First, I need to reiterate what Dr. Alesi and her coauthors have so clearly stated: that there is a paucity of published data on most aspects of the delivery of palliative care (PC) services in the outpatient setting, although this now appears to be changing.
Second, to clarify my perspective on the subject, I am neither an oncologist nor a health services researcher but a full-time clinician and PC physician; I trained in internal medicine, palliative and hospice medicine, and pain medicine; and I have worked full time in palliative medicine for most of the past decade, and during the past 3 years increasingly in outpatient and home-based palliative care, as distinct from home hospice care.
Third, the definition of palliative care that I use is the same as that cited by Alesi et al, originally formulated by Diane Meier, MD. As a clinician, I very much agree with Meier’s description of palliative care as “…an extra layer of support….” for the patient, the family… and for the treating oncologist. Practically, I view the palliative medicine specialist’s skills to include (1) expert pain and symptom management; and (2) clarification of patients’ and families’ individual goals of treatment. In my clinical practice, I view hospice care as a subspecialty within the broader specialty of palliative medicine and operationally define it as specialized treatment for patients with a likely prognosis of 6 months or less in whom the primary clinical goals are comfort and avoidance of hospitalization, rather than disease-modifying treatment and the prolongation of life.
Finally, I do not view palliative medicine as ‘pre-hospice’ care or enrollment in hospice care as a necessary goal of PC, although many oncology patients who receive concurrent PC eventually receive hospice care.
Concurrent PC has been documented by numerous investigators to be beneficial both for patients receiving oncologic treatments and for their family members. In their article, the authors review concurrent oncologic and outpatient PC in four settings—a Canadian hospital, two US teaching hospitals, and a for-profit oncology practice, with emphasis on the latter, a ‘business-based practice.’
What is most notable to me about the article is the inherent adaptability of PC to a wide variety of ambulatory oncologic practice settings: a large Canadian hospital, where the healthcare and reimbursement system supports a high level of integration of concurrent palliative and oncologic care; two US teaching hospitals with well-established PC programs, including ambulatory clinics; and a pilot program embedding a PC practice within a business-based outpatient oncology practice. From the outcome data presented, the concurrent provision of PC to oncology patients in the US Oncology practice appears to have enhanced patients’ quality of life and improved the efficiency of the practice from a strictly business perspective. The description of the other practice venues strongly suggests that concurrent PC benefits cancer patients, their families, and their oncologists.
The adaptability of PC, particularly ambulatory PC provided concurrently with oncologic treatment, is highly relevant to the innovative modes of healthcare delivery that are being developed in light of impending changes in the US healthcare delivery system, the necessity of cost containment, and demographic shifts in the US population that are associated with aging of the ‘baby-boom generation.’ As healthcare delivery modalities such as the accountable care organization (ACO) and the patient-centered medical home (PCMH) are vetted and refined, this inherent adaptability will be key in program development offering wide patient access to the “extra layer of support” that PC provides.
Also notable about the authors’ description of four models of ambulatory PC provided concurrently with oncologic treatment, particularly the US Oncology model, is the significant contributions of advanced practice nurses (APNs) in patient assessment and, especially, in ongoing patient management. As a palliative care physician, it is notable to me that the US Oncology PC practice evolved from being composed of an attending PC physician and a fellow to a service including a PC attending and an APN.
In my own clinical practice, on the inpatient PC service in both University of California, Los Angeles (UCLA) hospitals, in my outpatient pain and PC clinic, and in the home-based PC practice run by the Los Angeles Jewish Home’s Skirball Hospice Program, I work in close collaboration with APNs, both nurse practitioners and clinical nurse specialists, to manage patients. One of the focuses of the profession of nursing is on the experiences of patients and their families in illness and in the healthcare system, a unique perspective that informs the ‘extra layer of support’ offered by palliative care.
As discussed in the article by Alesi et al, Muir estimates that embedding a PC practice within the US Oncology group saves referring oncologists 170 minutes per palliative care consultation which “… could [then] be used by the oncologist to see additional patients and to spend more time focusing on the oncologic aspects of their patients’ care.” He also cites the benefits to patients, in terms of better symptom management and a more nuanced goals-of-care discussion resulting from ongoing close collaboration between oncologists and PC providers in the US Oncology practice.
Closer collaboration between oncologists and PC providers can only be beneficial to all, not only in practice but also in training. (Note the description of the Virginia Commonwealth University program, in which oncology and PC fellows work in collaboration.) At UCLA, as we design the curriculum for our palliative care fellowship, we are very deliberately building collaborative experiences with oncology into our training program.
I do see some areas of concern in the US Oncology Model of care. As the PC practice embedded in the US Oncology practice is described, it sounds as if total responsibility for the goals-of-care discussion lies with the PC team. I am not sure that this is salutary. A goals-of-care discussion, time-consuming as it may be, is as much a part of oncologic treatment as is planning chemotherapy or staging disease. While I would never presume to speak for oncologists as a profession, my understanding in talking with my UCLA oncology colleagues is that most would not be inclined to relinquish complete responsibility for goals-of-care discussions to their PC colleagues. Again, in my practice, close collaboration between myself and the treating oncologist is the key and, when I am consulted to assist with goals-of-care discussions, I generally contact the oncologist and ask, “What are your treatment plans?”
From the purely business perspective, the authors, citing the unfortunate example of the specialty of medical genetics, point out that PC, like other ‘cerebral’ specialties, is not financially self-supporting; this raises concerns about the sustainability of the field.
In the US Oncology practice, embedding the PC practice helped to increase the productivity—and presumably the revenues—of the oncologist, apparently by contracting out some of the less highly remunerative components of patient care to the lower-paid PC physician and APN. Aside from issues of fairness in physician compensation, does this sort of arrangement support the growth, health, and long-term viability of PC as a medical specialty? Recall that there is no CPT code specifically for goals-of-care discussions and time spent in such activity is uncompensated, unless it is directly linked to treatment or evaluation. In practice, billing codes for extended patient counseling are poorly remunerated compared with other codes, it is often difficult to generate revenues from such counseling, and some institutions discourage providers from routinely using these billing codes, fearing that their repeated use will trigger audits from entitlement programs and insurers.
As Alesi and coauthors have demonstrated, outpatient palliative care provides an extra layer of support for patients, families, and healthcare providers when provided concurrently with outpatient oncologic treatment in a wide variety of practice settings. The key to the success of concurrent outpatient palliative care will be strategic implementation and integration, with the goal of promoting the sustainability of palliative medicine as a specialty.
Financial Disclosure: The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.