End‐of‐Life Care Matters: Palliative Cancer Care Results in Better Care and Lower Costs

There are clearly two problems facing people at the end of life. The first is that quality care does not reach enough people, and the second is that the rising costs of health care over preceding decades have imposed a substantial financial burden on patients, families, and the health care system. These two major problems may be mitigated with earlier and increased palliative care (PC) involvement, with mounting evidence confirming the benefits of PC on both costs and quality of care [1–8]. This is a significant realization, as the primary goal of any medical intervention is never cost reduction, and reducing costs also reduces the quality and intensity of services being delivered. For example, an orthopedics practice attempting to reduce costs by delaying hip replacement surgery would inevitably create more pain and disability for the patient. Such attempts at cost reductions that disregard outcomes are potentially dangerous and unacceptable. PC is unique in that sense, for by increasing PC interventions, the primary clinical effects—decrease in symptom burden, increased communication between teams, and better alignment of treatment with patient’s goals—occur in conjunction with cessation of ineffective or unwanted treatments and decreased hospital and intensive care unit (ICU) services, thereby achieving the secondary and unintended outcome of cost reduction. Despite much evidence, end-of-life care and planning continues to be ignored in most contexts. The politics of the matter are especially controversial. Prior to the enactment of the 2010 Patient Protection and Affordable Care Act (ACA) [9], a proposal for providing Medicare coverage for end-of-life counseling became highly charged, as some opponents misrepresented such planning to be synonymous with physician “death panels,” deciding who will live or die. The myth was quickly discredited but not before the final ACA bill had been stripped of any reference to end-of-life care. Not until 2016 did Medicare fix it, and voluntary end-of-life counseling became reimbursable. This correction was most appropriate because the Institute of Medicine (IOM) identifies patient-centeredness along with the delivery of safe and effective treatments as crucial aspects of quality health care, including at the end of life [10]. In recent years, value-based health care performance measures have been proposed, with rising recognition that care must deliver effective patient-based outcomes through patientcenteredness, quality, and cost containment. Michael Porter has defined value in health care in terms of patient health outcomes being achieved relative to the costs of care, although, importantly, such value is only created when health outcomes are never compromised [11]. Focusing on value, not just costs, avoids the pitfall of choosing expensive or obligatory treatments and allows for the consideration of effective personalized treatments that may become best practice [11]. In terminally ill cancer patients, effective outcomes inevitably vary with the stage of illness and functionality, necessitating individualized approaches that respect the patient’s goals, even ones not necessarily related to increasing survival. PC has emerged as a valuable intervention in recent years. To measure its value in oncological care, it is important to discuss the most common problems and challenges facing cancer patients, the effectiveness of PC interventions in addressing these, and the impact PC has on reducing health care costs. This article reviews the current state of end-of-life care, analyzes the clinical and financial impact of PC, and proposes areas of future research and development.