Palliative Care Cost : A look at the evidence Stephen R. Connor, PhD International 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 Use clinical examples! Talk about why you went into it – Mr. Santana Talk about what you do every day.

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

Care Management Focuses on the Needs of Patients 100 90 80 70 60 50 40 30 20 10 % Patients Cost per Patient Management Approach Patient Type Worried well Self-resolving illness Low grade acute illness Demand Management Low Chronic diseases Moderate to severe acute illness Disease Management Medium Complex Patients Significant diagnosis Multiple co-morbidities Often terminal Several providers of care Psychological / social / financial upheaval Case Management Complex Care Management High

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 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 18% 4% 14%* *P<.001 **P<.01 ***P<.05 Morrison 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