Vol. 48 No.

4 October 2014 Journal of Pain and Symptom Management 719

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 health-
care 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,

Introduction
Hospice Casa Sperantei, Sitei 17A, 500074 Brasov, Romania is a beacon country for palliative care
Romania. E-mail: daniela.mosoiu@hospice.ro development.1 The first palliative care services in
Accepted for publication: December 12, 2013. the country were set up in the early 1990s,

Ó 2014 American Academy of Hospice and Palliative 0885-3924/$ - see front matter
Medicine. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jpainsymman.2013.11.017
720 Mosoiu et al.
mainly as initiatives of nongovernmental organi-
zations 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 tech-
nical support from international sources. The
major challenge was to adapt functional models
of care from countries with experience in palli-
ative 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 un-
derstanding 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 to-
tal deaths. This estimation was based on an
average death rate of 11.78 per 1000 popula-
tion 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 frame-
work partially regulating the place of palliative
care in the general context of health services
currently includes provisions regarding the ed-
ucation and training of palliative care profes-
sionals (palliative care was officially recognized
in 2000 as a medical subspecialty4 and subse-
quently postgraduate training curricula devel-
oped); 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 provi-
sion for the funding of inpatient admission in
palliative care hospital departments or indepen-
dent hospices since 2005 and home-based palli-
ative 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 meth-
odology for calculating the cost of palliative
Vol. 48 No. 4 October 2014
care. The aim of this project was to develop a
minimum set of cost analysis elements for palli-
ative care providers in different settings (inpa-
tient units and home-based palliative care) to
provide a general, national model of the fund-
ing necessary to ensure access to these special-
ized 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 Na-
tional 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 re-
sources, eligibility, access to the services, the pro-
cess of patient’s care with medical, nursing,
psycho-emotional, social and spiritual compo-
nents, family support during the time of care
and bereavement support, staff training and sup-
port, 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
Vol. 48 No. 4 October 2014 Costing Palliative Care Services 721

Fig. 1. The integrated model of palliative care.

of time for symptom control, 24 hour supervi-
sion, family respite, or end-stage care.
Home-Based Palliative Care. The home-based
palliative care service involves visits to the pa-
tient’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 sys-
tem does not distinguish, either by definition
or financing, between basic medical home
care, applicable in principle for discharged
patients aiming for recovery after curative inter-
ventions in hospital, and home-based palliative
care. Palliative care patients require a special-
ized team and the recognition of responsibil-
ities for the initial and ongoing evaluations of
a patient with life-threatening illness, often bed-
bound and in an advanced stage of illness. The
working group highlighted the differences be-
tween 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.

722 Mosoiu et al. Vol. 48 No. 4 October 2014

Table 1
Specialists Involved in Developing Standards
Physicians Nurses Social Workers Psychologists Managers

21 22 6 3 5
Public NGO Public NGO Public NGO Public NGO Public NGO
4 17 3 19 1 5 1 2 2 3
NGO ¼ nongovernmental organization.

using the search words ‘‘palliative’’ and ‘‘hos-
pice,’’ and then a manual search was conduct-
ed for articles on funding palliative care.
Data were included in the table alongside
information from a providers’ survey concern-
ing 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 sur-
veyed concerning registered palliative care pro-
viders, 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 av-
erages 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 be-
tween 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 Funding Agent Service Provider

Ministry of Finance Ministry of Health / County Health Boards Public Inpatient units, for initial capital costs
Ministry of Labor / County Agencies for Social NGO (annual application, funding awarded on
Services (based on law 34/1998) competitive basis) for the social component
of:
- Day carea
- Home-based palliative careb
- Respite care in inpatient unitsc
Ministry of Public Administration / County Public or private providers, funding awarded
Council (based on law 350/2005) based on priorities in local development
strategiesd
National House of Health Insurance / Local Public and private in-patient unitse
Houses of Insurance Public and private home-based palliative care
services
Community Employeesdthrough 2% provision of the fiscal NGOf
code
Employers through sponsorship law 32/2002 Public and private providers
General population through donations Public or private providers
Foreign Germany Hospice Carl Wolf, Sibiu, Romania
Governments
The Netherlands PACARO project (ended) for GPs
Foreign NGOs Charitable NGOs in UK, U.S., The Netherlands, Romanian NGOs
Switzerland, and France
International grant Open Society Foundations through CPSS and NGO
making bodies FOSI
EU / PHARE, etc. 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.
Vol. 48 No. 4 October 2014 Costing Palliative Care Services
aligned with accurate cost structures and na-
tional standards rather than local conditions.
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 num-
ber 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:
- allow the provider to present the sponsors
and financing agencies with realistic bud-
gets for quality palliative care services;
- avoid the discrepancies between costs re-
ported by various providers throughout
the country because of differences be-
tween 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 inpa-
tient units and home-based palliative care ser-
vices: a) human resources costs, b) direct costs
(drugs and medical consumables, medical in-
vestigations and service-specific costs), c) over-
head 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
723
disadvantages of both types of services and to
allow an annual budget forecasting.
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 ser-
vices, the cost unit agreed was per patient per
visit and per month following the model of
the Hungarian home-based palliative care ser-
vices. 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.
Stage III: Advocacy. Although there was a gen-
eral support for conducting research that bet-
ter 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 dia-
logue. 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 Insur-
ance (the main local funding authority for
health services) survey, it was found that pay-
ments 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 hous-
es 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 cap-
ital 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
724 Mosoiu et al.
palliative care, 3) number of patients attended
annually, and 4) average expenditure per pa-
tient (total amounts and specific allocations
for food, bed day costs, medication, and
administrative costs). The information re-
ported by health authorities (the main health
management units at the county level) was
rather inconsistent (e.g., average cost per pa-
tient) because of the lack of a unitary calcula-
tion formula. Costs ranged from of $53 per
patient to $593.
Neither the allocated funds nor the expenses
reflected the actual costs of palliative care ser-
vices provided. Some health authorities only re-
ported 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 pro-
vide information about the number of palliative
care providers and the funding provided for the
contracted services. The results showed consid-
erable 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 measure-
ment was an occupied bed per day. An occu-
pied bed per day is when a patient occupies
that bed at midnight or a bed to which a pa-
tient 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 physicians (1.5 full-time equivalent per
10 beds),
B nurses and nurse assistants (14e18 full-
time equivalent per 10 beds, one nurse
per three to five beds, and one nurse
Vol. 48 No. 4 October 2014
Table 3
Cost of Palliative Care in Inpatient Units
Variable Costs Per Patient/Day
Direct patient costs (per patient)
Total human resource cost $62.21
Bed day cost 5.04
Drug costs 5.04
Medical supplies costs 2.67
Investigation costs (laboratory, 1.18
CT, etc.)
Total direct per patient $76.14
Overhead costs (by facility)
A. Free standing palliative care $19.26
facilities (with several
facilities)
Fixed costs (per day)
Building and capital depreciation
A. Free standing palliative care $1.18
facilities (with several
facilities)
Total per patient per day $96.58
(direct þ overhead cost)
assistant per five to seven beds, all per
8 hours shift),
B psychologist (0.5 full-time equivalent
per 10 beds),
B other specialized personnel (four full-
time equivalent, including part-time
for social worker, therapist, cleric, phar-
macist, pharmacist assistant, and
others), and
B auxiliary personnel (one full-time medi-
cal 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 holi-
days. 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 inpa-
tient 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 bene-
fits were included: for very dangerous working
conditions 50% [cf. Art. 13, paragraph ‘‘pallia-
tive 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
Vol. 48 No. 4 October 2014 Costing Palliative Care Services
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 accord-
ing 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). Medica-
tion 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 in-
vestigations, 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 ac-
cording to allocation factors, calculated ac-
cording 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/compart-
ments) in big hospitals, and
C. units in small or chronic hospitals.
Indirect common costs were calculated sepa-
rately, 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 pa-
tients, communication, etc.). The resulting indi-
rect 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 re-
quirements in the Romanian health-care laws
and regulations:
725
- 20-bed units were considered as this was
the minimum number of beds for a hospi-
tal department, and
- start-up costs included initial training of
clinical staff (theoretical courses and su-
pervised 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. Home-
based 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 vol-
unteers, provide palliative care. The service
includes:
- clinical observation and symptom control
(initial evaluation and regular re-
evaluations, as needed);
- psychosocial support, patient and family
education, and counseling;
- coordination of care in the interdisci-
plinary team; and
- consultancy and collaboration with gen-
eral 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 calcu-
lated cost per visit is $30.37. The episode of
care includes an average of 45 visits per pa-
tient. 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 Na-
tional Frame Contract. Costs are divided into
726
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 (trans-
port 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 con-
tacts and interventions, relationship with
authorities and other organizations to
obtain legal benefits; average visits per pa-
tient, 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 frame-
work; average visits per patient, one per
month;
- Therapist: part-time for a team with 60 cur-
rent 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.
Costs for Home-Based Palliative Care
Cost Category
Personnel costs
Direct costs
Indirect costs
Total cost/patient in RON
Initial start-up costsa
a
Includes office equipment and furniture, six low-cost cars, and initial staff training.
Mosoiu et al. Vol. 48 No. 4 October 2014
Salaries were calculated as for inpatient
units, using the actual legal framework (see ex-
planations 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 pro-
vides 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), commu-
nication costs ($2.37), medication from emer-
gency kit used during visits ($0.59), and
medical supplies used ($2.37). The costs for
medication prescription and diagnostic investi-
gations, 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 ac-
cess 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 calcu-
lated 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 in-
vestment costs for basic equipment and office
furniture, refurbishing space for activities,
Table 4
Cost Per Episode
Cost Per Visit Cost Per Month of Care (45 Visits)
$18.58 $445.93 $836.11
7.83 183.29 352.34
3.96 94.38 179.16
$30.37 $723.60 $1367.71
$109,849
Vol. 48 No. 4 October 2014 Costing Palliative Care Services
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 ac-
quire competence in palliative care), four
nurses (eight week theoretical training and su-
pervised 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 ac-
count 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 pa-
tient’s care because it assumes patients being
cared for in an inpatient unit for months.
This is in contradiction with the population ex-
pectations 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 au-
tonomy and control of the care and involves
the family in daily care, with support from a
specialized team. From an economic stand-
point, this service involves less financial and
human resources and offers care to a larger
number of patients. At present, the govern-
ment funds only the palliative care inpatient
units, and development of home-based pallia-
tive 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
727
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 na-
tional 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 inpa-
tient 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 nonex-
istent to overly rigid and are very inpatient facil-
ity based. Moving from an approach that
emphasizes inpatient facilities to one that en-
courages home-based care requires health plan-
ners and providers to change their way of
providing health care to create efficiencies
that meet the expressed needs of a population
728 Mosoiu et al.
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 special-
ized palliative care education parallel with the
provision of essential palliative care medica-
tion 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 cre-
ates in the health-care system through more
appropriate use of inpatient care and improve-
ment in the quality of life of those receiving
palliative care over conventional care.
Limitations encountered during the devel-
opment of this framework include difficulty
creating definitions that clearly describe com-
ponents in a very complex system, inability to
include costs for amortizing some capital ex-
penses, 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
Vol. 48 No. 4 October 2014
useful for those planning palliative care ser-
vices 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/palliative-
care.
Disclosures and Acknowledgments
The Open Society Foundations Interna-
tional 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 Palli-
ative 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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