“No Margin No Mission” was a common saying when I studied about non-profits in business school. No matter how good your intentions are, whether it be creating new systems to get people access to care or opening a new animal rescue, if it couldn’t pay for itself it wasn’t going to happen.
So it should come as little surprise that an up and coming darling of CEOs of health systems is palliative care. Now, you think, what do end of life discussions, pain management, and spiritual care have to do with healthcare administration. A lot actually, in the form of preventing unpaid readmissions and prolonged ICU stays.
Is this a bad thing? Is helping the hospital margin a necessary task for providing the mission? I argue that maybe it isn’t such a bad thing. Palliative care as a field is young and growing. This is the first year that a physician is required to do fellowship training before they can sit for the ABIM Hospice and Palliative Medicine board certification. Approximately 80% of large health systems have a palliative care team, smaller ones may not. Why not use cost savings as a way to gain access into the system, then work to provide quality end of life care, facilitate difficult family meetings, and advocate for the treatment that will provide the best short term and long term quality of life for the patients in that system?
Some will think back to the “death panel” days of the early 2000s and say this just a reincarnation. Hospitals are hiring doctors and nurses to keep care away from sick elderly people to save the system money. But, this isn’t the case. Thousands of people yearly receive invasive testing and procedures that provide little or no mortality benefit and often decrease quality of life, at least in the short term.
You would be hard pressed to find a palliative care team advocating to withhold care from a patient because it was too expensive. More likely, you will find a palliative team recommending against a procedure because the evidence is less than convincing that it will give measurable benefit and extended quality of life at the end of life.
By contributing to “the margin,” palliative care teams can use this as one way of furthering the mission of quality end of life care. Is it ideal? No. Is it one realistic approach and tool to use to get a foothold in health systems and provide great care? Yes.
James Simmons is an internal medicine resident and a member, public health committee, resident and fellow section, American Medical Association.