Palliative Care Cost : A look at the evidence

Stephen R. Connor, PhDInternational Palliative Care Consultant, IPCI

Senior Executive, Worldwide Palliative Care Alliance

Palliative Care in Practice

• Controls pain and symptoms• Facilitates communication and decisions about goals

of care with patient and family• Interdisciplinary, multi-dimensional care• Coordinates care and transitions across fragmented

medical system • Provides education & practical support for family

caregivers

Value Proposition

• Palliative Care (PC) reduces unnecessary health care services

• Palliative care lowers costs (for hospitals and payers) by reducing hospital and ICU length of stay, ER use, and direct pharmacy and diagnostic costs.

• Home based care, complex case management, with after hours access

• Cost impact vs. cost effectiveness

100

90

80

70

60

50

40

30

20

10

%Patients

Cost perPatient

ManagementApproachPatient Type

Care Management Focuses on the Needs of Patients

• Worried well• Self-resolving illness• Low grade acute illness Demand

ManagementLow

CaseManagemen

t

• Chronic diseases• Moderate to severe acute illness

DiseaseManagement

Medium

High Complex CareManagement

Complex Patients

Significant diagnosis

Multiple co-morbidities

Often terminal

Several providers of care

Psychological / social / financial upheaval

US Studies on Hospice/Palliative Care Cost Impact

• Kidder (1992) ($1.26 saved per $1.00)– Congressional Budget Office ($1.52 saved)

• Pyenson, Connor, et al (2004) Study• Campbell et al (2004) Study• Taylor, et al (Duke, 2007) Study• Morrison et al (2008)

• Hospice reduces Medicare expenses $1.26 for every $1.00 spent– Selection issues

• 14 of 16 diagnoses saved $1097 - $8935/admit • Prostate and stroke more cost for hospice

• Decreased cost for cancer but not for non-cancer– Propensity adjustment not matched for length of

hospice use

• Propensity adjustment based on hospice use• Hospice use reduced Medicare program expenditures during the last year of life

by an average of $2309 per hospice user• The maximum reduction in Medicare expenditures per user was about $7000,

which occurred when a decedent had a primary condition of cancer and used a hospice for their last 58–103 days of life.

• For other primary conditions, the maximum savings of around $3500 occurred when a hospice was used for the last 50–108 days of life

• Live discharge savings $1696/admission• Deceased savings $4908/admission

Palliative Care and Costs

Live Discharges Hospital Deaths

Costs Usual Care

Palliative Care Δ Usual

Care Palliative

Care Δ Per Day $ 830 $ 666 $ 174* $ 1,484 $ 1,110 $ 374*

Per Admission $11,140 $ 9,445 $ 1,696** $22,674 $17,765 $4,908**

Laboratory $ 1,227 $ 803 $ 424* $ 2,765 $ 1,838 $ 926*

ICU $ 7,096 $ 1,917 $ 5,178* $14,542 $ 7,929 $7,776*

Pharmacy $ 2,190 $ 2,001 $ 190 $ 5,625 $ 4,081 $1,544***

Imaging $ 890 $ 949 ($58)*** $ 1,673 $ 1,540 $ 133

Died in ICU X X X 18% 4% 14%*

*P<.001 **P<.01 ***P<.05Morrison RS et al. Arch Intern Med 2008; 168:1783

Consistent Findings

• Dying (complex care) patients most expensive in health care systems

• Overall savings for palliative care vs. usual care• Maximal savings if hospice care 1-3 months

– Though early intervention is key• Savings for both cancer and non-cancer, but

more for cancer