Financial Aspects of Inpatient Palliative Care

  • Peter May
  • R. Sean MorrisonEmail author
Reference work entry


The economics of hospital inpatient palliative care is a subject of significant policy interest internationally. Older people, and particularly those with multiple serious chronic conditions, account disproportionately for hospital admissions (McCusker et al. 2003), and up to half of recorded deaths worldwide occur in hospital (Bekelman et al. 2016; Broad et al. 2013). Hospitalization costs represent the main component of end-of-life costs across healthcare settings (Simoens et al. 2010a). Economic studies of palliative care for adult hospital inpatients suggest that persons who receive palliative care have lower costs and earlier discharge than matched patients who receive usual care only, as well as improved outcomes. Additionally, palliative care’s effect is larger when provided earlier (raising questions of when palliative care should be introduced in the trajectory of illness for people both inside and outside the hospital) and is also larger for adults with higher numbers of comorbidities (suggesting that complex interdisciplinary interventions are more effective for complex clinical cases, an insight with major potential policy relevance worldwide).

Further economic evaluations of palliative care beyond the hospital silo to evaluate impacts across whole trajectories of care are needed. Only then will policymakers have the full story on the costs and benefits of complex care for those with complex illness.


  1. American Cancer Society. Cancer facts and figures 2015. Atlanta: American Cancer Society; 2015.Google Scholar
  2. Amporfu E. Estimating the effect of early discharge policy on readmission rate. An instrumental variable approach. Health. 2010;2:504–10.CrossRefGoogle Scholar
  3. Bekelman JE, Halpern SD, Blankart CR, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with cancer in 7 developed countries. JAMA. 2016;315(3):272–83.PubMedCrossRefGoogle Scholar
  4. Bendaly EA, Groves J, Juliar B, Gramelspacher GP. Financial impact of palliative care consultation in a public hospital. J Palliat Med. 2008;11(10):1304–8.PubMedCrossRefGoogle Scholar
  5. Broad JB, Gott M, Kim H, Boyd M, Chen H, Connolly MJ. Where do people die? An international comparison of the percentage of deaths occurring in hospital and residential aged care settings in 45 populations, using published and available statistics. Int J Public Health. 2013;58(2):257–67.PubMedCrossRefGoogle Scholar
  6. Centeno C, Lynch T, Donea O, Rocafort J, Clark D. EAPC Atlas of palliative care in Europe. Milan: EAPC Press; 2013.Google Scholar
  7. Ciemins EL, Blum L, Nunley M, Lasher A, Newman JM. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J Palliat Med. 2007;10(6):1347–55.PubMedCrossRefGoogle Scholar
  8. Davies E, Higginson IJ. The solid facts: palliative care. Copenhagen: World Health Organization, Regional Office for Europe; 2004. 9789289010917.Google Scholar
  9. Davis MA, Nallamothu BK, Banerjee M, Bynum JP. Identification of four unique spending patterns among older adults in the last year of life challenges standard assumptions. Health Aff (Millwood). 2016;35(7):1316–23.CrossRefGoogle Scholar
  10. Dumanovsky T, Augustin R, Rogers M, Lettang K, Meier DE, Morrison RS. The growth of palliative care in U.S. hospitals: a status report. J Palliat Med. 2015;19:8.PubMedCrossRefGoogle Scholar
  11. Elsayem AF, Elzubeir HE, Brock PA, Todd KH. Integrating palliative care in oncologic emergency departments: challenges and opportunities. World J Clin Oncol. 2016;7(2):227–33.PubMedPubMedCentralCrossRefGoogle Scholar
  12. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center. Am J Hosp Palliat Care. 2014;31(4):380–4.PubMedCrossRefGoogle Scholar
  13. Etkind SN, Bone AE, Gomes B, et al. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Med. 2017;15(1):102.PubMedPubMedCentralCrossRefGoogle Scholar
  14. Garrido MM. Propensity scores: a practical method for assessing treatment effects in pain and symptom management research. J Pain Symptom Manag. 2014;48(4):711–8.CrossRefGoogle Scholar
  15. Garrido MM, Deb P, Burgess JF Jr, Penrod JD. Choosing models for health care cost analyses: issues of nonlinearity and endogeneity. Health Serv Res. 2012;47(6):2377–97.PubMedPubMedCentralCrossRefGoogle Scholar
  16. Grudzen CR, Hwang U, Cohen JA, Fischman M, Morrison RS. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med. 2012;15(4):396–9.PubMedPubMedCentralCrossRefGoogle Scholar
  17. Hanson LC, Usher B, Spragens L, Bernard S. Clinical and economic impact of palliative care consultation. J Pain Symptom Manag. 2008;35(4):340–6.CrossRefGoogle Scholar
  18. Hatziandreu E, Archontakis F, Daly A. The potential cost savings of greater use of home-and hospice-based end of life care in England. Santa Monica: RAND CORP; 2008.CrossRefGoogle Scholar
  19. Higginson IJ, Finlay IG, Goodwin DM, et al. Is there evidence that palliative care teams alter end-of-life experiences of patients and their caregivers? J Pain Symptom Manag. 2003;25(2):150–68.CrossRefGoogle Scholar
  20. Hwang SJ, Chang HT, Hwang IH, Wu CY, Yang WH, Li CP. Hospice offers more palliative care but costs less than usual care for terminal geriatric hepatocellular carcinoma patients: a nationwide study. J Palliat Med. 2013;16(7):780–5.PubMedCrossRefGoogle Scholar
  21. Imbens GW. Nonparametric estimation of average treatment effects under exogeneity: a review. Rev Econ Stat. 2004;86(1):4–29.CrossRefGoogle Scholar
  22. Ishak KJ, Stolar M, Hu MY, et al. Accounting for the relationship between per diem cost and LOS when estimating hospitalization costs. BMC Health Serv Res. 2012;12:439.PubMedPubMedCentralCrossRefGoogle Scholar
  23. Jones AM. Models for health care. York: Health Economics and Data Group, University of York; 2010.Google Scholar
  24. Kistler EA, Sean Morrison R, Richardson LD, Ortiz JM, Grudzen CR. Emergency department-triggered palliative care in advanced cancer: proof of concept. Acad Emerg Med. 2015;22(2):237–9.PubMedCrossRefGoogle Scholar
  25. Latham LP, Ackroyd-Stolarz S. Emergency department utilization by older adults: a descriptive study. Can Geriatr J. 2014;17(4):118–25.PubMedPubMedCentralCrossRefGoogle Scholar
  26. Manning WG. The logged dependent variable, heteroscedasticity, and the retransformation problem. J Health Econ. 1998;17(3):283–95.PubMedCrossRefGoogle Scholar
  27. Manning WG, Basu A, Mullahy J. Generalized modeling approaches to risk adjustment of skewed outcomes data. J Health Econ. 2005;24(3):465–88.PubMedCrossRefGoogle Scholar
  28. May P, Normand C. Analyzing the impact of palliative care interventions on cost of hospitalization: practical guidance for choice of dependent variable. J Pain Symptom Manag. 2016;52(1):100–6.CrossRefGoogle Scholar
  29. May P, Normand C, Morrison RS. Economic impact of hospital inpatient palliative care consultation: review of current evidence and directions for future research. J Palliat Med. 2014;17(9):1054–63.PubMedPubMedCentralCrossRefGoogle Scholar
  30. May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745–52.PubMedPubMedCentralCrossRefGoogle Scholar
  31. May P, Garrido MM, Cassel JB, Morrison RS, Normand C. Using length of stay to control for unobserved heterogeneity when estimating treatment effect on hospital costs with observational data: issues of reliability, robustness and usefulness. Health Serv Res. 2016;51(5):2020–43.PubMedPubMedCentralCrossRefGoogle Scholar
  32. May P, Garrido MM, Cassel JB, et al. Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: where do cost-savings come from? Palliat Med. 2017a;31(4):378–86.PubMedCrossRefGoogle Scholar
  33. May P, Garrido MM, Aldridge MD, et al. Prospective cohort study of hospitalized adults with advanced cancer: associations between complications, comorbidity, and utilization. J Hosp Med. 2017b;12(6):407–13.PubMedCrossRefGoogle Scholar
  34. May P, Garrido MM, Del Fabbro E, et al. Does modality matter? Palliative care units associated with more cost-avoidance than consultations. J Pain Symptom Manag. 2017c;55:766. (epub ahead of print 2017/08/27).CrossRefGoogle Scholar
  35. Maynard L, Lynn D. Development of a logic model to support a network approach in delivering 24/7 children’s palliative care: part one. Int J Palliat Nurs. 2016;22(4):176–84.PubMedCrossRefGoogle Scholar
  36. McCarthy IM, Robinson C, Huq S, Philastre M, Fine RL.Cost savings from palliative care teams and guidance for a financially viable palliative care program. Health Serv Res. 2015;50(1):217–36.PubMedCrossRefGoogle Scholar
  37. McCusker J, Karp I, Cardin S, Durand P, Morin J. Determinants of emergency department visits by older adults: a systematic review. Acad Emerg Med. 2003;10(12):1362–70.PubMedCrossRefGoogle Scholar
  38. Mierendorf SM, Gidvani V. Palliative care in the emergency department. Perm J. 2014;18(2):77–85.PubMedPubMedCentralCrossRefGoogle Scholar
  39. Morrison RS. Models of palliative care delivery in the United States. Curr Opin Support Palliat Care. 2013;7(2):201–6.PubMedPubMedCentralCrossRefGoogle Scholar
  40. Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783–90.PubMedCrossRefGoogle Scholar
  41. Morrison RS, Meier D, Carlson M. The healthcare imperative: lowering costs and improving outcomes. Washington, DC: Institute of Medicine; 2011.Google Scholar
  42. Penrod JD, Deb P, Luhrs C, et al. Cost and utilization outcomes of patients receiving hospital-based palliative care consultation. J Palliat Med. 2006;9(4):855–60.PubMedCrossRefGoogle Scholar
  43. Penrod JD, Goldstein NE, Deb P. When and how to use instrumental variables in palliative care research. J Palliat Med. 2009;12(5):471–4.PubMedPubMedCentralCrossRefGoogle Scholar
  44. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973–9.PubMedCrossRefGoogle Scholar
  45. Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med. 2011;18(6):e70–6.PubMedPubMedCentralCrossRefGoogle Scholar
  46. Radbruch L, Payne S. White paper on standards and norms for hospice and palliative care in Europe: part 2. Eur J Palliat Care. 2010;17(1):22–33.Google Scholar
  47. Rubin DB. The design versus the analysis of observational studies for causal effects: parallels with the design of randomized trials. Stat Med. 2007;26(1):20–36.PubMedCrossRefGoogle Scholar
  48. Simoens S, Kutten B, Keirse E, et al. The costs of treating terminal patients. J Pain Symptom Manag. 2010a;40(3):436–48.CrossRefGoogle Scholar
  49. Simoens S, Kutten B, Keirse E, et al. Costs of terminal patients who receive palliative care or usual care in different hospital wards. J Palliat Med. 2010b;13(11): 1365–9.PubMedCrossRefGoogle Scholar
  50. Smith TJ, Hillner BE. Bending the cost curve in cancer care. N Engl J Med. 2011;364(21):2060–5.PubMedPubMedCentralCrossRefGoogle Scholar
  51. Smith TJ, Coyne P, Cassel B, Penberthy L, Hopson A, Hager MA. A high-volume specialist palliative care unit and team may reduce in-hospital end-of-life care costs. J Palliat Med. 2003;6(5):699–705.PubMedCrossRefGoogle Scholar
  52. Smith TJ, Coyne PJ, Cassel JB. Practical guidelines for developing new palliative care services: resource management. Ann Oncol. 2012;23(Suppl 3):70–5.PubMedPubMedCentralCrossRefGoogle Scholar
  53. Spetz J, Dudley N, Trupin L, Rogers M, Meier DE, Dumanovsky T. Few hospital palliative care programs meet national staffing recommendations. Health Aff (Millwood). 2016;35(9):1690–7.CrossRefGoogle Scholar
  54. Starks H, Diehr P, Curtis JR. The challenge of selection bias and confounding in palliative care research. J Palliat Med. 2009;12(2):181–7.PubMedPubMedCentralCrossRefGoogle Scholar
  55. Starks H, Wang S, Farber S, Owens DA, Curtis JR. Cost savings vary by length of stay for inpatients receiving palliative care consultation services. J Palliat Med. 2013;16(10):1215–20.PubMedPubMedCentralCrossRefGoogle Scholar
  56. Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA. 2013;309(5):470–7.PubMedPubMedCentralCrossRefGoogle Scholar
  57. Weinstein MC, Siegel JE, Gold MR, Kamlet MS, Russell LB. Recommendations of the panel on cost-effectiveness in health and medicine. JAMA. 1996;276(15):1253–8.PubMedCrossRefGoogle Scholar
  58. Whitford K, Shah ND, Moriarty J, Branda M, Thorsteinsdottir B. Impact of a palliative care consult service. Am J Hosp Palliat Care. 2014;31(2):175–82.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Centre for Health Policy and ManagementTrinity College DublinDublinIreland
  2. 2.Brookdale Department of Geriatrics and Palliative MedicineIcahn School of Medicine at Mount SinaiNew YorkUSA
  3. 3.The Irish Longitudinal study on Ageing (TILDA)Trinity College DublinDublinIreland

Personalised recommendations