Death and Dying in Tough Economic Times

Cash-strapped states and private health care providers are looking for ways to cut costs and save money in these economic times. While across-the-board cuts in spending are intuitively appealing and a seemingly straightforward method for saving money, it turns out that some health care expenditures actually lead to cost savings. Spend money to save money — at least when patients are dying.

One of the newest areas of specialization in health care is hospice and palliative care. (The Centers for Medicare and Medicaid Services (CMS) just began recognizing hospice and palliative care early in 2009.) This new specialty focuses on treating not just physical symptoms, but psychological, social, and spiritual suffering that accompanies a terminal illness. Hospice and palliative care strive to optimize the quality of life for critically and terminally ill patients and their families when facing life-threatening illness or injury. Ideally, hospice and palliative care are provided by an interdisciplinary team, and emphasize communication, symptom management, and family support. In order to improve this new specialty, many hospitals, professional organizations, and palliative care advocacy groups are formulating objective measures of quality care. Also, many quality and benchmarking groups, such as the National Quality Forum and HealthGrades, are receiving increasing pressure from health care providers and payors to implement quality standards for hospice and palliative care. Still, quality of life near the end of life is not an easily measured or demonstrated outcome, making impartial and tangible conclusions difficult.

To standardize the quality of hospice and palliative care, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) proposed a palliative care certificate program for hospitals. The program was supposed to be in place in August of 2008, and was eagerly anticipated by practitioners and hospitals. However, due to the current economic environment, JCAHO has recently announced that the rollout of the certificate program is being put on hold, with no release date set for the future. This delay has frustrated many in the hospice and palliative care community who strive to provide high standards of care for patients and their families.

While quality care at the end of life is important, many proponents of spending cuts cite the Medicaid Hospice Benefit as a place to control spending and clean up the budget mess in many states. (Many hospice programs do make a sizable profit on stable, long-term patients.) However, cutting the entire benefit may not be a reasonable target. Many recent studies are reporting that paying for hospice benefits actually saves money in state-funded programs, as well as hospitals. To provide time and resources to sort out the truth, President Obama extended a 1-year moratorium on reductions in hospice reimbursement through the end of September 2009 as part of the economic stimulus package.

Spending money on hospice and palliative care may actually be part of the solution to the health care spending crisis. One study reported that coordinated palliative care led to a savings of $300 per patient per day receiving palliative care. For an average 400-bed hospital, this translates to a savings of $1.3 million annually. Actions as simple as physician-patient-family conversations in the last week of life as part of a comprehensive palliative care approach led to significantly lower costs (often thousands of dollars per week) in the final weeks of a patient’s life. The same patients, with decreased costs, showed improved quality of death versus those without physician discussions of end-of-life issues.

Recently, the legislators of Florida proposed cutting the state’s hospice benefit to reduce overall health care costs. The legislature concluded that the state would save $343 million. To fight back, Florida Hospices and Palliative Care conducted its own research and concluded that cutting the benefit would actually cost the state an additional $3.7 million. Similar results were found in a study conducted by Duke University that claimed the average hospice patient receiving palliative care actually saved health care payors $2300 compared to patients receiving traditional care.

With an aging population filled with chronic disease, hospice and palliative care will be a growing specialty in the decades to come. Similarly, cutting costs — in health care and other arenas –- will remain an important priority for America in the years to come. But, we must respect the need for quality care at the end of life. Health care is a lot more than lab tests, medicines, and people running around in white coats; health care, particularly near the end of life, is the attention paid to the whole patient and his or her family. If that attention to patients saves a few dollars, then maybe the health care system is on the right track, after all.

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