Promoting Excellence : Forum Summary : Next Steps: Moving from Research to Policy

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In summing up, Ira Byock observed that, with the graying of the American population and the rise in health costs, it is understandable that any Medicare reform “to encourage concurrent, life-prolonging and palliative care for patients with serious, life-limiting illnesses” would run headlong into questions. If one were to project costs for such a benefit simply by adding the cost of palliative care to the cost of life-prolonging care, he said, government officials would conclude that such a benefit package is unaffordable.

But he pointed out that the results of the Promoting Excellence projects and other models presented at the conference suggest that improved quality and controlled costs are consistently the result when palliative care is introduced early, concurrently with life-prolonging care. The challenge, he said, is to align access to services with quality care and controlled costs.

In agreement with earlier speakers at the conference, Byock said that Medicare’s end-of-life care payment structure needs to be overhauled. He joined them in calling for a wide-scale government test of the palliative-care models that have been shown on a small scale to improve care quality and save money. Such demonstration programs would provide the data needed to redesign the way in which Medicare pays for end-of-life care.

Byock suggested that CMS could develop demonstrations in five to eight regions of the country, each encompassing perhaps a half million Medicare recipients. In each region Medicare rules would be temporarily altered so that specific models of palliative care could be tested. One region might test the feasibility of a tiered Medicare hospice benefit that could be adjusted according to the severity of a patient’s illness. Other regions might test a Medicare+Choice model including palliative care that could be evaluated by the same predetermined measures of access, quality and costs. Another region might test the feasibility of introducing palliative care at the point of diagnosis of a chronic illness, as described in the Medicaring model developed by Joanne Lynn, M.D.

“The time to act is now,” Byock said. “We have the potential for providing not only ethically sound and medically competent care, but also care that offers so much more in terms of comfort and quality of life.”

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

Promoting Excellence