Palliative care in managed Medicare: reasons for hope--and for concern.

Growing numbers of persons age 65 and older are enrolling in managed care plans to obtain benefits that are not available or are more expensive in free-for-service Medicare. The relatively greater prevalence of chronic disease and mortality in this population presents new challenges to managed care to provide cost-effective, yet laudable, palliative care. Certain aspects of managed care have the potential to improve the dying process. These include integrated care, reduced financial incentives for nonessential tests and procedures, portable and computerized medical records, and appropriate accountability for quality. On the other hand, possible barriers to attaining this goal in managed care include divided loyalties, conflicts of interest, the risk of devaluation of dying persons, and cost constraints.