A study of more than 13,000 veterans in Veterans Affairs Medical Centers (VAMCs) found that patients receiving hospice care concurrent with chemotherapy or radiation therapy were less likely to use aggressive treatments or be admitted to intensive care compared to similar patients who were not enrolled in hospice, significantly reducing medical costs.
Unlike organizations reimbursed through the Medicare Hospice Benefit, the Veteran’s Health Administration (VHA) does not require hospice patients to forgo curative care, making VAMCs a prime environment for researching concurrent treatments.
Currently, Medicare beneficiaries must opt out of or revoke the hospice benefit in order to receive curative treatment such as chemotherapy and radiation therapy. However, many hospice organizations provide services similar to hospice through palliative care programs. Beneficiaries are eligible to pursue curative treatment while receiving palliative care, which is also designed to alleviate symptoms, such as pain, as well as the emotional stress associated with serious illness.
“When hospice became a more widely available and referred service in the VHA, there was no requirement that patients stop receiving any other treatment,” study co-author Vincent Mohr, Professor of Health Services, Brown University School of Public Health, told Hospice News.”Our study took advantage of the fact that hospice use expanded without any prohibitions on receiving other services.”
In addition to fighting cancer, radiation and chemotherapy can help providers achieve goals of hospice and palliative care, such as pain reduction.
“There are many instances in which radiation therapy is used to alleviate bone pain due to bone metastases. Also,there are now many chemotherapeutic agents that may reduce the pressure that the tumor is placing on vital organs,” Mor said.
The study focused on patients who suffered from newly diagnosed end-stage lung cancer in 133 VAMCs who had received hospice care, cancer treatment, or both concurrently during the last month of life. The study authors aggregated data obtained from inpatient and outpatient records, pharmacy claims, and similar sources.
“Stage IV non–small cell lung cancer has a very short life expectancy,” Mor explained. “About 60% or more die within 6 months of diagnosis. We chose this diagnosis precisely because all had a very short expected life span.”
Though beneficiaries enrolled in the hospice benefit currently must forgo curative treatment, the U.S. Centers for Medicare & Medicaid Services is exploring alternatives to that policy through the test of its Medicare Care Choices Model, which the agency launched in 2016 and plans to conclude in 2020.
The model allows participating hospices to provide services that are currently available under the Medicare hospice benefit, but cannot be separately billed under Medicare Parts A, B, and D, while enrollees are also pursuing curative treatments. CMS pays participants a fee ranging from $200 to $400 per patient, per month while they are delivering services under the model, including care coordination, case management, symptom management, and other support for beneficiaries and families.
Following the conclusion of the program CMS will begin an evaluation phase expected to last two to three years. In addition to assessing the impact on costs, CMS is studying the impact of the model on patient satisfaction and the quality of care.
Currently 96 hospices nationwide are participating. Though participants hospices reported that they were losing revenue via the program in the early phases, CMS theorizes that losses could be offset by increased utilization.
“Having to forgo Medicare payment for treatment aimed at curing the terminal condition may impede the choice of electing hospice care,” the agency indicated in a 2017 announcement of hospices the agency selected as participants. “[The model] tests whether eligible Medicare and dually eligible beneficiaries would choose to receive hospice support services, if they could also continue to receive treatment for their terminal condition.”