Given these statements from patients and family caregivers, how can providers best shape their ­practices to achieve those goals? Optimizing palliative care is one strategy that will contribute to this outcome. The Center for Medicare and Medicaid Services defines palliative care as follows: Palliative care means patient and family–centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and facilitates patient autonomy, access to information, and choice (73 Federal Register 32204 2008).

Hospice, a specialized form of palliative care has been effectively caring for patients with limited life expectancies and their families for many years. The success of hospice is characterized by its remarkable utilization statistics. According to the National Hospice and Palliative Care Organization as of 2009, there were 3,400 programs of which 93% were Medicare-certified. These programs served 1.56 million Americans, primarily in their homes (56% of days), nursing homes (29% of days), or assisted living facilities (10.9% of days). In 2009, over 40% of Medicare decedents utilized hospice in their care, an increase from 23% in 2000 (National Hospice and Palliative Care Organization 2010; MedPAC 2010). It is noteworthy that more than 80% of hospice beneficiaries are over age 65 and more than a-third are over 85 years of age. Ten years ago, the majority (53%) of hospice patients died from cancer. By 2008, that percentage had dropped to 31% reflecting a pattern of utilization increasingly correlated with the current leading causes of death (cancer accounts for less that 25% of U.S. deaths) (MedPAC 2010; National Hospice and Palliative Care Organization 2008). This shift demonstrates that hospices are responding to the circumstances and needs of Medicare beneficiaries.

Unlike the hospice community, palliative care as a recognized specialty service is a relative ­newcomer to the health care arena. Palliative care embraces the interdisciplinary focus of hospice and extends expert pain and symptom management and supportive care to patients with complex chronic illnesses who are not yet eligible for, or who have not elected hospice.

What is it about palliative care and hospice care services that makes them a good fit for the needs of patients and families and with the challenges of health care reform? According to the National Consensus Project Clinical Practice Guidelines for Quality Palliative Care, “the goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care is both a philosophy of care and an organized, highly structured system of delivering care. Palliative care expands traditional disease-model medical treatments to include the goals of enhancing quality of life for patient and family, optimizing function, helping with decision-making, and providing opportunities for personal growth. As such, it can be delivered concurrently with life-prolonging care or as the main focus of care” (National Quality Forum 2006).

The Guidelines continue: “Palliative care is operationalized through effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care with ­consideration of patient/family needs, preferences, values, beliefs, and culture. Evaluation and ­treatment should be comprehensive and patient-centered with a focus on the central role of the ­family unit in decision-making. Comprehensive palliative care services often require the expertise of various providers to adequately assess and treat the complex needs of seriously ill patients an their families. Leadership, collaboration, coordination and communication are key elements for effective integration of these disciplines and services” (National Quality Forum 2006).

Why do we need palliative care? Despite enormous expenditures, studies demonstrate that patients with serious illness and their families receive poor-quality medical care, characterized by untreated symptoms, unmet psychosocial and personal care needs, high caregiver burden, and low patient and family satisfaction (Field and Cassel 1997; Thorpe and Howard 2006; Foundation 2005; Foundation 2009; Teno et al. 2004). The patients served by palliative care providers are those with chronic complex illnesses. This population of represents more than 95% of all health care spending. About 64% of all Medicare spending is for the 10% of beneficiaries with 5 or more chronic conditions. However, despite the heavy allocation of health care dollars spent on this population of patients, the data in these studies offer abundant evidence that the care they receive is poor.

How do we know that palliative care and hospice help to conserve health care dollars? Based on recent findings, the per patient net costs saved by hospital palliative consultations are $2,659 (Morrison et al. 2008). This figure is clearly an underestimate of the potential savings as many ­hospitalized patients with advanced and chronic illnesses do not have access to a palliative care consultation referral.

Hospices have also been shown to contribute significant cost-savings among the majority (70%) of Medicare beneficiaries (Taylor et al. 2007; Taylor 2009). Using propensity score analysis to control for selection bias, an estimated $2,300 is saved per beneficiary on average. Extrapolating this average savings across the number of hospice patients served each year yields overall savings of more than $3.5 billion a year. The savings attributed to hospice patients persisted through 233 days of hospice care for cancer patients and 154 days of care for noncancer patients (ASPE et al. 2010). In addition, recent analysis have found that the costs of care for patients who disenrolled from ­hospice were nearly 5 times higher than for patients who remained with hospice. Patients who ­disenroll from hospice are far more likely to use emergency department care and to be hospitalized (Carlson et al. 2010).