Palliative Care Accounting: Financial Management for End-of-Life Care Services
Introduction
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
End-of-life care currently represents a sizable portion of healthcare spending in many
countries. As populations age and chronic illness rises globally, more resources will be
devoted to caring for patients with advanced illnesses and the dying. Palliative care aims to
humanely manage pain and symptoms for seriously ill individuals, giving priority to quality of
life. While palliative services importantly shift focus from treatment to comfort, navigating
financial aspects presents challenges due to complex needs, funding streams, and sensitive
discussions around death. Improved accounting models tailored for palliative care delivery
can help optimize available resources ensuring sustainable, compassionate care for all at
life's end regardless of ability to pay. This paper explores specialized approaches for
palliative care accounting and financial management to guide equitable provision of end-of-
life services.
Defining Palliative Care
Palliative care seeks to prevent and relieve suffering through early identification, assessment
and treatment of pain as well as physical, psychosocial and spiritual problems for patients
with serious illness. It aims to:
- Improve quality of life by preventing, assessing and treating pain and other distressing
symptoms
- Support psychological and spiritual aspects of patient care
- Assist with end-of-life planning and decision making consistent with patient values
- Facilitate caregiver coping through education and bereavement support
- Coordinate transition from active therapy to focus on comfort as the treatment goal
Ideally palliative care occurs alongside curative treatment or mainstreams into chronic illness
management. It can be provided in varied settings including hospitals, nursing homes,
private homes, and hospices. The focus shifts to comfort, dignity and choice as death nears.
Financial Challenges in Palliative Care
Current fee-for-service and treatment-oriented payment models often fail to adequately
cover realistic costs of palliative care delivered across settings over time. Other challenges
include:
- Complex needs arise but funding streams are fragmented across medical, social,
community providers
- Costs concentrate non-linearly in final days disproportionate to reimbursement levels
- Services require substantial time commitment for education, emotional support yet face
time constraints
- Discussing prognosis, goals of care and death is difficult yet essential for informed consent,
advanced care planning
- Affordability is a concern as serious illness frequently impacts work and incomes of
patients/families
- Not-for-profit hospice model faces sustainability pressures from rising costs and demand
- For-profit providers can compromise on quality/values to maximize margins
Improved financial management is needed to navigate these multifaceted realities ensuring
fiscally responsible yet compassionate palliative care remains accessible to all.
Accounting Frameworks for Palliative Care
Traditional medical accounting focuses on costs of tests, procedures and provider
transactions, missing broader economic and human factors in palliative scenarios. Newer
approaches could help:
Palliative Episode of Care Modeling
Grouping all related palliative costs over the span of a patient’s illness into “episodes of care”
allows for a more holistic view of resource use. Analytics can identify:
- Typical resource trajectories and cost drivers as death nears to inform bundled payment
pilots.
- savings from preventing undesired intensive care admissions through earlier palliative
involvement.
- Optimal timing, dosing and settings of palliative interventions that optimize quality at
minimum waste.
- Impact of multi-disciplinary team-based models coordinating medical, social, spiritual
support.
This retrospective analysis supports value-based alternative payment design and
prospective budgeting/resource allocation.
Return on Investment Accounting
Look beyond costs alone to quantitatively gauge broader impacts:
- Assign dollar amounts to hard/soft outcomes like reduced caregiver bereavement costs or
productive years saved through relief of suffering at end-of-life.
- Track savings from complications, prolonged hospitalizations or irreversible procedures
avoided through advance care planning facilitation.
- Financially model ripple effects on families, employers and society from optimized end-of-
life experiences.
- Compare morbidity and mortality rates between seriously ill patients receiving early
palliative versus standard care.
Demonstrating returns on investments in comprehensive palliative services through
numerical accounting strengthens the case for prioritizing and expanding available
resources.
Shared Savings Population Health Management
For integrated systems managing attributed populations:
- Risk-stratify member panels to proactively identify those with advanced illnesses and
complex needs.
- Close gaps in real-time between potential costs and actual savings from preventing low-
value treatments near end through timely involvement of palliative specialists.
- Formulas attribute shared savings across providers to incentivize multidisciplinary
collaboration and maximized resource optimization.
This approach holds healthcare organizations financially accountable for total cost and
quality of palliative/end-of-life care for defined patient rosters.
When applied with care coordination, these accounting methodologies can help drive the
kind of value-based transformation required for sustainable universal access to high-quality
palliative care services.
Palliative Care Budgeting Considerations
Budget planning also requires adapting to palliative realities:
- Forecast non-linear demand increases and costs concentrating in final weeks/months of life
cohorts.
- Budget adequately and flexibly for staffing, facilities and 24/7 availability as needs spike
unpredictably.
- Include costs for psychosocial and spiritual support in addition to medical
supplies/equipment.
- Anticipate higher initial startup and training investments to build specialized palliative
programs.
- Estimate post-death family support including bereavement programs and advance care
planning engagement costs.
- Budget contingencies for serving under-reimbursed populations through philanthropic
support.
- Consider total societal costs and savings rather than organizational bottom line alone.
- Integrate capital expenditure forecasting for facilities enabling comfort-focused dying in
home/community.
Proactive, empathetic and nuanced budgeting is key to developing sustainable healthcare
financing models able to meet escalating needs of aging populations for end-of-life care.
Implementation Challenges
While customized accounting approaches hold promise to optimize palliative care delivery
and steward scarce resources, meaningful implementation also presents challenges:
Data and Analytics Barriers
Comprehensive datasets spanning medical, social service and family financials needed to
track complete palliative episodes are often unavailable or siloed. Complex modeling
requires robust data infrastructure and skills not universally present.
Reimbursement Reform Hurdles
Transitioning payment away from fee-for-service incentives toward risk-adjusted, outcomes-
oriented bundles attuned to palliative realities demands coordinated policy changes across
public/private payers. Providers also need flexible financing to adapt.
Cultural Paradygm Shift
Openly discussing death and priorities of comfort over aggressive interventions challenges
entrenched norms. Sensitively transforming mindsets, measuring non-clinical values, and
gaining stakeholder buy-in for reform will take sustained effort.
Resistance to Resource Restraint
Rationing of disproportionately expensive, low-yield end-of-life interventions engenders
ethical controversy. Finding consensus on value judgments in high-stakes scenarios remains
difficult.
Scaling Barriers
Even successful local palliative programs struggle to replicate complexity of multidisciplinary
teams, advanced illness expertise and relationship-oriented models at broader levels due to
constraints.
While not insurmountable, overcoming these kinds of implementation barriers will require
long-term commitments, multi-stakeholder collaboration, and compassionately tackling
difficult social and cultural challenges alongside technical accounting solutions.
Case Study: Medicare Shared Savings Program
One promising real-world example is the U.S. Medicare Shared Savings Program (MSSP)
experimenting with accountable care organization (ACO) models for advanced illness
populations. Key aspects showing early success:
- ACOs receive retrospective bonuses for costs coming in below spending benchmarks while
meeting quality metrics for assigned high-need panels.
- One MSSP ACO achieved $10 million in total cost savings over 3 years in part by
augmenting primary care with timely specialist palliative involvement.
- Rate of cost growth for participants slowed compared to traditional Medicare spending
trends.
- Quality scores improved, including lower acute care use at end-of-life demonstrating value
of coordinated palliative approach.
- Participating providers noted importance of flexibility, risk-sharing and focus on total cost of
care over time rather than per-visit fees.
Early evidence indicates accountable population health management incorporating
customized advanced illness/end-of-life care can optimize resource utilization if provided
requisite payment and delivery system support. Ongoing evaluation and spread to broader
programs is underway.
Recommendations
Considering opportunities and challenges to using specialized financial management
approaches to achieve sustainable, quality universal palliative care access, a few
recommendations emerge:
- Develop uniform dataset/analytics standards to capture complete multi-sector palliative
episodes of care, resource use longitudinally, quality/experience indicators across settings to
facilitate reform.
- Pilot bundled, risk-adjusted advanced illness payment models rewarding comprehensive
coordinated care incorporating medical, social and family support over episodes/populations.
- Craft risk corridors/contingency funding pools absorbing unpredictably high costs to enable
local program stability and scaling.
- Leverage coalitions to build community/philanthropic capacity ensuring no one must die in
pain or suffering due to inability to pay.
- Continuously refine palliative program models through transparent evaluation, sharing best
practices between regions on staffing, facilities, service delivery shown to optimize outcomes
per dollar spent.
- Engage diverse stakeholders through education reforms advancing cultural paradigm shift
from cure-focused, technology-reliant interventions toward priorities of comfort, dignity and
shared decision making at life's end.
- Institute payer, provider, patient protections delimiting non-beneficial high-intensity
treatments that fail respect patient values, do more harm than good or waste collective
resources better spent elsewhere.
With commitment to these types of multi-pronged strategies and accounting innovation
tailored to palliative care realities, health systems worldwide can gain the financial
management tools necessary to universally guarantee compassionate, sustainable support
for all through their dying process according to individualized needs and wishes.
Conclusion
End-of-life care consumes a substantial and growing portion of healthcare spending globally.
Yet traditional accounting models struggle to optimize palliative care resources given
complex needs spanning medical, social and existential realms and costs concentrating non-
linearly at death. Specialized financial management approaches incorporating
comprehensive, longitudinal data on complete palliative episodes show promise to help align
scarce resources more equitably and efficiently with patient priorities of comfort, autonomy
and dignity at life's end. Overcoming entrenched paradigms through multi-stakeholder
cooperation and innovations in payment policy, program design and delivery infrastructure
reform will be required to achieve the sustainable universal palliative care access urgently
needed in aging populations worldwide. With commitment to comprehensive accounting
alongside cultural change, health systems can ensure compassion prevails through
humanity's final journey regardless of ability to pay.
