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Evidence-Based Oncology April 2015
Palliative Care Integrates Value in Cancer Care
Joseph Alvarnas, MD
NCCN 2015: Reviewing the Past to Build the Future
Joseph Alvarnas, MD
A Need for More, Better, and Earlier Conversations With Cancer Patients About Goals of Care
Rachelle Bernacki, MD, MS; and Ziad Obermeyer, MD, MPhil
Creating Value-Based Metrics for Cancer Care: A Stakeholder-Informed, Evidence-Driven Approach
Scott D. Ramsey, MD, PhD; and Gary H. Lyman, MD, MPH
Q&A on Palliative Care
Andrew Smith
The Challenges With Ensuring the Validity and Utility of Diagnostic Tests
Surabhi Dangi-Garimella, PhD
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Mary K. Caffrey
From Choosing Wisely, Advice for Palliative Care Specialists and Guidance for Cancer Patients
Mary K. Caffrey
When Is the Right Time for Palliative Care in Oncology? The Sooner, the Better!
Marian Grant, DNP, CRNP, ACHPN, FPCN
How and Why Oncologists Should Do Palliative Care-or Get Some Assistance Doing It
Alessandra Colaianni, BA, MPhil; Sarina Isenberg, BA, MA; and Thomas J. Smith, MD, FACP, FASCO, FAAHPM
Palliative and End-of-Life Care: Issues, Challenges, and Possible Solutions in the United States
Kashyap Patel, MD; and Mary Kruczynski
Global Outlook on Palliative Care in Cancer
Megan O’Brien, PhD
Comprehensive Support for Individuals Living With Prostate Cancer and Their Caregivers Complements Palliative Care Services
Dan Klein, and Jamie Bearse
Patient, Physician, and Payer Conversations in Palliative Care: Moving Beyond Fear
Patti Forest, MD, MBA, FAAFP
Trading Conflict for Synergy: The New Normal for Oncology and Palliative Care
Michael D. Fratkin, MD
Currently Reading
The Role of Palliative Care in Accountable Care Organizations
Amy S. Kelley, MD, MSHS; and Diane E. Meier, MD

The Role of Palliative Care in Accountable Care Organizations

Amy S. Kelley, MD, MSHS; and Diane E. Meier, MD
Palliative care is specialized medical care for people with serious illness, focused on providing patients with relief from the symptoms, pain, and stress associated with the illness—irrespective of the diagnosis or stage of the disease. The goal is to improve quality of life for both the patient and the family. Palliative care is appropriate at any age and at any stage in a serious illness and is provided concurrent with routine disease treatment.1

Accountable Care Organizations (ACOs)—designed to improve quality while containing the cost of care for a defined population of patients—are proliferating in the setting of healthcare reform (Figure). Palliative care has become vital to the success of ACOs because of the high concentration of healthcare spending among seriously ill patients and palliative care’s ability to improve value (ie, raise quality and reduce costs) for this group. In this paper, we summarize the evidence supporting palliative care’s impact on healthcare value, describe the key characteristics of successful palliative care programs integrated with ACOs, and provide a case study of 1 such program.


In 2011, the United States spent $2.7 trillion on healthcare costs, and projections suggest that by 2040, 1 out of every 3 dollars spent in this country will be used for healthcare.2,3 Healthcare spending is highly concentrated among a small seriously ill population, whereby 5% of the sickest and most complex patients account for 60% of healthcare costs.4 This population is characterized by both chronic conditions and functional limitations. Notably, most (89%) high-cost patients are not in the last year of life.5 Despite the intensity of spending, quality of care for this group is often low, marked by poor communication, high burden of pain and other symptoms, low satisfaction, and preference-discordant treatments.6-9

Data consistently demonstrate that palliative care improves quality of care for the seriously ill, and in so doing reduces need for emergency services and hospitalization. Compared with usual care, palliative care for seriously ill patients has been shown to reduce symptom distress,10-12 enhance quality of life,11-13 and decrease spiritual distress.14,15 Additionally, all studies that have compared patients receiving palliative care with those receiving usual care have shown equivalent survival rates and, in fact, palliative care interventions among select groups showed improved survival.11,16

Direct and indirect evidence suggests that palliative care also enhances family outcomes. Studies of palliative care and hospice have demonstrated improved family satisfaction and quality of life, decreased depression and anxiety, better bereavement adjustment, and improved survival among spouses.8,17-20 Indirect evidence supports possible mechanisms for these benefits. For example, families of patients receiving palliative care consultation reported greater attention to their emotional and spiritual needs and enhanced self-efficacy, compared with routine care.21 Those who could recall a discussion of goals of care—a key component of palliative care—experienced improved patient and caregiver quality of life, lower risk of major depression, and fewer feelings of regret.18,19 Furthermore, palliative care, and the discussion of goals of care in particular, is associated with lower rates of death in an intensive care unit and decreased use of other forms of high-intensity medical intervention,22 which have been linked to post-traumatic stress disorder and prolonged grief disorder among bereaved family members.18,19

Research has also demonstrated that the improved quality of care associated with palliative care leads to lower costs through prevention of symptom crises, by reducing depression, supporting family caregivers, and matching treatments with patient priorities (such as receiving care at home). To date, 15 studies have examined the effect of inpatient palliative care on hospital costs and all have found an association with reduced costs.23 A smaller group of studies has also demonstrated that outpatient palliative care can reduce costs and utilization across the entire course of illness.23,24 For example, a randomized controlled trial (RCT) of outpatient palliative care, in addition to standard oncologic care, among patients newly diagnosed with stage 4 non-small cell lung cancer found that those in the palliative care intervention group had better quality of life, improved survival (a gain of almost 3 months), lower rates of emergency department (ED) visits and hospital admissions within the last 30 days of life, were less likely to receive chemotherapy within the last 14 days of life, and were more likely to be referred to hospice 4 days or longer prior to death—measures indicative of higher quality and lower costs.11 Similarly, an RCT of a home-based palliative care program demonstrated improved satisfaction, fewer hospital and ED visits, and lower costs.25 Finally, an RCT of palliative care consultation in a primary care clinic setting resulted in fewer primary care and urgent care visits, yet no difference in use of the ED and hospital.26

While quality, the numerator of the value equation, is clearly of greatest priority, the importance of palliative care’s impact on costs cannot be ignored. In particular, ACO leadership—charged with providing high-quality care for a population of patients within strict budgetary constraints—have taken notice and many are embracing palliative care as a high-value solution for their highest risk patients. To date, over 70% of all ACO hospitals and 82% of ACO hospitals with 50 or more beds have active palliative care programs.27

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