Geography Determines Access to Palliative Care

The study found that 90% of hospitals with palliative care are in urban areas, and 17% of rural hospitals with fifty or more beds provide palliative care.

Access to and quality of hospital-based palliative care in the United States has more to do with geography than need, a new state-by-state report card finds.

The report – America's Care of Serious Illness: 2019 State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals – found "persistent gaps in access" across the nation for the estimated 12 million adults and more than 400,000 children living with chronic illnesses such as cancer, dementia, heart disease and kidney disease.

The study found that 90% of hospitals with palliative care are in urban areas, and only 17% of rural hospitals with fifty or more beds report palliative care programs.

 "As is true for many aspects of healthcare, geography is destiny. Where you live determines your access to the best quality of life and highest quality of care during a serious illness," said Diane E. Meier, MD, director of the Center to Advance Palliative Care, which compiled the report.

"The aging of the baby boomer generation is contributing to a growing population of patients in need who live for years with serious and chronic illness. The need to improve the quality of their health care is therefore urgent," Meier said.  

The report card found robust growth in palliative care teams at hospitals, with 72% of U.S. hospitals with 50 or more beds having palliative care teams. That's up from 53% in 2008 and just 7% in 2001. These hospitals 87% of the nation's inpatients.

Meier credited many of the advances in palliative care access and quality to a growing palliative care workforce, changes in reimbursements, evidence-based quality initiatives, and enhanced clinical training.

"We want to acknowledge that progress does not happen in a vacuum," she said. "Over the last few years, we have seen growing support from federal and state officials and private sector leaders, as well as continued work from organizations in the field."

"These efforts have contributed to an environment in which more stakeholders recognize the value of palliative care and have the tools to implement it," she said.

Despite this overall growth, the 2019 grade for the nation is a B, just as it was in 2015, owing to the large swaths of the country that still have limited access to palliative care, the report said.

"Many gaps remain in access," Meier said. "Access to palliative care in U.S. hospitals depends on where you live and the type of hospital to which you are admitted."

The report found that larger, not-for-profit hospitals were more likely to provide palliative services than were for-profit hospitals.

"Larger hospitals are probably more likely to provide palliative care programs because the size of the hospital and volume of patients can support a full interdisciplinary team," she said.

As for why for-profit hospitals are less likely to offer palliative care services, Meier said "the reasons are unknown."

"However, there are studies that have shown that for-profit hospitals have a higher emphasis on providing services that are immediately profitable to the hospital," she said, pointing to a study that CAPC published in Health Affairs which found that for-profit hospitals were also less likely to provide other high-value, but low-revenue services to patients.

"Palliative care provides significant cost savings to a hospital, but that's not the same as bringing in revenue," she said.

As for what could entice for-profit hospitals to take up palliative care, Meier said changes to Medicare's Conditions of Participation for hospitals that "would require accountability for access to high-quality care for patients with serious illness across all types of hospitals."

In addition, Meier recommended "payment reform recognizing and rewarding quality of care and outcomes important to patients, instead of the current fee for service financial incentives driving volume and procedures."

Meier was asked to identify a "common thread" among the states that scored well on the report card.

"There are some differences in the makeup of the hospitals within states or regions, although these differences may not fully explain the differential prevalence rates," she said.

"For example, the three regions that received A grades (New England, East North Central, and Mid-Atlantic) all have the highest proportions of non-profit hospitals in the United States and subsequently, the lowest rates of for-profit hospitals," she said. "More than 85% of the hospitals in those regions are non-profit compared to 71% nationally."

Meier said the two regions that scored the lowest and received C grades (East South Central and West South Central) have disproportionately more for-profit hospitals than other regions.

"More than one-quarter of the hospitals in East South Central and more than one-third in West South Central are for-profit, compared to only 16% of hospitals nationally," she said. "Rural hospitals are also less likely to provide palliative care and in East South Central, rural hospitals account for 13% of the hospitals with 50 or more beds compared to only 4% nationally."