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To increase access of palliative care, turn to primary care


America is facing an epidemic of chronic illness.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Glen Stream, MD, FAAFP, MBI, a family physician practicing in La Quinta, California, who is also past president of the American Academy of Family Physicians. He serves as the president and board chair of Family Medicine for America’s Health. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


Glen Stream, MD, MBIAmerica is facing an epidemic of chronic illness. Today, half of all adults in the United States have a chronic disease like chronic lung disease, cardiovascular disease or cancer.


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By 2030, a projected 70% of those over 65 will have at least one such disease. Chronic illness also places a heavy financial burden on the nation’s health system, accounting for 86% of all healthcare spending in 2010.

A recent article in The Journal of the American Board of Family Medicine (JABFM) noted that two segments of the health care system-palliative care delivered by specialists and primary care-are known to treat these seriously ill people while meeting the “triple aim”: improving the patient’s care experience, improving the health of those with chronic illness and reducing per capita healthcare costs.

In its 2014 report, Dying in America, the Institute of Medicine recommended that all people with advanced serious illness should have access to palliative care-care that provides patients with relief “from the symptoms, pain and stress of a serious illness, whatever the diagnosis.” 


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The reality, though, is that there is a severe shortage of palliative care specialists and their services are often only available to those in the hospital or in hospice. As the population ages and more Americans begin to suffer from chronic illnesses, the gap between patient need and the availability of palliative care will only widen.

Enter primary care-doctors whose long-term relationships with their patients best position them to provide basic palliative care to them.

As I (Nowels) and my co-authors observe in our JABFM article, “the need for all providers to deliver basic palliative care has emerged as patients’ needs outstrip the capacity of specialty palliative care,” many patients with complex illnesses have unmet needs and are seen in primary care more than other settings.

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The California HealthCare Foundation has also recognized the role primary care physicians can play in delivering much-needed palliative care.

“Both focus on and treat the whole person, not just the disease or health condition,” the foundation noted in a 2015 report. “Both recognize that physical, psychological, social and spiritual issues and concerns, and primary relationships (family and community) impact health and well-being. And both educate, support, and advocate for patients, families and caregivers across all health care settings.”

A new study by Claire Ankuda and the Robert Graham Center, published in the Annals of Family Medicine, underscores the important role primary care physicians play in caring for people nearing the end of life.


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The study of 306 hospital regions found that where there was higher primary care physician involvement, Medicare spending per patient was lower for the two years preceding death and that intensive care and hospice use were both less in the last six months.

It’s well-documented that strong primary care can improve the quality of care and lower healthcare costs. Study after study has shown that states with higher ratios of primary care physicians have lower mortality rates in general, lower rates of neonatal mortality as well as mortality associated with cancer, heart disease and stroke. By controlling these and other chronic conditions, primary care clinicians can improve the health of their patients, keep them out of the hospital and help them live longer.

That’s why integrating basic palliative care into primary care practice could go a long way toward meeting the needs of people with life-limiting illnesses. For many primary care physicians, the same processes and structures they already use in their practices could facilitate whatever changes might be needed to deliver basic palliative services to their patients.

In Washington State, the four Seattle-area hospitals associated with the University of Washington Medicine system have taken an innovative approach to palliative care that could also serve as a model for primary care physicians. Through its Primary Palliative Care Clinic, interdisciplinary teams of palliative care professionals-doctors, nurses, social workers, pharmacists and spiritual care providers-work together to develop treatment plans to “prevent and ease suffering” and enhance the quality of life for seriously ill patients “by addressing physical symptoms, emotional, social and spiritual needs, and the practical aspects of daily living.” 

As specialists in primary (Stream) and palliative care (Nowels), we recognize the need for all healthcare providers to deliver basic palliative care to close the gap between the demand for specialty palliative care and the supply. But it will be impossible to achieve that goal without expanding the capacity of primary care clinicians to provide such care to the growing number of Americans of all ages who need it.


Glen R. Stream, MD, MBI, is a family physician in La Quinta, California, and president of Family Medicine for America’s Health, which sponsors Health is Primary. David Nowels, MD, MPH, is associate professor of family medicine and director of the Palliative Medicine Fellowship Program at the University of Colorado School of Medicine.

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