Palliative Care Works, So Why Is It Rarely Used? Follow the Money

Editor’s note: This blog was originally published by STAT on March 23, 2021. 

A decade ago, a team of researchers showed clearly that a new treatment for advanced lung cancer significantly improved patients’ quality of life, reduced symptoms of depression, lowered the likelihood of being admitted to the hospital for a complication of their disease, and improved survival. Subsequent research has found similar beneficial effects in other cancers and diseases.

Flash forward to today: Two-thirds of patients living with a serious illness who could benefit from this therapy don’t get it, and the majority of cancer physicians do not prescribe it despite endorsements from the American Cancer Society and the American Society of Clinical Oncology.

The treatment is not a drug or a procedure. It is palliative care: a team of specially trained doctors, nurses, social workers, and chaplains who focus on improving quality of life and reducing the disease burden for seriously ill individuals and their families. This is different than hospice — care for those who are dying, which focuses on comfort. Palliative care is provided alongside other treatments to people of any age facing serious ailments. Once engaged, a palliative team can treat pain and other distressing symptoms, address family needs, coordinate care, and provide emotional and spiritual support.

Study after study shows that the outcomes of palliative care for patients and families can be substantial.

So why are such teams used so little? Like so many problems in American health care, the answer can be found by following the money. Palliative teams require an upfront investment by hospitals and health systems. Given current payment systems, the return on this investment to health systems can actually be negative.

Palliative care’s contribution to well-being comes in part from reductions in unnecessary hospital admissions or emergency department visits due to better symptom management, along with reduced spending due to better care coordination. While the health care payment system in the U.S. is evolving to reward providers for quality and efficiency, more often than not reducing hospitalizations and emergency department visits generate losses for health systems. Expecting physicians to act against their own financial interests and those of their health systems is not realistic and likely contributes to dated thinking about palliative care.

Physicians’ reticence to institute palliative care is compounded by misunderstanding. Physicians often confuse this approach with hospice, and patients end up sharing this misunderstanding when their doctors tell them “they aren’t yet ready for palliative care.” Generations of physicians have been trained to expertly diagnose and treat disease but don’t have the skills to treat the physical, emotional, and spiritual suffering that accompanies serious illness. Across 10 years of medical education, one of us (R.S.M.) received one 30-minute lecture on pain medications, no training in communication skills, and no education regarding the types of non-hospital and physician services available to patients and families and whether such services are covered by Medicare and other insurance programs.

Two straightforward steps could make a significant difference in the lives of seriously ill patients and their families. First, Medicare needs to incentivize physicians and financially reward health care institutions for providing high-quality palliative care. It should add measures to its quality reporting programs that capture reductions in symptom burden as a result of palliative care, and pay more to hospitals that meet those standards.

Second, adding questions about palliative care into medical student and physician board exams and requiring participation in continuing education regarding palliative care for state licensing and hospital credentialing would rapidly change educational curricula and retrain a generation of practicing physicians.

The year 2034 will mark a milestone for the United States. In that year, for the first time the country will have more people age 65 and over — the group at highest risk for cancer and other serious illness — than under the age of 18. Over the course of their lives, most people will develop one or more serious illnesses they will live with for many years. We have a treatment — palliative care — that can increase quality of life and longevity. It’s past time to take the necessary steps to ensure that everyone has access to it.

R. Sean Morrison is a geriatric and palliative medicine physician and professor and chair of the Department of Geriatrics and Palliative Medicine at the Mount Sinai Health System in New York. Mireille Jacobson is co-director of the Aging and Cognition Program at the USC Schaeffer Center for Health Policy and Economics in Los Angeles and an associate professor at the USC Davis School of Gerontology.