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Palliative care funding needs reform

The debate about assisted dying in Victoria at the end of 2017 heightened interest in palliative care with opponents of assisted dying arguing for improvements in palliative care as the alternative. Many submissions to the Legislative Council inquiry into end-of-life care recounted stories of inadequate palliative care – of failures of access, failures of implementation, failures of knowledge about what can or should be done to relieve pain or distress, and failures of treatment.

For me, though, the biggest failure is the failure of policy, in particular funding policy. The palliative care system in Australia is still a Cinderella – kept behind in a darkened castle while the siblings dance in the media and money spotlight. This may be because we live in a death-defying society: people, including health professionals, don’t want to admit to limitations of treatment and that death comes to us all.

In a 2014 Grattan Institute report, Dying Well, we outlined how end-of-life care could be improved.  We know that palliative care works. People referred to palliative care early live longer than people not so referred. People who use palliative care are less likely to end up in an Intensive Care Unit, potentially not able to communicate with their loved ones in their final days. We called for more open discussions about death, specifically about what people wanted to happen to them in terms of treatment as they neared death.

Palliative care services are cost effective but state (and Commonwealth) government funding arrangements don’t reflect that. The arrangements in each state are different but the funding arrangements are riddled with perverse incentives, with the funding design not consistent with the rhetoric we hear from politicians. Funding often implicitly encourages hospital over home deaths, and inhibits access.

I’ve canvassed funding issues for palliative care in a recent paper, and suggested potential new directions and approaches for palliative care, summarised below.

Table: Desirable funding model direction for palliative care

Current models

More desirable models

Per diem or fee-for-service payment

Activity-based funding using an agreed classification such as AN-SNAP

Capped funding

Uncapped funding with performance monitoring

Separate funding mechanisms for different sites of care or death

Funding arrangements designed in light of policy objectives to encourage death in preferred location. Funding could be separate for different sites but must be aligned to reduce incentives on providers to choose site of care inappropriately and to ensure policy objectives are achieved

Regular use of out-of-pocket payments

Reduced use of out-of-pocket payments

No, or implicit, performance metrics

Explicit use of performance metrics and reporting, potentially including use as part of a pay for performance program

Source: Duckett, Stephen (2018), ‘Aligning policy objectives and payment design in palliative care’, BMC Palliative Care, 17 (42).

If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted. As palliative care policies are redeveloped, governments should give explicit consideration to adopting new funding approaches to ensure funding policy and aspirational service objectives are aligned.

Palliative care in Australia will not fulfil its promise until it is established on a sound funding basis with clear performance criteria, and clear goals for its place in the wider health system.

 


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