Policy initiatives to address this knowledge gap are straightforward and easily integrated within current biomedical research funding structures:
While physician and (in some states) advanced practice nursing services provided by a palliative care team are covered by most private insurance, as well as Medicare and Medicaid, palliative care is not readily accessible to all Americans. It is offered primarily in hospital settings, with only a few major medical centers providing outpatient or home-delivered palliative care programs. As of 2009, 63 percent of U.S. hospitals with at least fifty beds and 85 percent of hospitals with more than 300 beds reported the presence of a palliative care team. While this represents an increase of 138 percent from 2000, it is not good enough. Currently, there are only about 1,568 hospitals out of a total of 2,489 (American Hospital Association estimate for 2010) nationwide that offer some type of palliative care program.
Part of the problem is that the current business model for palliative care is based on cost avoidance (reducing unwanted and unnecessary utilization) rather than on revenue generation. This model is unusual in health care, requires sophisticated analytic methods to employ successfully and is thus difficult to integrate into hospitals’ current operating metrics. Additionally, accreditation standards for hospitals and nursing homes do not currently require the presence of a quality palliative care program despite publication of consensus standards by the National Quality Forum (NQF). Near-term policy solutions that could increase access to quality palliative care are as follows:
If you are a hospital administrator or clinician:
If you are an administrator or clinician in a medical school:
If you are an administrator or clinician in a teaching hospital:
For a directory of hospital palliative care programs by state, visit getpalliativecare.org