Dr. Amy P. Abernethy, medical director of oncology quality, outcomes and patient-centered care in the Duke University Health System, Durham, N.C., and a coauthor of the ASCO provisional clinical opinion, agrees that there are multiple impediments to reimbursement of palliative care.
"The Stark law is one impediment; a second is that the reimbursement mechanisms that are clear in hospice aren’t necessarily as clear in community-based care, and then there are workforce issues. Right now, we have only a finite number of palliative care practitioners, and we only have a finite number of blocks in our graduate training programs, and we're not going to be able, using those slots, to train enough palliative care docs to fill the need that's highlighted in this provisional clinical opinion," she said.
Insurers, Younger Clinicians May Be Open to Change
Insurers seem to be coming around to the idea that palliative care can mean better patient care, however, said Dr Smith.
He points to Aetna, which has a "Compassionate Care" program in which specially trained triage nurses coordinate care, identify resources, and help manage palliative care and hospice benefits for patients with terminal illnesses and their families.
Clinicians in training or new to practice are also more comfortable with the idea of advance directives, palliative care, and hospice than are their more seasoned colleagues who were trained to never give up, Dr. Smith added.
Dr. Abernethy agreed: "What we’re seeing is that young physicians totally get this. Probably because they haven’t grown up in a world where the only thing you focus on is survival, they’ve understood the language of focusing on quality of life from the time they were first exposed to what medicine is," she said.
Randomized Trials Show Benefits, No Harm
In their provisional opinion, the researchers reviewed the study by Dr. Temel and her colleagues, as well as six other randomized controlled trials looking at palliative care in patients with various terminal illnesses; two of the seven total studies evaluated palliative care in cancer patients exclusively, whereas others included diagnoses such as heart failure and advanced chronic obstructive pulmonary disease.
They found that "overall, the addition of palliative care interventions to standard oncology care delivered via different models to patients with cancer provided evidence of benefit. No harm to any patient was observed in any trial, even with discussions of end-of-life planning, such as hospice and advance directives."
There were statistically significant improvements in symptoms with palliative care in 2 of 5 clinical trials that measured such changes, and improvements in quality-of-life measures in 2 of 5 trials. Additionally, in 2 of 3 trials palliative care was associated with improved satisfaction of patients and caregivers, the consensus panel found.
The studies also showed, to varying degrees, improvements in patient mood and a reduction in costs, in one study (J. Am. Geriatr. Soc. 2007;55:993-1000) from $20,222 for usual care to $12,670 for palliative care (P = .03), and in a second study (J. Palliat. Med. 2008;11:180-90) from a total mean of $21,252 for usual care to $14,486 for interdisciplinary palliative care (P less than .001). The latter study also found savings of nearly $5,000 per patient in staffing costs with palliative care.
"Therefore, most trials showed benefits ranging from equal to improved overall survival, reduced depression, improved caregiver and/or patient quality of life, and overall lower resource use and cost because end-of-life hospitalizations were avoided," the opinion authors wrote.
All physicians interviewed for this article reported that they did not have financial conflicts of interest.
Click here to see earlier coverage of this subject and a video of Dr. Temel discussing results of the randomized trial.