VIEWS & REVIEWS Palliative care and neurology Time for a paradigm shift Isabel Boersma, MS Janis Miyasaki, MEd, FRCPC, MD Jean Kutner, MD, MSPH Benzi Kluger, MD, MS Correspondence to Dr. Kluger: benzi.kluger@ucdenver.edu ABSTRACT Palliative care is an approach to the care of patients and families facing progressive and chronic illnesses that focuses on the relief of suffering due to physical symptoms, psychosocial issues, and spiritual distress. As neurologists care for patients with chronic, progressive, life-limiting, and disabling conditions, it is important that they understand and learn to apply the principles of palliative medicine. In this article, we aim to provide a practical starting point in palliative medicine for neurologists by answering the following questions: (1) What is palliative care and what is hospice care? (2) What are the palliative care needs of neurology patients? (3) Do neurology patients have unique palliative care needs? and (4) How can palliative care be integrated into neurology practice? We cover several fundamental palliative care skills relevant to neurologists, including communication of bad news, symptom assessment and management, advance care planning, caregiver assessment, and appropriate referral to hospice and other palliative care services. We conclude by suggesting areas for future educational efforts and research. Neurology® 2014;83:561–567 GLOSSARY MS 5 multiple sclerosis; PD 5 Parkinson disease. In a 1996 review, the American Academy of Neurology Ethics and Humanities Subcommittee stated: “Many patients with neurologic disease die after long illnesses during which a neurologist acts as the principal or consulting physician. Therefore, it is imperative that neurologists understand, and learn to apply, the principles of palliative medicine.”1 Similarly, the Accreditation Council for Graduate Medical Education requires neurology residents to receive instruction in end-of-life and palliative care.2 However, research suggests that there are major gaps in the education of neurology resident physicians in these topics and low levels among neurologists of referrals for palliative care services.3,4 While palliative care emerged in the treatment of patients with terminal cancer, more recent developments in this field suggest that palliative care may be appropriate for any patient living with advanced, progressive illness or multiple comorbidities. As examples, palliative care been successfully applied to chronic illnesses such as heart failure,5 chronic pulmonary disease,6 and end-stage renal disease.7 There is also an emerging interest, in both research and clinical care, to apply these principles in neurology.8–10 Our goal in this article is to provide a starting point for neurologists to become more knowledgeable and comfortable with the principles of palliative medicine. Supplemental data at Neurology.org WHAT IS PALLIATIVE CARE AND WHAT IS HOSPICE CARE? Many health care professionals, including neurologists, hold misconceptions about palliative care.11 The most common misconception is that palliative care is synonymous with hospice. The lack of clarity regarding the similarities and differences between palliative care and hospice likely influences the view that only patients nearing the end of life are suitable candidates for palliative care.12 Similarly, some health care professionals believe palliative care is “giving up on patients” or “no care”; however, research efforts suggest that early palliative care interventions may positively affect both quality of life and survival.13 Notably, palliative care can be used alongside curative treatments.14–16 From the Departments of Neurology and Psychiatry (I.B., B.K.) and Internal Medicine (J.K.), University of Colorado Anschutz Medical Campus, Aurora; and Department of Neurology (J.M.), University of Alberta, Edmonton, Canada. Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article. © 2014 American Academy of Neurology 561 Table Hospice guidelines for neurologic disorderse18 Dementia 1. Stage 7C or higher on the FAST scalee19 AND 2. One or more of the following in the past year: aspiration pneumonia, pyelonephritis, septicemia, stage 3 or 4 pressure ulcers, recurrent fevers, other conditions suggesting limited prognosis, or inability to maintain sufficient fluid/caloric intake in past 6 months (10% weight loss or albumin ,2.5 g/dL) 1. Palliative Performance Scalee20 score #40% AND Stroke or coma 2. Poor nutritional status with inability to maintain sufficient fluid/caloric intake (10% weight loss in 6 months, 7.5% weight loss in 3 months, serum albumin #2.5 g/dL, or pulmonary aspiration resistant to speech therapy interventions) Other neurologic disease including ALS, PD, MD, MG, or MS 1. Critically impaired breathing including dyspnea at rest, vital capacity ,30%, O2 need at rest, AND refusal of artificial ventilation, OR 2. Rapid disease progression (to bed-bound status, unintelligible speech, need for pureed diet, and/or major assistance needed for ADLs) with either: A. Critical nutrition impairment in the prior year (inability to maintain sufficient fluid/caloric intake, continuing weight loss, dehydration, AND refusal of artificial feeding methods) OR B. Life-threatening complications in the prior year (recurrent aspiration pneumonia, pyelonephritis, sepsis, recurrent fever, OR stage 3 or 4 pressure ulcers) Generic criteria 1. Terminal condition (can be multiple conditions) AND 2. Rapid decline over past 3–6 months as evidenced by progression of disease signs, symptoms and test results, decline in PPS #40%, and involuntary weight loss .10%, and/or albumin ,2.5 g/dL Abbreviations: ADL 5 activities of daily living; ALS 5 amyotrophic lateral sclerosis; FAST 5 Functional Assessment Staging Test; MD 5 muscular dystrophy; MG 5 myasthenia gravis; MS 5 multiple sclerosis; PD 5 Parkinson disease; PPS 5 Palliative Performance Scale. The Center to Advance Palliative Care defines palliative care as “specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.”17 Notably, palliative care may be applicable early in the course of illness, including the time of diagnosis, to help the patient adjust to the many changes in their life and life plans.18,19 Similarly, palliative care may complement life-prolonging therapies, such as chemotherapy or radiation therapy, and investigations needed to better understand and manage distressing clinical complications.15 Palliative care describes an approach to patient care available from the time of diagnosis through bereavement and may be delivered in conjunction with standard care or through specialized services including hospice care, inpatient palliative care, outpatient palliative care clinics, and home palliative care. Hospice care refers specifically to palliative care for the end of life. In the United States, the Medicare hospice benefit is available to patients certified by 2 physicians to have a prognosis of 6 months or less if their disease runs its natural course and who have chosen directly or through surrogates to focus medical care on comfort.20,21 It is offered when disease-directed treatments are no longer wanted or beneficial. The table provides 562 Neurology 83 August 5, 2014 hospice eligibility guidelines for specific neurologic conditions. However, it should be noted that patients with poor prognoses may be eligible for hospice without meeting these specific guidelines. The palliative care approach augments traditional care for neurology patients in several ways. While traditional approaches emphasize the preservation of function and prolongation of life, palliative care draws additional attention to the relief of suffering and places importance on planning for decline and death as an expected and natural outcome rather than as a failure of medical treatment.22 Palliative care transcends the historical patient-physician dyad by addressing caregiver strain and offering supportive services to family members such as respite care and counseling.22,23 Finally, palliative care assesses and treats medical, psychosocial, and spiritual issues including not only pathologic diagnoses but other sources of distress, including normal reactions to living with a life-threatening, progressive, and/or disabling illness. WHAT ARE THE PALLIATIVE CARE NEEDS OF NEUROLOGY PATIENTS? This question can be bro- ken down into related questions: Would neurology patients and family members benefit from palliative services? Are neurology patients receiving adequate care in these areas? On the basis of both questions, we believe there is a substantial and growing need for neurologists to apply the principles of palliative medicine to the care of patients with progressive, chronic illnesses.1,9 Regarding the question of benefit, neurologic diseases are largely incurable, reduce life expectancy,24 and are associated with pain, depression, and other symptoms that are difficult to control.25 Miyasaki et al.26 showed that symptom burden in advanced Parkinson disease (PD) is similar to that in metastatic cancer. Caregivers of neurology patients also have similar, if not higher, rates of distress and burnout as caregivers of patients with cancer.27 Regarding the question of adequacy of current palliative services, place of death and documentation of advance directives offer objective measures of physician performance. Hospital deaths among patients with chronic neurologic disorders are high: 43% for PD and 56% for multiple sclerosis (MS).28 However, hospice deaths are extremely uncommon in PD and MS: 0.6% and 2.5%, respectively.28 Only 9% of patients with idiopathic PD die in their own home compared with 17% of the general elderly population.29 These are striking statistics because research overwhelmingly indicates that the majority of patients prefer to die at home.30 Furthermore, although neurologists broach advance care planning late in the disease course if at all, patient surveys suggest that at least 50% of patients with PD want to discuss advance care documents with their physician early in their disease course.31 Even in patients with advanced dementia, less than 20% have advanced directives documented.32,33 Regarding symptom management, multiple studies show that neurologists frequently fail to adequately assess and treat many symptoms associated with quality of life including depression, fatigue, pain, and sleep.34–36 DO NEUROLOGY PATIENTS HAVE UNIQUE PALLIATIVE CARE NEEDS? We propose that tradi- tional models of palliative care do not sufficiently address the unique needs of patients and family members living with a neurologic diagnosis. Moreover, palliative physicians who are largely trained in internal medicine may have less comfort with neurologic illness than cancer or other medicine diagnoses.37 Patients with a life-limiting neurologic illness often have a long and variable disease progression punctuated by cognitive impairment, behavioral issues, and communication problems, in addition to motor symptoms.38 This trajectory differs from the sharp decline seen in many patients with cancer.39 Fortunately, palliative care services are increasingly recognizing the needs of noncancer patients, particularly in rapidly progressing neurologic conditions such as motor neuron disease.38 Differences between neurology and other patients include symptom profiles, psychosocial issues, caregiver needs, and effects on spiritual well-being. As examples, patients with motor neuron disease experience more demoralization, hopelessness, and suicidal ideation than patients with metastatic cancer40; patients with brain cancer have distinct symptom profiles including more cognitive problems, seizures, and communication deficits than patients living with other types of cancers41; and patients with Huntington disease have distinctive social work needs as the result of combined behavioral, psychiatric, movement, and cognitive issues.42 Notably, young patients with Huntington disease can be particularly challenging to place in nursing homes, and social workers experienced in caring for these patients are necessary to provide the highest quality of care.43 In our clinical experience regarding spiritual well-being, neurology patients experience their disease as something intrinsic to their person, which clearly differs from patients with cancer who see “the cancer” as something outside of themselves. The physical and cognitive disabilities associated with neurologic illness also contribute to feelings of being “useless” or a “burden” and may contribute to higher rates of demoralization.40 Neurologic diseases are associated with caregiver distress and reduced quality of life related to caregiving,44 well-being, depression, and demoralization.45,46 Caregivers of patients with dementia are more adversely affected by their role, have unique psychological issues compared with cancer caregivers (e.g., losing parts of their spouse one day at a time, delusions of infidelity),47 and are at high risk of complicated bereavement.48 WHAT PALLIATIVE CARE SKILLS DO NEUROLOGISTS NEED? All physicians, including neurologists, should have familiarity and comfort with several fundamental palliative care skills including communicating bad news, nonmotor symptom assessment and management, advance care planning, and caregiver assessment. For more complex or advanced patients, referral to palliative care specialty teams may be appropriate, including inpatient palliative care consultation, outpatient palliative care clinics, home palliative care, or hospice. COMMUNICATION AT THE TIME OF DIAGNOSIS Data from patients with heart failure have shown that palliative care should start at the time of diagnosis,49 yet research suggests that physician communication is often inadequate or ineffective, particularly for new diagnoses.50,51 This impression was reinforced at a round-table discussion at a continuing medical education event where patients with PD and caregivers discussed their experience of being diagnosed, including not having enough time for questions, not understanding what their diagnosis actually meant, not knowing where to go for support, and feeling abandoned by their doctor after being given bad news. Regarding ways to communicate bad news, there are a number of tools physicians can utilize including SPIKES (Setting up the interview, assessing patient’s Perception, obtaining patient’s Invitation, giving Neurology 83 August 5, 2014 563 Knowledge, address Emotions, Strategy and Summary)52 or the Vital Talk Web site and smartphone application.53 When delivering a serious diagnosis, physicians must bring their full attention to the patient and figure out what they know about the diagnosis. Obtaining an invitation before sharing sensitive information such as prognosis and other potentially distressing information refers to finding out how much the patient wants to know and is especially important in the initial interview. Using open-ended questions and assessing emotions and feelings are critical to optimally support the patient. It is crucial that neurologists finalize the meeting with a follow-up including what to do when the patient has had a chance to process the information and now has more specific questions. This practice is particularly helpful to support the patient and minimize feelings of abandonment.52 SYMPTOM ASSESSMENT AND MANAGEMENT Neurologists need to carefully assess and treat nonmotor symptoms such as pain, depression, anxiety, fatigue, sleep, constipation, urinary urgency, and sexual dysfunction. Multiple studies in several populations have shown that nonmotor symptoms over time are among the most function-limiting for patients, and affect caregiver burden and overall quality of life more than motor symptoms.54–56 The management of these debilitating symptoms depends on their recognition by physicians.57 Research suggests that as many as 50% of patients with PD who have depression are not treated, despite evidence that treatment parallels that of the general population (e.g., selective serotonin reuptake inhibitors for depression and anxiety).58,59 Some issues may not be readily treatable, but should still be closely followed (e.g., dementia, dysphagia, and weight loss/nutritional status) because they may require additional support or affect advance care planning. ADVANCE CARE PLANNING All neurologists should be knowledgeable about and feel comfortable discussing advance care planning with their patients while the patient is cognitively able. Many patients have never heard of advance care planning, and 30% of patients with advance care plans do not share these with their physicians.60 Contrary to the common clinical perception that patients do not want to discuss advance directives, patients often cite their expectation for physicians to initiate this discussion when asked about barriers to planning for the future, and patients who engage in end-of-life conversations with their doctors report greater satisfaction with their care.e1,e2 Notably, having conversations about death and dying with patients lowers the risk of aggressive treatment at the end of life.e2 Advance care planning includes topics such as medical durable power of 564 Neurology 83 August 5, 2014 attorney, financial power of attorney, living will, and cardiopulmonary resuscitation directive. Physicians may also want to less formally discuss overall goals of care including understanding important life goals and patient and caregiver fears. Health care professionals who care for neurology patients should have regionspecific information regarding these topics readily available for patients and keep an updated copy of completed forms with patient records. Patients should also be informed to keep these documents on their refrigerator and distribute copies to family members. CAREGIVER ASSESSMENT Caregivers are at risk of chronic illness,e3 impaired sleep,e4 depression,e5 and cardiovascular disease,e6,e7 and can have up to a 60% increased mortality rate compared with agematched controls that are not caregivers.e8 The increase in caregiver mortality rates is related to both providing care and strain,e8 which in caregivers of patients with PD, has been shown to increase with disease progression.e9 It has also been shown that caregivers of patients residing in nursing homes and caregivers who are well supported and do not report feeling distress have lower mortality rates.e8 Caregiver quality of life is also associated with patient quality of life—thus, when patients spend their last months of life in the intensive care unit or die a traumatic death, it affects caregivers.e10 Caregiver support from neurologists begins by adequately assessing their needs. The very act of asking caregivers how they are doing is often met with gratitude and may relieve caregiver concerns that their only role in the patient’s illness is supportive. Caregiver assessments should include questions relating to their ability to provide adequate care to the patient and also to self-care.e11 Assistance with providing care may include home safety evaluations, information regarding the illness, understanding the role of medications, and knowing who to contact and how to handle complications or emergencies including backup plans for caregiver incapacity. The following are example questions neurologists can use to assess caregiver well-being: Are you feeling overwhelmed? How is your health? What are you doing to take care of yourself? Do you feel isolated? Do you have time to meet your financial, work, parental, or other obligations? With these simple questions, neurologists can provide caregivers with important validation and may be able to address issues directly or refer caregivers for further counseling or other necessary support (e.g., respite or home health services). APPROPRIATE REFERRAL FOR SPECIALIZED PALLIATIVE CARE SERVICES AND HOSPICE There are many barriers preventing neurologists from appropriately referring patients to specialized palliative care services and hospice. Unsatisfactory prognostic predictors for specific illnesses, fear of diminishing hope in patients, and physicians’ lack of fundamental palliative care skills are examples of obstacles that contribute to the underutilization of these services. Limitations of Medicare hospice guidelines for neurologic illnesses (see table) also present a potential obstacle, including being overly conservative for patients with amyotrophic lateral sclerosis and dementia compared with newer empiric criteriae12,e13 and nonspecific or nonexistent for patients living with PD, MS, and other less common conditions.21 Referral to specialist palliative care services are warranted if patients or family members have needs going beyond their physicians’ ability to manage and may include the following: end-of-life care, feeding tube discussions or other complex interventions, spiritual concerns, distressing psychological issues, lack of caregiver or need for additional caregiver support, difficult to control physical symptoms, need for capacity assessment or power of attorney disputes, home safety issues, or communication issues within a family. Red flags such as frequent hospital admissions (e.g., pneumonia, falls, and urinary tract infection), unexplained weight loss, dysphagia, restricted activities of daily living, increased somnolence, or a rapid decline in function may signify the need for referral to hospice. Research suggests that patients are referred to hospice too infrequently or too late. Thirty percent of patients with advanced dementia go to hospice, and 25% of hospice stays are 3 days or less.e14 The benefits of referral to palliative care services are becoming increasingly well-documented, including in neurologic populations.26 A well-publicized randomized controlled trial of palliative care vs standard oncology care for 151 patients with metastatic lung cancer found improvements in not only quality of life and depression but also median survival (11.6 vs 8.9 months).13,26 Similarly, a well-performed randomized controlled trial of 52 patients with advanced MS showed that outpatient palliative care improved caregiver burden and reduced the cost of care, including less inpatient care.e15 WHAT RESOURCES ARE NEEDED TO SET UP A PALLIATIVE CARE TEAM IN MY PRACTICE? The following is an outline of resources needed to set up a palliative care team in a neurology practice and is based on the University of Colorado Hospital Outpatient Neurology Supportive & Palliative Care Clinic and the University of Toronto Palliative Program for Parkinson Disease and Related Disorders. Part of our impetus for setting up these clinics was the need for an interdisciplinary team to adequately address the full breadth of palliative care issues facing our patients. Ideally, a palliative care team should consist of a physician, social worker, and counselor with some spiritual training. Notably, spiritual support services are associated with higher quality of life across multiple studiese16; however, having spiritual support from the community, but not from a medical team, may be associated with more aggressive treatment.e17 More important than the specific makeup of the team is the commitment of its members. The University of Toronto team includes a neurologist, palliative care physician, and a spiritual advisor, whereas the University of Colorado Hospital team includes a neurologist, a nurse with prior hospice experience, a social worker, a chaplain, and an acupuncturist. We strongly encourage all team members to pursue palliative-specific readings and workshops if they do not have a background in this area.10 The American Academy of Neurology and many subspecialty meetings now have neurology-specific palliative care offerings. The logistics of palliative care may differ from standard patient visits. Our initial visits may last more than 2 hours, and we encourage family members and informal caregivers to attend palliative care appointments. Both clinics were started with volunteer help and are partially dependent on philanthropy to maintain their full operation. Local disease-specific organizations may be interested in providing social work or other support for clinics. We find that on-site and integrated consultations do make a difference regarding both access and quality of care. RESEARCH AND EDUCATIONAL PRIORITIES Interest in palliative care within the neurologic community is increasing, but there are several research gaps that need to be addressed, including: 1. Development and validation of more accurate prognostic predictors, particularly for 6-month survival to alert physicians for potentially appropriate hospice referrals. 2. Better identification of high-risk patients and caregivers for palliative care referrals. 3. Clinical trials including implementation studies to improve management of nonmotor symptoms. 4. Patient-centered studies to identify and characterize palliative care needs in neurology and patient preferences for addressing these needs. 5. Cost-effectiveness and outcome studies of palliative care interventions. Despite recent efforts to improve the palliative care training of neurology resident physicians, only 52% of programs offer a didactic experience in endof-life and/or palliative care, and less than 8% provide a clinical rotation.3 These data support the continuing need for enhanced palliative care training of neurology resident physicians. Neurologists and primary Neurology 83 August 5, 2014 565 care physicians may benefit from further training regarding primary palliative care skills through meetings, journals, and other continuing medical education opportunities. Palliative care teams may also need specialized training for managing neurology patients. Finally, patients and caregivers need more/better information about palliative care and hospice and may benefit from talks given in the community and online resources. 13. 14. 15. 16. 17. AUTHOR CONTRIBUTIONS I.B.: writing of the first draft and revision of subsequent drafts. 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Motor neurone disease family carers’ experiences of caring, palliative care and bereavement: an exploratory qualitative study. Palliat Med 2012;26:842–850. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP. SPIKES: a six-step protocol for delivering bad news—application to the patient with cancer. Oncologist 2000;5:302–311. VITAL talk. Available at: http://www.vitaltalk.org. Accessed March 18, 2014. Cheon SM, Ha MS, Park MJ, Kim JW. Nonmotor symptoms of Parkinson’s disease: prevalence and awareness of patients and families. Parkinsonism Relat Disord 2008;14: 286–290. Fruehwald S, Loeffler-Stastka H, Eher R, Saletu B, Baumhackl U. Depression and quality of life in multiple sclerosis. Acta Neurol Scand 2001;104:257–261. Simmons Z, Bremer BA, Robbins RA, Walsh SM, Fischer S. Quality of life in ALS depends on factors other than strength and physical function. Neurology 2000;55: 388–392. Chaudhuri KR, Healy DG, Schapira AH; National Institute for Clinical Excellence. Non-motor symptoms of Parkinson’s disease: diagnosis and management. Lancet Neurol 2006;5:235–245. Chen JJ, Marsh L. Depression in Parkinson’s disease: identification and management. Pharmacotherapy 2013;33: 972–983. Lemke MR, Fuchs G, Gemende I, et al. Depression and Parkinson’s disease. J Neurol 2004;251(suppl 6): VI/24–VI/27. Heyland DK, Barwich D, Pichora D, et al. Failure to engage hospitalized elderly patients and their families in advance care planning. JAMA Intern Med 2013;173: 778–787. Neurology 83 August 5, 2014 567 Top 10 Things Palliative Care Clinicians Wished Everyone Knew About Palliative Care Strand, Jacob J, MD;Kamdar, Mihir M, MD;Carey, Elise C, MD Mayo Clinic Proceedings; Aug 2013; 88, 8; ProQuest Central pg. 859 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Vol. 50 No. 6 December 2015 Journal of Pain and Symptom Management 741 Special Article The Business Case for Palliative Care: Translating Research Into Program Development in the U.S. J. Brian Cassel, PhD, Kathleen M. Kerr, BA, Noah S. Kalman, MD, MBA, and Thomas J. Smith, MD, FACP, FASCO, FAAHPM Massey Cancer Center (J.B.C., N.S.K.), Virginia Commonwealth University, Richmond, Virginia; Kerr Healthcare Analytics (K.M.K.), Mill Valley, California; and Johns Hopkins University (T.J.S.), Baltimore, Maryland, USA Abstract Specialist palliative care (PC) often embraces a ‘‘less is more’’ philosophy that runs counter to the revenue-centric nature of most health care financing in the U.S. A special business case is needed in which the financial benefits for organizations such as hospitals and payers are aligned with the demonstrable clinical benefits for patients. Based on published studies and our work with PC programs over the past 15 years, we identified 10 principles that together form a business model for specialist PC. These principles are relatively well established for inpatient PC but are only now emerging for community-based PC. Three developments that are key for the latter are the increasing penalties from payers for overutilization of hospital stays, the variety of alternative payment models such as accountable care organizations, which foster a population health management perspective, and payer-provider partnerships that allow for greater access to and funding of community-based PC. J Pain Symptom Manage 2015;50:741e749. Ó 2015 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Key Words Palliative care, finance, health economics, payment reform, policy Introduction In his famous ‘‘Escape Fire’’ speech, Dr. Donald Berwick diagnosed the foundational problems with the U.S. health care system and articulated a vision for its transformation. He stated that for a comprehensive solution to succeed and be broadly adopted today, it must make sense from four distinct perspectives: Whatever ‘‘escape fire’’ [revolutionary innovation] we create has to make sense in the world of science and professionalism, in the world of the patient and family, in the world of the business and finance of health care, and in the world of the good, kind people who do the work of caring. I think the toughest part of this may be in terms of the business and financing of care. There is a tendency to assume that financial successde.g., thriving organizationsdand great care are mutually exclusive. However, we will not make progress unless and until these goals become aligned with each other.’’1 Address correspondence to: J. Brian Cassel, PhD, 1101 E Marshall Street, Box 980230, Richmond, VA 23298, USA. E-mail: JBCassel@VCU.edu Ó 2015 The Authors. Published by Elsevier Inc. on behalf of American Academy of Hospice and Palliative Medicine. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). This is certainly true of the field of palliative care (PC). The clinical-moral imperative that has driven innovators and practitioners in the field is necessary but insufficient for catalyzing and sustaining widespread investment in PC programs. Unless and until stakeholdersdhealth system administrators, physicians, and payersdperceive a clear path to the financial viability of specialist PC programs, they will not support fully the development of such services.2,3 Clinical leaders who have struggled for years to garner support for PC services can attest to the degree to which the misalignment of clinical and financial incentives has stymied the creation and expansion of specialist PC services. This phenomenon has been explored in at least one national study: in a survey of cancer centers in the U.S., financial issues were the most-often perceived barrier to PC program implementation.4 Accepted for publication: July 7, 2015. 0885-3924 http://dx.doi.org/10.1016/j.jpainsymman.2015.06.013 742 Cassel et al. The Clinical-Financial Disconnect Why is there such misalignment between clinical and financial interests? The U.S. health care system is fundamentally rooted in a fee-for-service (FFS) model, where third parties compensate providers for each service delivered to patients. In such a system, there is a direct correlation between the quantity and intensity of health care provided and the amount of revenues collected by systems and individual providersdmore activity (procedures, tests, and hospitalizations) results in more revenue. In contrast, the field of PC uses a ‘‘less is more’’ philosophy, where attention to patient and family needs and clarification of care goals often lead to reduced use of the most expensive health care services (such as inpatient admissions and emergency department [ED] visits) and increased use of less expensive services (such as home-based services). With hospice, insurers cut through this obstacle by offering an entirely separate benefit that is mutually exclusive with continuation of disease-focused health care. The business case for specialist PC outside of hospice is more complex and more subtle, in part because PC needs to be provided concurrently with disease-focused therapies, rather than in the ‘‘either/ or’’ forced choice inherent in the current regulations of the Medicare Hospice Benefit. From the perspective of a hospital entrenched in the FFS reimbursement model, shifting activity away from hospital care does not make much financial sense. In a description of the Advanced Illness Management Program developed by SutterHealth, a program leader noted that although the intervention was successful in increasing hospice utilization, reducing hospitalizations and lowering costs of care, the misalignment of quality and financial incentives posed a serious challenge: ‘‘The current reimbursement system does not pay for Advanced Illness Management-type services, such as care coordination and hospital-to-home transition. Reduced hospitalizations cost Sutter hospitals more in lost revenue than they gain from dollar savings.’’5 The goal of this article is to help insurance and hospital executives, PC leaders, and policy makers to understand the extent to which the clinical/moral and financial imperatives for PC are actually aligned and the congruence between positive clinical and financial outcomes. Although numerous studies have documented the impact of PC on costs,6e9 no prior article has presented a comprehensive assessment of the financial or business imperative for PC and how it could be aligned with the clinical/moral imperative. Drawing on the published literature and our technical assistance work with hundreds of PC programs over the past 15 years, we articulate the 10 principles that together create the economic rationale for specialist Vol. 50 No. 6 December 2015 teams to provide an additional layer of support for patients (and families) facing progressive life-limiting diseases. These principles also refer to and reflect the increasing importance of the pay-for-quality movement that is slowing supplanting the FFS model. The 10 Principles of the Business Case for PC Principle 1: Persons with serious illness, especially those with progressive life-limiting diseases [and their families] are at risk for pain and suffering from multiple sources; PC helps prevent or improve those outcomes. The business case for specialist palliative care (SPC) begins with the clinical case. Without a clinical imperative, there would be no need for a financial model; recall that the national Medicare Hospice Benefit followed (by eight years) the founding of the first hospice in the U.S. Voluminous evidence speaks to the extent to which patients with serious illness and their families suffer; there is equally strong and abundant evidence of how SPC services help to mitigate or even prevent that suffering.10e16 Principle 2: Persons with progressive life-limiting diseases often have heavy utilization of expensive health care services (e.g., ED visits, frequent and lengthy hospital admissions), some of which are avoidable. These utilization patterns are often evident in the last months of life but may occur earlier in the disease course. The literature on this, too, has become voluminous; three studies are worth highlighting. A recent study showed that one-half of older Americans go to a hospital ED in the last month of life; once there, threequarters are hospitalized; and of those hospitalized, more than two-thirds die in the hospital.17 For three major diseases, Medicare patients are increasingly receiving intensive care unit (ICU) care in the last month of life, and more than one-quarter of those dying in hospice care have received hospice for less than three days.18 This utilization of hospital services at the very end of life would be acceptable if such care was aligned with patient and family preferences. Unfortunately, this is not the case: studies continue to show that the proportion of people who die in hospitals and nursing homes exceeds the proportion of those who identify these sites as their preferred location of death.19 Worldwide, more than 80% of people want to die at home.20 Principle 3: Hospitalizations toward the end of life tend to be lengthy and costly; these can result in negative fiscal outcomes for hospitals and payers, in both FFS and risk-based revenue models. Published studies have documented the duration and cost of hospitalizations near the end of life, which Vol. 50 No. 6 December 2015 Business Case for Specialist Palliative Care have clear implications for payers.6,7,21,22 But studies on either hospital costs or on payer expenditures do not in themselves describe whether the reimbursement from payers to hospitals results in positive or negative financial outcomes for the hospitalsdare they breaking even or experiencing positive or negative margins? One needs to know both parts of the equation, but such results are not usually published. To understand the magnitude of financial risk for both payers and providers, we present below some data from the Virginia Commonwealth University (VCU) Health System, which contrasts hospital costs and reimbursements (payer expenditures) across three groups of Medicare beneficiaries: those who died in the hospital, those with very serious illness and high mortality risk, and all other admissions (Fig. 1). Reimbursement for the cases in the first two groups (deaths and high-risk survivors) is around three times greater than that seen in the ‘‘all other’’ group, representing the burden on Medicare; but even more striking is that Medicare’s reimbursement falls short of the actual costs incurred by the hospital. The net loss for hospitalizations of Medicare patients at this hospital for that year was driven entirely by the 16% of cases that ended in death or had high risk of deathdcases that may be PC relevant. Another analysis of VCU data depicts the worsening net margin among cancer and congestive heart failure (CHF) admissions in the six months before death (Fig. 2). As this graph indicates, the FFS reimbursement model for inpatient care does not guarantee a positive net margin. With the inpatient prospective payment system that Medicare uses (and which is emulated by many other payers), the amount of reimbursement per case is predetermined by the clinical and utilization characteristics that are used in the diagnosis-related group (DRG) classification system. Within any given DRG, a hospital may have a positive net margin if their costs are low but a negative margin if their costs exceed the predetermined payment. Fig. 1. Inpatient admissions of Medicare patients at Virginia Commonwealth University hospital in Fiscal Year 2011, stratified by their disposition at discharge: deaths, survivors with high risk of mortality, and all others. aHigh-risk survivors defined as discharged to hospice or those with all patient refinedediagnosis-related group risk of mortality score of 4 combined with severity of illness score of 3 or 4. bNet margin represents revenues less total costs. 743 Hospitals may be unaware of the extent to which end-of-life care is driving such losses; in our experience, most hospitals conduct their financial analyses by major disease groups (e.g., cancer, cardiology, neurological) and not in terms of disease course. As pay-for-performance and shared savings programs become more prevalent, financial analytics will have to adopt this population health management perspective. Analyses such as these may reveal previously underappreciated financial risks for hospitals regarding the unprofitability of near-end-of-life hospitalizations (i.e., those ending in death or that occur in the last few months of life). It may be that some hospitals would rather examine contribution margin (reimbursement minus direct costs) rather than net margin (reimbursement minus total costs), but the principle is the samedlong resource-intensive admissions toward the end of life may not be generating the kind of positive net margin that hospitals see for the bulk of their admissions. Further research is certainly warranted on this issue of the net margin for hospitalizations near the end of life, taking into account both hospital costs incurred and payer expenditures. Principle 4: Hospitals are penalized by payers, notably the Centers for Medicare and Medicaid Services (CMS), for high 30-day readmission rates, 30-day mortality rates, and similar measures; a significant portion of this is driven by care at the end of life. In a major shift, CMS is now penalizing hospitals for excessive rates of hospitalizations associated with poor coordination of care (high readmission rates) and poor quality (high 30-day mortality rates). Medicare has two separate programs in effect. In the Readmission Reduction Program at issue is the rate of readmissions within 30 days for initial hospitalization for specific conditions or procedures.23 When the program started in federal fiscal year (FFY) 2013, the penalties were as much as a 1% reduction in DRG payments, and penalties have increased to up to 3% for FFY 2015. It is important to note that the penalty affects all Medicare hospitalizations for a given hospital, not just the conditions used to measure performance. The Kaiser Foundation reports that 2610 hospitals are being fined in 2014 and that 39 hospitals are receiving the highest penalty of 3% of payments.24 In Maryland, the last state in which Medicare pays for hospitalizations without DRGs, reimbursement is now fixed per hospital per year so that Medicare will not pay for any additional hospitalizations, thus having the same effect.25 The second program is the Value-Based Purchasing Program, which increases or reduces payments to acute-care hospitalsdup to 1.25% currently, increasing to a maximum of 2.0% by FFY 2017.26 An 744 Cassel et al. $2,00,000 $1,00,000 $- Vol. 50 No. 6 December 2015 Annual net margin by month for cancer and heart failure inpaƟent admissions of Medicare paƟents in final 6 months of life $1,04,660 $13,624 $4,587 $(14,745) $(7,956) $(17,810) $(46,798) $(67,749) $(1,00,000) $(93,668) $(98,622) $(2,00,000) Cancer Annual CHF Annual $(3,00,000) $(3,44,533) $(3,73,002) $(4,00,000) 6 mo 5 mo 4 mo 3 mo 2 mo 1 mo Fig. 2. Virginia Commonwealth University hospital data Fiscal Year 2010 to Fiscal Year 2012. X-axis is the month before death, ascertained from inpatient deaths and by querying data from the Social Security Death Master File to identify patients who died in other settings. The Y-axis is the net margin for this hospital (reimbursement minus total costs). CHF ¼ congestive heart failure. overall score for a hospital is based on its performance on process measures, outcome measures (including 30-day mortality rates for three conditions), and patient experience (satisfaction); outcome measures recently increased to 40% of the total score. Like the readmission program, Value-Based Purchasing affects all acute care payments from Medicare for a given hospital, not just payments for the conditions used in the metrics. From a hospital finance perspective, a single end-oflife hospitalization can have all three unwanted characteristics: it can produce a negative net margin, it can be a readmission from a prior hospitalization, and it can be associated with death within 30 days.27 Led by CMS, the largest health care payer in the U.S., payers are slowly shifting from paying for quantity to paying for quality; CMS has announced that by the end of 2018, 50% of Medicare payments will be tied to quality or value28 through alternative payment models or value-based payments. The implications for hospitals are clear: business as usual is beginning to shift, opening up greater alignment between the clinical and nonclinical outcomes for the field of PC (although some of the metrics used by CMS to date focus on sudden conditions such as acute myocardial infarction for which PC is not involved). PC has always been associated with quality and has been shown to have a mitigating effect on overutilization of some types of health services. Indeed, many measures of quality, such as those endorsed for cancer end-of-life care by the National Quality Forum,29 make an explicit link between quality and overutilization of some types of health care services (hospitalizations, ICU stays, and ED visits) and underutilization of other services (such as hospice and PC). The attention that payers are giving to measures of overutilization presents a clear opportunity to the PC field, which can demonstrate that some of these admissions and readmissions near death could be avoided through better outpatient and home-based care. This represents a different interpretation of what kind of quality the 30-day mortality measure purports to be monitoring.30 A high rate of 30-day mortality for CHF admissions may not represent poor quality of inpatient CHF care; but it could very well represent poor quality of ambulatory CHF care or inadequate access to early PC. Principle 5: Community-based PC (CBPC) improves symptoms, coordinates care, and reduces ED visits and hospitalizations in the months before death. Hospice care is being used very close to the time of death,18,31 and inpatient PC can only be provided once patients are hospitalized. Thus, there is a profound need for nonhospice PC to be provided in the weeks and months before death, in settings outside the inpatient hospitaldwhat is being termed CBPC. Rabow et al.32 summarized the evidence that CBPC reduces hospital utilization while improving patient-reported outcomes, such as distress, symptom management, and satisfaction with health care. Dramatic growth and interest in CBPC in the past few years is driven by the recognition that inpatient PC alone is insufficient and by the compelling evidence from randomized controlled trials of home-based Vol. 50 No. 6 December 2015 Business Case for Specialist Palliative Care PC33 and of outpatient clinic-based PC.34 We discuss the financial implications of CBPC in Principle 9. Principle 6: Inpatient PC improves symptoms, coordinates care, and reduces the cost of hospital admissions that do occur. Numerous studies provide evidence that inpatient PC consultation services and units improve symptoms10e13,35 and reduce hospital costs6e9,36 in the days after consultation, and this finding is not limited to decedents.37 The key to understanding the business case for inpatient PC is to understand whose costs are saveddare hospital cost savings passed on to payers? Largely, nodbecause of the payer mix, payers’ reimbursement structures for inpatient care, and the timing of PC involvement within a hospitalization.9  Payer mix. According to one multisite study, the payer mix for inpatient PC is about 70% Medicare, 11% Medicaid, and less than 20% all otherdcommercial, health maintenance organizations, preferred provider organization, Tricare, self-pay, indigent, and so on.38  Structure of reimbursement for the predominant payers. Medicare and most states’ Medicaid reimbursement for hospital care is paid through DRGs or similar per-case mechanisms.39  Timing. Extended lengths of stay are often a trigger for PC consultation,40,41 and several articles have described a significant proportion of PC referrals occurring only after a week or more of hospitalization has passed.38,42e45 Consider a scenario in which a patient was admitted to the ICU from the ED and remained in that unit until the PC team was consulted on hospital day 8. The PC intervention could reduce costs in the days after consultation but could not affect the costs of procedures or ICU use that occurred during the first eight days: and it is very likely that the patient’s diagnosis and the utilization that occurred in hospital days 1e8 would determine the DRG designation and, therefore, reimbursementdthese would not be changed by a PC intervention that began on day 8. If the PC intervention results in clarification of goals and alteration of treatment plans such that the patient is transferred out of the ICU and into a less expensive unit, the cost savings that the hospital sees are real, because the payment is already fixed (set) regardless of actual costs. Conversely, in such a scenario, cost savings would not be passed on too payers who use a DRG-based fixed payment system because their payment or expenditure was prospectively determined and is not linked to the details of the services rendered. There is some evidence that inpatient PC indirectly helps to influence postdischarge utilization to the 745 extent that it increases access to CBPC or hospice,42,46 and such changes would reduce payer costs. Similarly, it is possible that PC involvement early in a hospitalization could affect what procedures are done, thus affecting the DRG assignment and payer expenditures. But overall, there is a strong incentive for hospitals, but no incentive or only a weak one for payers, to invest in inpatient PC. Principle 7: In the usual FFS model, third-party revenue for PC services covers only a portion of the full cost of a multidisciplinary PC team, so subsidies or new contractual approaches are needed. Services that are provided to patients with progressive diseases often generate substantial clinical revenues (e.g., chemotherapy for cancer; surgery and implanted devices for cardiac care), whereas revenues for PC are quite modest. CMS and most commercial plans do not offer any supplemental payments or special benefit packages to health systems for providing PC. Specialists who can bill for their services are reimbursed at modest rates for evaluation and management visits, but such billings are typically insufficient to cover the entirety of salary and benefit costs of the multidisciplinary team.47 This is the case for both inpatient and community-based services. Moreover, some core PC team membersdregistered nurses, many hospital-based social workers, and chaplainsd cannot bill third parties despite their central role in providing interdisciplinary PC. The inadequacy of clinical revenue may be exacerbated by poor billing practices48 and/or the increasingly competitive salaries required for recruiting and retaining PC specialists. Therefore, specialist PC programs often need a funding source other than (traditionally structured and priced) clinical revenue to support the full costs of their interdisciplinary teams.47 It is important that PC programs be able to describe or project the cost of delivering care, as well as the direct cost savings and indirect financial contributions the program will make.43 Understanding the full cost of the PC intervention and the full spectrum of expected (or actual) benefits is a prerequisite to securing program support from a health system or a service contract from a payer. Tools are available to help institutions estimate their costs and benefit.49,50 Principle 8: For hospitals, the combined value of lower costs and operational impacts from inpatient PC almost always exceed the cost of staffing the service (positive return on investment); this would be applicable in both FFS and risk-based revenue models. Because inpatient PC reduces costs in the context of case-rate payments (see Principles 3 and 6), and the relative ease with which the cost reduction can be measured and attributed to SPC involvement,7 it is fairly easy for inpatient PC programs to demonstrate 746 Cassel et al. that they produce cost savings greater than the subsidies needed for the multidisciplinary team. An example in a published article was provided by Morrison et al.,43 in which financial impact was estimated at greater than four times more than the investment for program personnel. Similar estimates at VCU have resulted in a return on investment of greater than five times the investment. All that is required is a quantification of two thingsdcost savings caused by SPC involvement, and the annual amount of PC program funding that is not covered directly by third-party reimbursement. Principle 9: The return on investment for CBPC depends on the degree to which fiscal and quality incentives are aligned; in general, entities that are at risk for high cost care at the end of life have the greatest incentive to invest in CBPC. Although the return-on-investment analyses for inpatient PC are relatively straightforward, the issue is a bit more complex for CBPC. As shown in Principle 5, early engagement of PC may help to prevent hospitalizations by making them unnecessarydthrough better symptom management and care coordination, for example. From a payer perspective, the cost savings may be real and significant, a circumstance that has fueled a number of payer-provider partnerships to deliver CBPC.51e54 Why would a health system or hospital invest in such a CBPC program? One scenario is that the hospital realizes that the status quo for end-of-life care is resulting in negative net margins and that it is being penalized for readmissions and 30-day mortality admissions; even in a traditional FFS context, that hospital may recognize that the clinical and financial incentives for CBPC are already aligned (see Principles 3 and 5). Alignment is much more likely in hospitals that are part of alternative payment methodologies, such as health maintenance organizations, shared savings programs, and accountable care organizations (ACOs), in which there is a stronger and more explicit reward for minimizing overutilization of the costliest health care services.55 Indeed the push to overcome barriers can come from health plans, which have a strong interest in controlling their expenditures, and providers.56e58 Although the primary purpose of CBPC is to proactively manage symptoms, prevent and alleviate distress, and coordinate care more effectively, there is a strong need to align these patient-centered outcomes to an entity’s financial interests to get programmatic supportd budgetary, political, and operational. This must include quantification of the costs and revenues associated with reducing some forms of health care, such as hospitalizations; increased costs and revenues associated with increasing other forms of health care (e.g., CBPC, Vol. 50 No. 6 December 2015 home health, hospice); reductions in unwanted penalties from overutilization (e.g., 30-day morality admissions); and, where relevant, the financial rewards of more efficient care, for example, when entities have risk-bearing contracts, or are part of an ACO. Health care reimbursement is a moving target. As payers and providers continue to coevolve in the context of their changing symbiotic relationships, we will continue to see new structures for sharing savings and sharing risk, which create incentives for bending the cost curve while maintaining quality and patient-centered outcomes. Understanding the role of CBPC in this, and quantifying projected and actual impacts, is not a one-time event; it is a process that must be done continually. Principle 10: All types of health care organizations can evaluate opportunities for and impact of PC. Although much of the evidence cited here has come from studies and systematic reviews conducted at academic centers, we believe that the essential pieces of data could be analyzed by any community hospital, integrated health system, or insurer. Many of the analyses regarding inpatient PC are well established and have been translated to inpatient SPC programs of all sizes nationwide through the ‘‘Palliative Care Leadership Center’’ technical assistance program, operated by the Center to Advance Palliative Care since 2004.59 Emerging data-based approaches to planning and evaluating CBPC programs have been made available as well.49,50 Use of These Principles There are several ways that these principles can be put to use. First, we would encourage researchers to note that there are some principles for which the published empirical evidence is rather thin. Three areas stand out: the impact of CBPC in noncancer populations; how much of a PC program’s budget is covered by clinical revenue (in the context of third-party reimbursement); and the worsening financial margin for hospitalizations closer to the date of death (in the context of third-party reimbursement). An obstacle to research on the latter two is that health systems treat their revenue data, and their net margin, with greater secrecy than their cost data alone. But in the FFS environment, knowing the costs of care relative to revenue is a key issue in understanding the sustainability of the status quo or of innovations. Second, these principles can provide the framework for program-specific business plans. Each component of this model can draw on institutional dataddescribing the clinical need for new or expanded SPC services; the potential or actual impact of inpatient and/or community-based SPC; the anticipated or existing gap between third-party Vol. 50 No. 6 December 2015 Business Case for Specialist Palliative Care revenues and the program budget; the intensity and cost of various kinds of inpatient hospitalizations and the use of hospital care in the months leading up to death for various disease groups. These components can then be pulled together into a cohesive plan that makes a compelling argument for administrators to consider. It is important for SPC leaders to understand these principles to make their case in a clear and internally coherent way and equally important to know where their institution stands in the shifting health care reimbursement landscape. Is it entrenched in the FFS model or transitioning to the population health management and pay-forquality model? The answer will have significant implications for how much traction one can expect for various pieces of the business case. It may be most difficult to get traction for CBPC in an institution that is firmly entrenched in the FFS modeldfor example, not participating in ACOs or other payer initiatives that would welcome more efficient patient-centered health care. Third, we have found repeatedly that neither researchers nor hospital administrators necessarily believe that research findings produced at another institution are valid and relevant at one’s own. Local data are almost always needed to make the business case for such programs, and then published data are used to validate and support the local findings. However, any health system that uses this or a similar framework should recognize that producing local evidence for some of these principles (e.g., ED visits and hospitalizations increase in frequency and cost toward the end of life) will demand some sophisticated financial analyses. Technical assistance materials are now available from a variety of sources including the Center to Advance Palliative care (https://www.capc.org), the California State University Institute for Palliative Care (csupalliativecare.org), and the California Coalition for Compassionate Care (http://coaliti onccc.org/tools-resources/palliative-care/). 747 Conclusions In the U.S., health care is often performed as a set of business transactions, and the health system is both revenue centric and hospital centric. In that context, the easiest innovations for providers (physicians and hospitals) to implement are those that generate more revenue from payers than the costs the providers incur. A special business case for PC is necessary because the specialist teams cost more than they produce directly in revenue, and in fact PC involvement may reduce hospitalizations, which are the primary source of revenue for hospitals. The U.S. health care system may be unique in the extent to which it applies capitalistic principles to health care, but the development of PC is a global phenomenon. Some of the principles are universaldsuch as the clinical imperativedwhereas others may be uniquely relevant in the FFS context that underlies so much of the U.S. health care system. The business case for inpatient SPC is well established and is reflected in the rapid growth of SPC programs in more than 60% of U.S. hospitals.65 The business case for community-based SPC is emerging and is most relevant where health systems are partnering with payers to deliver more efficient patientcentered high-quality care. Disclosures and Acknowledgments This work was supported in part by NCI Cancer Center Support Grant P30CA016059 to VCU Massey Cancer Center; National Center for Advancing Translational Science grant UL1TR000058 to VCU Center for Clinical and Translational Research; and grants 17686 and 17373 from the California HealthCare Foundation. Funders did not play any role in the content of this article. The authors declare no conflicts of interest. The authors thank Diane Meier, Lynn Spragens, Egidio Del Fabbro, Irene Higginson, and Michael Rabow for their contributions. Limitations Beyond the paucity of evidence of some principles as described earlier, the major limitation of this synthetic review is that the findings cited are largely from nonexperimental studies and thus subject to the weaknesses inherent in observational research, such as the potential for selection bias.60 Researchers using nonexperimental methods have used several techniques including the use of an instrument variable and using propensity scores to control or select matched comparison cases.61e64 A recent article that used a large number of clinical and demographic characteristics in its propensity-based matching found a significant effect of PC involvement on cost reduction among hospitalized cancer patients.41 References 1. Berwick DM. Escape fire: Lessons for the future of health care. 1999. Available at: http://www.commonwealthfund.org/ usr_doc/berwick_escapefire_563.pdf. Accessed November 25, 2014. 2. Meier DE. 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