Developing a Costing Framework for Palliative Care Services

Vol. 48 No. 4 October 2014

Journal of Pain and Symptom Management

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Special Article

Developing a Costing Framework for Palliative Care Services Daniela Mosoiu, MD, PhD, Malina Dumitrescu, MA, and Stephen R. Connor, PhD Faculty of Medicine (D.M.), Transylvania University, and Hospice Casa Sperantei (D.M., M.D.), Brasov, Romania; and Open Society Foundations (S.R.C.), New York, New York, USA

Abstract Context. Palliative care services have been reported to be a less expensive alternative to traditional treatment; however, little is known about how to measure the cost of delivering quality palliative care. Objectives. The purpose of this project was to develop a standardized method for measuring the cost of palliative care delivery that could potentially be replicated in multiple settings. Methods. The project was implemented in three stages. First, an interdisciplinary group of palliative care experts identified standards of quality palliative care delivery in the inpatient and home care services. Surveys were conducted of government agencies and palliative care providers to identify payment practices and budgets for palliative care services. In the second phase, unit costs were defined and a costing framework was designed to measure inpatient and home-based palliative care unit costs. The final phase was advocacy for inclusion of calculated costs into the national funding system. Results. In this project, a reliable framework for determining the cost of inpatient and home-based palliative care services was developed. Inpatient palliative care cost in Romania was calculated at $96.58 per day. Home-based palliative care was calculated at $30.37 per visit, $723.60 per month, and $1367.71 per episode of care, which averaged 45 visits. Conclusion. A standardized methodology and framework for costing palliative care are presented. The framework allows a country or provider of care to substitute their own local costs to generate cost information relevant to the healthcare system. In Romania, this allowed the palliative care provider community to advocate for a consistent payment system. J Pain Symptom Manage 2014;48:719e729. Ó 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. Key Words Palliative care, cost, hospice, cost analysis

Address correspondence to: Daniela Mosoiu, MD, PhD, Hospice Casa Sperantei, Sitei 17A, 500074 Brasov, Romania. E-mail: [email protected] Accepted for publication: December 12, 2013. Ó 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

Introduction Romania is a beacon country for palliative care development.1 The first palliative care services in the country were set up in the early 1990s, 0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.11.017

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mainly as initiatives of nongovernmental organizations in response to an immediate need to improve the care of patients of all ages with advanced progressive illness. These charitable organizations emerged with financial and technical support from international sources. The major challenge was to adapt functional models of care from countries with experience in palliative care to the needs of patients and families in Romania, within the limited human and financial resources of the health-care system. At that time, there was little concern about understanding the actual costing of a service based on standards of quality and cost efficiency. The need for palliative care in Romania was estimated in 2010 at 169,636 patients per year for a population of 21,600,000 in 42 counties.2 This represents 66% of the total mortality for the country, which was estimated at 254,454 total deaths. This estimation was based on an average death rate of 11.78 per 1000 population reported for 2010.3 Over the past decade, there have been slow changes toward the inclusion of palliative care in the national health policies. The legal framework partially regulating the place of palliative care in the general context of health services currently includes provisions regarding the education and training of palliative care professionals (palliative care was officially recognized in 2000 as a medical subspecialty4 and subsequently postgraduate training curricula developed); palliative care was included in the basic nursing training curricula in 20065 and became an accreditation requirement for inpatient and home-based care service providers under the annual frame contract6 for the provision of health-care services. Access to appropriate pain control medication was legalized in 20057 as were funding sources for the various types of palliative care services (frame-contract provision for the funding of inpatient admission in palliative care hospital departments or independent hospices since 2005 and home-based palliative care services since 2010). To provide a rationale for funding palliative care in Romania, a project was undertaken to develop a standardized system for measurement of costs and cost impacts. Although there are a number of studies that have examined the cost impact of palliative care, we were unable to find literature describing a standardized methodology for calculating the cost of palliative


care. The aim of this project was to develop a minimum set of cost analysis elements for palliative care providers in different settings (inpatient units and home-based palliative care) to provide a general, national model of the funding necessary to ensure access to these specialized services that could be used in all counties. This aim is in accordance with the partnership signed in 2008 between the Ministry of Health, Hospice Casa Sperantei, and the Federation of Oncological Patients’ Associations, to develop the first National Program for Palliative Care as a component of the National Cancer Plan, using an integrated model of palliative care as depicted on Fig. 1.

Methods Stages of the Project The project was implemented in three stages, as depicted in Fig. 2. Stage I: Preparing the Way. Romanian palliative care providers who were members of the National Coalition of Palliative Care formed groups of specialists (physicians, nurses, social workers, psychologists, and service managers) and met in four workshops to elaborate the minimum standards of quality for palliative care services in inpatient units and home-based palliative care. This stage was necessary to reduce subjectivity regarding the use of the limited financial resources of each provider and to agree on the quality of services, in line with international recommendations. Table 1 shows the composition of the expert group. The standards included definitions and models of service organization, general principles of accreditation and organization, human resources, eligibility, access to the services, the process of patient’s care with medical, nursing, psycho-emotional, social and spiritual components, family support during the time of care and bereavement support, staff training and support, ethical principles, and quality improvement. Definitions of the Types of Services for Cost Calculation Inpatient Units. Inpatient units offer services for patients admitted in palliative care hospital departments or independent hospice facilities. Admissions can be for limited, planned periods


Costing Palliative Care Services

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Fig. 1. The integrated model of palliative care.

of time for symptom control, 24 hour supervision, family respite, or end-stage care. Home-Based Palliative Care. The home-based palliative care service involves visits to the patient’s residence (home or residential center for elderly people or children). Specialized staff, including physicians, nurses, social workers, psychologists, clerics, nurse assistants, and volunteers, provided services. Basic Medical Home Care vs. Specialized Palliative Home Care. In Romania, the health-care system does not distinguish, either by definition or financing, between basic medical home

care, applicable in principle for discharged patients aiming for recovery after curative interventions in hospital, and home-based palliative care. Palliative care patients require a specialized team and the recognition of responsibilities for the initial and ongoing evaluations of a patient with life-threatening illness, often bedbound and in an advanced stage of illness. The working group highlighted the differences between the two when developing definitions. Funding Streams for Palliative Care. National regulations on palliative care were retrieved from the Romanian national legal database

Fig. 2. Description of the implementation process. PC = palliative care.

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Table 1 Specialists Involved in Developing Standards Physicians

Nurses

21 Public 4

Social Workers

22 NGO 17

Public 3

Psychologists

6 NGO 19

Public 1

Managers

3 NGO 5

Public 1

5 NGO 2

Public 2

NGO 3

NGO ¼ nongovernmental organization.

using the search words ‘‘palliative’’ and ‘‘hospice,’’ and then a manual search was conducted for articles on funding palliative care. Data were included in the table alongside information from a providers’ survey concerning funding sources for their work (Table 2). In parallel to the refinement of standards and creation of definitions for costing, surveys were conducted of the government to determine which services were valued and what resources are currently being dedicated to palliative care provision. Forty-one district health boards and 41 district health insurance houses were surveyed concerning registered palliative care providers, allocation for palliative care, and

expenditures on palliative care. Information on existing reimbursement to providers for services related to palliative care needed to be requested under the freedom of information act.8 A matrix on payment for housing, food, drugs, staff, and other costs was assembled that allowed some averages to be calculated for cost per day and cost per patient; however, these averages were affected by wide variations in payments. These variations were because of differences in local contractual agreements that were influenced by many factors including the relationships between local officials and health-care providers. One of the objectives of this project is to normalize the payment systems so that they are

Table 2 Sources of Funding for Palliative Care in Romania Funding Source Ministry of Finance

Funding Agent

Service Provider

Ministry of Health / County Health Boards Ministry of Labor / County Agencies for Social Services (based on law 34/1998)

Public Inpatient units, for initial capital costs NGO (annual application, funding awarded on competitive basis) for the social component of: - Day carea - Home-based palliative careb - Respite care in inpatient unitsc Public or private providers, funding awarded based on priorities in local development strategiesd Public and private in-patient unitse Public and private home-based palliative care services NGOf

Ministry of Public Administration / County Council (based on law 350/2005) National House of Health Insurance / Local Houses of Insurance Community

Foreign Governments Foreign NGOs International grant making bodies

Employeesdthrough 2% provision of the fiscal code Employers through sponsorship law 32/2002 General population through donations Germany The Netherlands Charitable NGOs in UK, U.S., The Netherlands, Switzerland, and France Open Society Foundations through CPSS and FOSI EU / PHARE, etc.

Public and private providers Public or private providers Hospice Carl Wolf, Sibiu, Romania PACARO project (ended) for GPs Romanian NGOs NGO NGO and public providers

PACARO ¼ PAlliative CAre in ROmania; CPSS ¼ Centre for Policies and Health Services (Centrul pentru Politici si Servicii de Sanatate); FOSI ¼ Foundation for Open Society Institute; EU ¼ European Union; PHARE ¼ Poland and Hungary Assistance for Reconstruction of Economy. a Legal the cost for staffing: social worker, social carer, transport, food, occupational therapies in an amount per patient per month varying up to 175 RON. b Legal the cost for staffing: social worker, carers, food in an amount per patient per month up to 210 RON. c Legal provision not currently applied because of lack of resources. d Palliative care currently not included as priority. e Finance mechanism is cost per bed per day negotiated by providers individually varying between 90 and 410 RON Institute for Public Policies. f 2% of the annual due taxes can be directed to any NGO or church regardless of the object of activity.



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aligned with accurate cost structures and national standards rather than local conditions.

disadvantages of both types of services and to allow an annual budget forecasting.

Stage II: Costing Frameworks. In the second part of the project, a costing framework was developed for different types of palliative care services, which can be used by providers and associations in their own cost analyses, regardless of the organization type (public or private), the setting of the service (inpatient units, home-based palliative care), or the number of services provided by the organization (single service or combinations). The framework proposed was intended to give a more accurate image of the real costs of services, based on agreed standards, rather than on individual experience or available funding of services in various settings. Specific staff salaries, direct costs, and indirect costs applied are based on Romanian laws currently in use in the public health system in January 2010. Users can substitute their own costs based on their local standards and real costs. The frameworks are meant to:

Unit Cost. For the palliative care services in inpatient units, the total cost per patient per day of admission was preferred as this is currently the financing approach legally accepted by the Romanian Houses of Health Insurance. For the palliative home care services, the cost unit agreed was per patient per visit and per month following the model of the Hungarian home-based palliative care services. This also was done to differentiate from the per-service model used for funding the basic home care services. Original costing was done in Romanian New Leu, but all figures have been converted to equivalent U.S. dollars for this report.

- allow the provider to present the sponsors and financing agencies with realistic budgets for quality palliative care services; - avoid the discrepancies between costs reported by various providers throughout the country because of differences between available funds or to individual ways of cost calculation; - give a clearer picture to the sponsors and financing bodies about the comparative costs of services from different providers, based on common calculation modalities; and - increase awareness and understanding of the home-based palliative care services and the costs involving their development. The costing process was based on a general framework, covering similar costs for both inpatient units and home-based palliative care services: a) human resources costs, b) direct costs (drugs and medical consumables, medical investigations and service-specific costs), c) overhead costs, and d) capital costs (initial set-up costs for new building or refurbishment and initial staff training). The costing units (cost per day per patient in inpatient units and cost per visit for home-based PC) were then compared with highlight advantages and

Stage III: Advocacy. Although there was a general support for conducting research that better defined palliative care services and costs, it was up to the local advocates to champion this effort. A combination of advocacy methods was used: building partnerships, involving leaders, policy monitoring, and dialogue. The figures generated from our research presented in printed materials were coupled with patient stories and presented by our extended palliative care network in formal and informal meetings with policy makers.

Results Stage I Survey Results. In a House of Health Insurance (the main local funding authority for health services) survey, it was found that payments to local health providers for palliative care services varied quite widely around the country, with an allocation between $27 and $121 per day per patient in inpatient palliative care services, as negotiated with the local houses of health insurance. A survey conducted by the Romanian Institute for Public Policies, a partner in this project, collected information from all 41 county-level Houses of Health Insurance and 41 Local Health Authorities and from the capital Bucharest, using Freedom of Information Act questionnaires. Information requested was related to: 1) the existence of palliative care services, 2) number of beds allocated to

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palliative care, 3) number of patients attended annually, and 4) average expenditure per patient (total amounts and specific allocations for food, bed day costs, medication, and administrative costs). The information reported by health authorities (the main health management units at the county level) was rather inconsistent (e.g., average cost per patient) because of the lack of a unitary calculation formula. Costs ranged from of $53 per patient to $593. Neither the allocated funds nor the expenses reflected the actual costs of palliative care services provided. Some health authorities only reported the existence of palliative care services in the public system (12 providers), although the majority (23) of known palliative care services in 2010 were in the nongovernmental system and one in a for-profit agency.9 All 41 local Houses of Health Insurance were asked to provide information about the number of palliative care providers and the funding provided for the contracted services. The results showed considerable differences in costs of services, both in inpatient admissions and in home-based care, with the lowest average cost per patient per day of $41 in one county and the highest at $500 in another. The heterogeneity of reports made comparison between actual costs of care difficult.

Stage II: Unit Cost Calculations Costs of Palliative Care in Inpatient Units. For the inpatient units, the basic unit of measurement was an occupied bed per day. An occupied bed per day is when a patient occupies that bed at midnight or a bed to which a patient was admitted and died in on the day of admission. The results of the calculations showed an average cost of $96.58 per patient per day (Table 3). Personnel Costs. The expenditures were broken down into personnel costs, direct cost, indirect cost, and capital cost for starting up the service. Based on the standards, the cost assumptions for staffing were as follows: B

B

physicians (1.5 full-time equivalent per 10 beds), nurses and nurse assistants (14e18 fulltime equivalent per 10 beds, one nurse per three to five beds, and one nurse


Table 3 Cost of Palliative Care in Inpatient Units Variable Costs Direct patient costs (per patient) Total human resource cost Bed day cost Drug costs Medical supplies costs Investigation costs (laboratory, CT, etc.) Total direct per patient Overhead costs (by facility) A. Free standing palliative care facilities (with several facilities) Fixed costs (per day) Building and capital depreciation A. Free standing palliative care facilities (with several facilities) Total per patient per day (direct þ overhead cost)

B

B

B

Per Patient/Day $62.21 5.04 5.04 2.67 1.18 $76.14 $19.26

$1.18 $96.58

assistant per five to seven beds, all per 8 hours shift), psychologist (0.5 full-time equivalent per 10 beds), other specialized personnel (four fulltime equivalent, including part-time for social worker, therapist, cleric, pharmacist, pharmacist assistant, and others), and auxiliary personnel (one full-time medical secretary).

We calculated the average daily contact time with the patient for the clinical staff in the inpatient unit (physicians, psychologist, and therapist). For nurses and nurse assistants, the cost for working time refers to three shifts, 8 hours each for the working days, and two shifts, 12 hours each for weekends and holidays. Also, the salaries include lunch tickets ($2.58 each, 21.25 days/month) and employer taxes (28.129% as of January 1, 2010). Monthly staff costs per patient for the inpatient unit included $1324.22 for nursing, $680.77 for physicians, $648.78 for carer costs, $85.32 for psychologists, $26.37 for social workers, $15.40 for pharmacy assistants, $8.30 for pharmacists, and $6.81 for therapist costs. (The following added salary and benefits were included: for very dangerous working conditions 50% [cf. Art. 13, paragraph ‘‘palliative care departments and compartments’’]; length in serviceeaverage 15% [cf. Art. 8 from GEO 115/2004]; increased psychological stress 15%; and legal benefits for night hours



and for working during off days or legal holidays.). Direct Costs (Other Than Personnel). Average bed day costs were calculated to include cost for meals ($3.55) and laundry services ($1.48). Meals are prepared internally according to individualized patient diet and include breakfast, lunch, dinner, and supplements. A one month audit was conducted to estimate the average cost per day for medications ($5.04) and medical supplies ($2.67). Medication costs included both hospice provided and those obtained by the patient and used for palliative purposes (not for comorbidities). When diagnostic procedures were conducted, including laboratories, CT scans, and other investigations, the cost averaged $1.18 per day averaged over all patient days (Table 3). Indirect Costs. The majority of all indirect costs were distributed to different services according to allocation factors, calculated according to the type of inpatient unit, as follows: A. hospice-free standing units (unique admission service or part of a complex of services), B. units (palliative care sections/compartments) in big hospitals, and C. units in small or chronic hospitals. Indirect common costs were calculated separately, according to a framework for each of the above-mentioned services and to the allocation factors. These allocation factors were established as follows: 1) used surface area (e.g., utilities costs, taxes, building insurance, maintenance and refurbishing of buildings, etc.); 2) personnel (ongoing training, labor medicine, malpractice insurances, administrative staff, etc.); and 3) patients’ number (informative materials for patients, communication, etc.). The resulting indirect rate was 20% for inpatient operations. Start-Up Costs. Details about start-up costs were included in the costing framework based on the following assumptions and on legal requirements in the Romanian health-care laws and regulations:

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- 20-bed units were considered as this was the minimum number of beds for a hospital department, and - start-up costs included initial training of clinical staff (theoretical courses and supervised practical training). This was considered essential. As palliative care is still a new field in the health-care system, the basic and academic training included limited or no training in PC, and the newly employed staff needs thorough training both in their specific profession and in interdisciplinary work.

Costs for Home-Based Palliative Care. Homebased palliative care is defined as a program of care that includes visits to patients’ residences (house or residential center for adults or children). Specialized personnel, including physicians, nurses, social workers, psychologists, therapists, clergy, carers, or volunteers, provide palliative care. The service includes: - clinical observation and symptom control (initial evaluation and regular reevaluations, as needed); - psychosocial support, patient and family education, and counseling; - coordination of care in the interdisciplinary team; and - consultancy and collaboration with general medicine (family physician) and other services accessible to the patient (hospital or outpatient clinic physician). This costing framework does not include bereavement services. For home-based palliative care services, the unit cost was defined as the cost per visit, per month, and per episode of care. The calculated cost per visit is $30.37. The episode of care includes an average of 45 visits per patient. To be eligible for home care, according to national standards, patients had to have an Eastern Cooperative Oncology Group score of 3 or higher and an estimated survival of months. The monthly cost per patient also has been calculated to be used in comparison with the costs for other palliative care services and to demonstrate the financial advantage of including palliative care services in the National Frame Contract. Costs are divided into

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personnel costs, direct costs, and indirect costs (Table 4). Personnel Costs. To quantify the costs, we needed to standardize the average number of visits done by each professional and we started from the description in the national palliative care standards for the workload of each profession: - Physician: 20e30 current patients, the average time for a visit, 90 minutes (transport and documentation of activities are included), five visits per day plus phone contacts for follow-up; average visits per patient, four per month; - Nurse: 10e15 current patients, the average time per visit, 90 minutes (transport and documentation of activities are included), five visits per day plus phone contacts for follow-up; average visits per patient, eight per month; - Social Worker: 50e60 patients, the average time per visit, 45 minutes, plus phone contacts and interventions, relationship with authorities and other organizations to obtain legal benefits; average visits per patient, three per month; - Psychologist: 50e60 patients, the average time per visit, 90 minutes; average visits per patient, two per month; - Cleric: one for the whole team, volunteer, the average time per visit, 90 minutes, costs were not included in the costing framework; average visits per patient, one per month; - Therapist: part-time for a team with 60 current patients, the average time per visit, 90 minutes; average visits per patient, one per month; and - Nurse assistant: eight patients, 150 minutes per visit (transport included); average visits per patient, six per month.


Salaries were calculated as for inpatient units, using the actual legal framework (see explanations for inpatient unit) adding salary and benefits and including 50% for weekend shifts. As palliative care services are in an initial stage of development, 24 hour coverage by the service is not yet available, but the team provides visits and advice during weekends for the patients already in care. Personnel costs include ongoing training, which according to the standards, is two hours per month for each clinical team member. Direct Costs (Other Than Personnel). Direct costs calculated per visit ($7.83) and per month ($183.29) included transport ($3.26), communication costs ($2.37), medication from emergency kit used during visits ($0.59), and medical supplies used ($2.37). The costs for medication prescription and diagnostic investigations, which are supported by the Health House Insurance, are not included in the cost per visit and in the cost for care episode, but they are added to the monthly costs for the comparative analyses between different types of services (Table 3). Transport cost was calculated assuming that staff used company-owned cars to visit patients to reduce time for transport and to allow access in rural areas. The costs for cars are included in the initial investment costs, and amortization is included in indirect costs. Indirect Costs. Indirect costs have been calculated as 15% of the total staff and direct costs; the percentage resulted from applying the allocation factors specific for these services (by space used, by number of specific staff, and by number of patients). Start-Up Costs. Start-up costs include initial investment costs for basic equipment and office furniture, refurbishing space for activities,

Table 4 Costs for Home-Based Palliative Care Cost Category Personnel costs Direct costs Indirect costs Total cost/patient in RON Initial start-up costsa a

Cost Per Visit

Cost Per Month

$18.58 7.83 3.96 $30.37

$445.93 183.29 94.38 $723.60 $109,849

Includes office equipment and furniture, six low-cost cars, and initial staff training.

Cost Per Episode of Care (45 Visits) $836.11 352.34 179.16 $1367.71



according to the standards for home-based palliative care, costs for six automobiles, and costs associated with initial staff training for a team of two doctors (18 month training to acquire competence in palliative care), four nurses (eight week theoretical training and supervised clinical practice), and one social worker (2 week training). We calculated these costs to support organizations that want to set up this kind of service and took into account that there are no qualified personnel for palliative care. Comparative Analysis of Inpatient and Home-Based Palliative Care Costs. Care in inpatient units is complex, ensures care around the clock, and reduces demand on families. Inpatient care should not cover the whole period of the patient’s care because it assumes patients being cared for in an inpatient unit for months. This is in contradiction with the population expectations as shown in the population survey, and costs for such a service are prohibitive. Home care allows the patient to be in his or her own environment and to have greater autonomy and control of the care and involves the family in daily care, with support from a specialized team. From an economic standpoint, this service involves less financial and human resources and offers care to a larger number of patients. At present, the government funds only the palliative care inpatient units, and development of home-based palliative care is scarce. Personnel costs for a home-based palliative care interdisciplinary team are a large component of the total cost but are only about one-quarter of the staffing costs of inpatient units. To highlight the economic advantage of home-based palliative care, we compared the costs of the two services, using the monthly cost per patient for both services. The cost for one patient receiving home-based palliative care for one month is $723.60 and $2932.84 for a month in the cancer inpatient unit, which is over 4 times more than home-based palliative care. These are average costs for a cancer patient in the advanced stages of illness, that is, at the time when palliative care is most appropriate. Patients with life-threatening illness do not ordinarily spend all their time in a hospital setting, so we cannot assert cost savings simply

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on the basis of a lower cost per month for home care services. However, hospitalization is the most expensive component in most health-care systems and even if we can reduce the number of hospital days and admissions, those savings could be used to support increased home care services as has been shown in multiple studies in developed countries.10e26

Stage III After presentation of the standards and frameworks by the coalition to local and national funding bodies, state financing for specialized palliative care home-based services and requirement criteria for accreditation of specialized palliative care home-based services were included in the National Frame Contract. The unit cost accepted in 2010 was $29.62 per visit with a maximum of 90 visits per patient once in a lifetime27 and the following year a maximum accepted reimbursement of $73.05 per patient per day in palliative care inpatient units.28

Discussion This article reports on the development of a methodology for costing palliative care inpatient and home care services in Romania. The results show that it is possible to create a model that includes all the necessary elements and that has the potential to be replicated in other countries. An Excel spreadsheet using the framework described in this article can be used to calculate costs as defined in this article. Costs will vary from one country to another, and using this framework, palliative care planners can insert their local data into the spreadsheet to calculate local costs. One such replication was done successfully in Moldova, and others are underway in former Soviet Republics. Low- and middle-income countries face a set of challenges incorporating palliative care into health-care systems that range from nonexistent to overly rigid and are very inpatient facility based. Moving from an approach that emphasizes inpatient facilities to one that encourages home-based care requires health planners and providers to change their way of providing health care to create efficiencies that meet the expressed needs of a population

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of patients that are increasingly suffering from chronic noncommunicable diseases.29 A public health approach to palliative care development has been advocated30 to assist health-care systems in transition. This approach requires that for palliative care to be successfully grafted into an existing health-care system, policy changes are needed that support the provision of basic and specialized palliative care education parallel with the provision of essential palliative care medication and the existence of model programs of care at the community level. Barriers to palliative care development include a general lack of financial and human resources devoted to health care, public and professional fear of acknowledging mortality, mistaken beliefs about palliative care and lack of correct information and education, overly restrictive policies on access to opioids and other essential palliative care medications, corrupting influences, and lack of competence in implementing change. The lack of health-care resources necessitates that palliative care advocates provide evidence that accurately describes the costs of palliative care and the benefits that result from, including palliative care in a health-care system. This report helps provide a framework for describing costs. Further work is needed to demonstrate the value that palliative care creates in the health-care system through more appropriate use of inpatient care and improvement in the quality of life of those receiving palliative care over conventional care. Limitations encountered during the development of this framework include difficulty creating definitions that clearly describe components in a very complex system, inability to include costs for amortizing some capital expenses, use of cost projections where accurate actual data could not be calculated, and use of standards that are not yet government approved and may be higher than those that eventually are put into law. This framework may not be effectively replicated in countries where palliative care standards substantially differ. In spite of these limitations, it has been demonstrated that it is possible to create a framework for costing palliative care that is consistent and adaptable for use in different contexts and countries. This information is


useful for those planning palliative care services and for policy makers to ensure that standard-based services can be implemented, which will be of value to both the health-care system and those who need these services. An Excel template based on this framework that can be used to cost palliative care services can be downloaded at http://www. opensocietyfoundations.org/topics/palliativecare.

Disclosures and Acknowledgments The Open Society Foundations International Palliative Care Initiative in New York provided funding for this project. Staff of the foundation advised on the design of the study and analysis of the results. Dr. Connor was funded by the Open Society Foundations to help prepare this article, in close collaboration with Hospice Casa Sperantei. The authors declare no other conflicts of interest. The authors thank Mary Callaway, Kathleen Foley, Kiera Hepford, and Sara Pardy at the Open Society Foundations International Palliative Care Initiative for their support of this project. Teresa Guthrie, a health economist in South Africa, also contributed significantly to the design of the costing framework used in this study.

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