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The Health Economics of Palliative Care

The Health Economics of Palliative Care

Payne, Coyne, and Smith present a concise review of the
surprisingly meager literature regarding costs of end-of-life cancer care, an
issue with substantial ethical and financial implications. They present evidence
that improved coordination of care holds the potential to lower costs, or at
least to offer better services at the same cost. The authors are to be commended
for pursuing more rigorous studies regarding this difficult-to-quantify area of
medical and social services. Moreover, they appropriately highlight the
difficulties in attempting to capture direct costs of medical care and the far
more elusive indirect costs.

While we applaud the authors’ review and their ongoing work, they devote
meager attention to the biggest problem encountered by proponents of medical
cost containment—physician sabotage. Our own experience is that cost-benefit
data are routinely ignored by practicing physicians, who do so out of ignorance,
personal bias, apathy (lack of knowledge), or greed (lack of community
stewardship).[1]

Physician Sabotage

Glaring examples of such sabotage abound, both in curative and palliative
therapy. Probably the best documented example in the radiation oncology field is
the nearly universal practice of protracted, expensive courses of palliative
radiation despite overwhelming evidence from randomized trials showing that
abbreviated courses are equally effective.[2]

Similarly, research like that of Payne and colleagues frequently uncovers the
potential for substantial cost savings by modifying current medical practices,
with equivalent or improved outcomes. These studies show that dedicated
palliative care organizations—hospice, nursing homes, and nurse case managed
home care—offer more economical alternatives. But getting physicians to act on
such findings is another matter.

Working in the confines of the Department of Veterans Affairs (VA) budget, we
have found it easy to document excessive spending for medical care that has been
amply described in the medical literature as unnecessary. Tralins and
colleagues, for instance, identified rampant overuse of prostate cancer work-up
tests and follow-up visits in the VA, which continues despite efforts to
identify and curtail it.[3-5]

Managed Care—Our Only Hope?

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