Policy changes are key to the passage of the Palliative Care and Hospice Education and Training Act to prevent a very real possibility of palliative care doctors in the next 25 years.
An article in the June 2019 issue of HealthAffairs discussed the increasing need for palliative care doctors with an increasingly aged population in the next 25 years. The study, led by Dr. Arif Kamal, a medical oncologist and palliative medicine specialist at Duke Cancer Center, examined whether the specialty palliative care workforce can meet the growing demand for its services. The study showed that a declining number of physicians specialized in palliative care looms and won’t recover for 25 years without major U.S. health policy changes.
Kamal and his fellow researchers used 2018 clinician survey data to model risk factors associated with palliative care clinicians leaving the field early due to burnout and then projected physician numbers from 2019 to 2059. The base survey consisted of fifty-two questions and organized into four sections: burnout and compensation, work intentions, clinical practice characteristics, and areas of work life. Respondents were presented with up to nine additional questions based on their professional clinical discipline—chaplaincy, medicine, nursing, pharmacy, physician assistant, or social work
“Our modeling revealed an impending ‘workforce valley,’” he wrote, “with declining physician numbers that will not recover to the current level until 2045, absent policy change. If policies change, the sustained growth in the number of fellowship positions over ten years could reverse the worsening workforce shortage.
The bottom line is that there is an immediate need for policies that support high-value, team-based palliative care through expansion in all segments of the specialty palliative care workforce, combined with payment reform to encourage the deployment of sustainable teams.
“All scenarios demonstrated a worsening of the patient-to-physician ratio for at least 25 years (2020–45), due to an inadequate physician supply coupled with a growing cohort of Medicare beneficiaries eligible for palliative care,” the study revealed.
“Our analysis also predicted untenable current and projected workloads for specialty palliative care physicians,” the Duke researchers and colleagues wrote. “We estimated that there was one palliative care physician for 808 eligible patients, and if each patient was evaluated, on average, once every three months (in either a clinic or a hospital), each palliative care physician would need to perform 10 patient visits per day over 48 weeks per year to meet the current demand.”
The integration of palliative care specialists, which was once viewed and associated with end-of-life care, has grown exponentially as part of consultation teams, outpatient clients, community-based palliative role models and medical specialty societies that recommend specialty care involvement, thus making it an important and much-needed part of the health care system and evidence demonstrates improvement in outcomes for patients, caregivers, and health systems when specialty palliative care teams are integrated into the care of people with serious illnesses.
Kaplan and his colleagues presented five policy changes the sustainability of palliative care.
First and foremost, the researchers recommend Congress pass the Palliative Care and Hospice Education and Training Act, which was introduced in the U.S. House of Representatives earlier this year. “Among its key provisions, the act would fund the development of physician leaders through palliative care academic career development awards, which are modeled on the federally funded Geriatrics Academic Career Award (GACA) Program,” Duke researchers and their colleagues wrote.
The next recommendation is that the Act includes the expansion of Medicare graduate medical education funding for palliative medicine physician fellowship and support for additional research into the workforce capacity and growth of non-physician palliative care specialist clinicians such as nursing, social work, and chaplaincy professionals.
“Even while specialty training is most prevalent among physicians, we project significant and worsening physician shortages over coming decades” and suspect that other disciplines involved in the palliative care and part of the team will face more significant shortages.
The research also recommends that payment models for specialty palliative care continue to become less reliant on the services of physicians and advanced practice professionals currently eligible to bill under fee-for-service Medicare, and more focused on providing adequate support for a fully interdisciplinary team.
Finally, they recommend policies that prevent the worsening of the burnout rate and support resilience. The concern is the projected worsening of the patient-to-physician ratio, combined with the erosion of interdisciplinary teams (due to the lack of both adequate training and sustainable payment models for palliative care delivery), will drive future increases in the burnout rate and thus a more substantial effect of that rate on the available workforce.
Dr. Janis Orlowski, chief health care officer of the Association of the American Medical College, said the projected physician shortage remains real and significant “with a shortfall of up to 122,000 by 2032. “To help address this shortage, there are now bipartisan bills, in both the U.S. House and Senate, that would add an additional 3,000 Medicare-supported residency positions each year for five years.”
