A path forward on Medicare readmissions.

consultations are initiated, consideration should be given to returning the patient to the referring specialist or the primary care physician for ongoing palliative care management when that’s deemed desirable by everyone involved. This model allows increased access to specialty palliative care consultation and reinforces delivery of primary palliative care by everyone caring for seriously ill patients.5 In addition, this model could simplify the health care system and reinforce existing relationships. It would enhance the skills of all clinicians, improving their ability to address basic palliative care needs. It could also increase their satisfaction, by enabling deeper, more meaningful relationships with patients across the continuum of care. Finally, it might help control costs by reducing the number of specialists routinely comanaging cases. In fact, generalist-plus-specialist palliative care, bridged by primary care clinicians, is the main model endorsed worldwide. This approach seems unlikely to undermine the field of specialty palliative medicine. There are far too many seriously ill patients with unaddressed palliative care needs to have specialized palliative care teams caring for all of them. There are currently about 5000 board-certified palliative care specialists, about half of whom work less than full time providing palliative care. As the Baby Boomers age and the number of patients with serious chronic illnesses increases, even if it were a good idea for palliative care specialists to care for all such patients, the gap between demand and supply would be too large to close. Furthermore, it is not a good idea, in terms of cost or quality, to always require adding a palliative care team to all the other teams managing their fragments of care. We hope that every medical field will define a set of basic palliative skills for which they will be primarily responsible and distinguish them from palliative care challenges requiring formal consultation. Such a model might be better and more sustainable than our current system, as we strive to make high-quality health care available to all Americans. The opinions expressed are those of the authors and do not necessarily represent those of the American Academy of Hospice and Palliative Medicine. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.