Abstract
American academic hospitals and cancer center executives face unprecedented challenges. In addition to pharmaceutical executives continuously increasing the price of drugs (by far the most expensive in the world), 1 and decreased reimbursement by insurance executives,2,3 this year federal politicians added to the perfect storm with large cutbacks in the indirect funds associated with research grants, an overall reduction in the research budget for NIH, and proposed reductions in the eligibility for Medicaid. 4
Hospitals and cancer centers that for many decades have been considered the best in the world are now starting to cut back clinical and academic programs and lay off staff.
Palliative care programs were adopted by these institutions incompletely and at a glacial pace. A survey we conducted among cancer centers in the United States twice, one decade apart, showed some progress, but the majority of cancer centers reported late patient access and limited or no palliative care structures such as outpatient centers, inpatient consult teams, and palliative care units. 5 Most executives in these cancer centers plan no growth in these limited programs, and the two main barriers they report are limited institutional budgets and poor reimbursement. 6
This is very concerning at moments when these ill-informed executives need to make financial decisions that might result in the elimination and/or externalization of palliative care.
Some of us have been there before and have learned from the experience.
The Edmonton Financial Crisis
In the early 1990s, we had a good academic palliative care program in Edmonton at a few hospitals and the cancer center. However, patients had limited access, and there was no integration between the different clinical and academic teams. We made several proposals for a larger and integrated program aimed at increasing access and reducing unnecessary aggressive care near the end of life. Executives were not interested in making any changes. Then the price of oil collapsed. The Edmonton health care system at that time was largely dependent on oil royalties, and there was no more money. Hospitals started closing inpatient units, reducing procedures, and laying off staff. Patients were not accessing care, including cancer care, and the executives found themselves under pressure. We went back to them, this time emphasizing our likely reduction of bed utilization, expensive procedures, and treatments close to the end of life. We presented assumptions for financial and clinical outcomes, and this time we got their attention. After two years of planning and recruiting, the Edmonton Regional Palliative Care Program started in 1995 with a strong clinical and academic specialist team. The executives, to their credit, understood the need to invest approximately $7M a year in a difficult financial environment to hire faculty, nurses, and staff and for reallocation of space. This pilot, a two-year program, became permanent within six months, with savings of $1.6M a year,7,8 and increased patient access to palliative care before death from about 20% to 82%. The program has continued uninterrupted since, and in addition to clinical care, it has made multiple discoveries and contributions to the literature and education.
Some things we learned from the Edmonton crisis
We made many errors in our planning and negotiations, and from those we learned some points that can help palliative care teams.
The process of meeting and negotiating with multiple executives will be demanding and stressful, and we need to find the time and energy to do this in addition to our regular working hours. A team is always better, and it might include colleagues who work in other institutions and share similar goals. When possible, the team should also include one of the executives who might be supportive of palliative care and will be able to provide valuable tips. Most executives do not think or behave like academics do, even if they were in the past. Our planning needs to consider this, and our presentations during meetings need to use their preferred language. Most executives are unaware of the clinical and financial benefits of palliative care because they do not read our literature. We need to provide them a limited number of systematic/scoping/narrative reviews, evidence-based guidelines, and editorials. These are better than clinical trials and other studies they may see with more skepticism. While palliative care is our passion, it is a relatively small part of the executives’ portfolio. We need to keep our papers and presentations short and start from the basics, with no assumptions that they understand our area. This will allow them to truly understand the issues. It is better to present to several executives at one time, and ideally to have identified and met with those who are more likely to feel positively toward our ideas. Inviting them to a comfortable room with food is better than video if possible. The presentation should be no more than 15–20 minutes and have some data from our own institutions. This will help “personalize” our clinical and financial assumptions. After some failures we learned that rehearsing with our team before the presentation is invaluable. We need to include assumptions for clinical and financial outcomes. Executives are used to making decisions with a much lower quality of evidence than required in the academic world, and they expect to see a complete budget and expected outcomes. In times of stress and distress, they look for, and they are more likely to support, innovators who present an optimistic alternative to the generalized gloom around them. A pilot, two-year proposal is often much more acceptable to executives. Knowing they can always cancel the program if we do not meet the expected outcomes helps them perceive the proposal as less risky in times of financial distress.
The current financial crisis
American hospitals and cancer centers are making much less money for what they do, and they largely have underdeveloped palliative care teams. 5 Some executives believe we result in “reduced reimbursement.” Unless they change their understanding, when they start the financial triage, they may dismantle palliative care teams even more, since they see us as less profitable as compared to other services. Some have already externalized palliative care to private for-profit palliative care companies with glossy brochures and charismatic executives, yet without independent evidence supporting their advertised processes and outcomes.
We can change this, but only if we initiate the process:
We have now overwhelming evidence supporting our clinical and financial benefits to all kinds of institutions, from those with global budgets to Diagnosis Related Group (DRG) and even DRG-exempted like mine, since insurers only pay a low percentage of the charges, and those are mostly close to end of life. We have evidence of financial benefit for both outpatient
9
and inpatient palliative care.
10
We did not have that data in Edmonton 30 years ago. There will always be some participants who will ask, “How do you know this would work here?”. They may even encourage you to spend the next 5–10 years of our careers applying for funds and then conducting a clinical trial. Our response has always been: “How do you know pembrolizumab works here?”. Being asked to repeat what has been demonstrated to work else leads to “analysis paralysis” and burnout. Executives will not approach us since they ignore how we can help. It is our challenge and opportunity to engage them. We know much better how to educate executives on the massive savings they can make by investing in palliative care teams. There are very few areas where care and quality metrics (particularly important to executives) can be dramatically improved,9,10 while at the same time making huge savings. They can hire clinicians capable of improving the well-being of patients, caregivers, and clinicians in their institution by reducing the money that currently goes to pharmaceutical, diagnostic imaging, and laboratory companies. Table 1 includes a checklist that might help teams who will be starting this process.
As I face the last years of my career, I cannot avoid a sense of déjà vu, but this time it catches us so much better prepared than during the Edmonton crisis. Carpe diem!
A Checklist for Palliative Care Planning Negotiations with Executives
Footnotes
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.