How Can We Get Better Value in End-of-Life Care?

Today’s healthcare controversies often lead to explosive debates. Few discussions in healthcare can be as incendiary as those concerning the care provided at the end of life. Addressing the real systemic problems seen during a patient’s last weeks is complicated by (1) erroneous, dire characterizations of health reform legislation resulting in “death panels”; (2) the latest evidence of the great health expenditures in the last weeks of life; and (3) questions about care quality in patients with terminal illness.

The philosophy of “keeping hope alive” despite the almost certain likelihood of near-term mortality fuels efforts to continue to try new active treatments right up until the end. On a population-wide basis, fiscal concerns and clinical facts show that this way of thinking cannot be supported for long.

High Costs and Variation in Services

The last year of life is associated with high health expenditures in the United States, and the costs are increasingly focused on patients’ last few months. According to a 2002 landmark study, the last month of life accounts for fully onethird of the health resources expended during the final 12 months.¹In another investigation of 230,000 Medicare patients who died as a result of congestive heart failure from 2000 to 2007, researchers found that the rate of hospitalization in the last 6 months of life was approximately 80%.²In their study, published in 2011 in theAnnals of Internal Medicine, 50% of the patients spent time in the hospital’s intensive care unit (ICU), and mean length of stay in the ICU increased as the study progressed. By 2007, ICU stays for these terminal patients reached nearly 5 days. This translated to an average cost per patient of $36,000 (in 2007).²

Complicating the issue is the variance in most healthcare costs from one geographic location to another. The same is true with end-of-life care. In 2008, the Dartmouth College group led by John Wennberg, MD,³revealed that in patients with serious chronic diseases (including cancer) treated at one of 3000 hospitals, costs per patient in the last 2 years of life ranged from $53,432 (Mayo Clinic) to $105,000 (New York University Medical Center). Compared with lower-cost centers, the higher-cost institutions were associated with longer hospital stays, greater ICU use, more doctor and specialist visits, and greater use of other hospitalprovided services. The researchers could find no difference in patient outcomes among the centers studied. They speculated that medical centers that received capitated payments or paid their physicians on a salary basis may be less likely to order unnecessary (or nonbeneficial) tests and procedures at the end of life.

Another study found that in-hospital end-of-life care was 65% greater in Los Angeles than in San Diego, and this was principally related to the more aggressive care observed in the Los Angeles institutions.⁴The researchers found that “San Diego residents are significantly more likely to die with the assistance of hospice services and less likely to spend time in hospitals and intensive care units during the last 2 years of life.”

Palliative Care, Hospice Care, and the End of Life

In patients with advanced metastatic disease, palliative therapy may be the only remaining option: Relieve the symptoms, ease the pain, and provide the best supportive care possible, with “the goal of improving quality of life for both the patient and the family,” said Diane Meier, MD, professor of geriatrics and palliative medicine at the Mount Sinai School of Medicine in New York City.

Sidebar

Palliative care is provided by a team of doctors, nurses, and other specialists who work with a patient’s other doctors to provide an extra layer of support. Dr Meier toldEvidence-Based Oncology, “Palliative care is appropriate at any age and at any stage in a serious illness, and can be provided together with curative treatment.” Theprovides some of the key recommendations from the American College of Physicians, which are backed by solid evidence.

The demand for palliative care has increased significantly, according to a 2012 national poll. The surveyors found that 71% believe that “It is more important to enhance the quality of life for seriously ill patients, even if it means a shorter life.”⁵

Ample evidence exists that hospice care plays a highly cost-effective role in end-of-life care. It seems that payers agree: “Commercial and government payers reimburse palliative care as in any other physician or advanced practice nurse services. For patients who are clearly dying, hospice is the most appropriate model of palliative care. It is covered by virtually all payers in the United States,” said Dr Meier.

Although few would dispute the cost-effectiveness of palliative care, perhaps the most challenging issue is convincing providers, patients, and their families to avail themselves of hospice services earlier in the course of serious disease. Patients eligible for hospice services are generally considered to have a life expectancy of 6

months or less. Why don’t more people use hospice services? Dr Meier responded, “The greatest challenge is the statutory requirement for patients to give up insurance coverage for life-prolonging/ disease-modifying treatment once they elect hospice. This is a very difficult decision for patients, families, and oncologists.” She added, “Because palliative care services can be delivered at the same time as active cancer treatment, there is no need to choose between approaches—it is sometimes easier for the team to address achievable goals of care earlier in the disease course, and this influences the understanding of and acceptability of hospice for many patients and families.”

The physician has a great deal of influence in the patient/family’s decision to use hospice services. “The decision to enter hospice is a deeply personal one for both the patient and his or her family,” according to Val Halamandaris, president of the National Association for Home Care and Hospice (NAHC). “The factors that lead to the decision will vary on a case-by-case basis. Physicians play a pivotal role in hospice— they are frequently the most knowledgeable about a patient’s condition and prognosis, and are frequently the source of education about and referral to hospice for care.” He added that generally, an individual will choose hospice “when he or she comes to believe that hospice will afford them a better quality of life, and a higher level of participation in their lives, for the remainder of their days.”

Roughly 82% of all hospice services are provided at home, not in hospice facilities, according to the NAHC.⁶The concept of hospice, first introduced in 1972 in Connecticut,⁶is not one of care based only in a separate facility, but of comprehensive palliative services that can be given anywhere.

Medicare accounts for the lion’s share of financing for hospice services (Table), and therefore, the vast majority of providers seek Medicare certification. The NAHC estimates that in January 2010, 3407 hospices were Medicare-certified, with 66% of these being free-standing facilities, 17% being home health agency—based, 15% being hospital-based, and less than 1% based in skilled nursing facilities. Of total Medicare expenditures, hospice care accounts for roughly 3%. In terms of Medicaid, the Center for Medicare & Medicaid Services does not mandate hospice benefits, but as of 2010, Oklahoma and New Hampshire were the only state programs to specifically exclude it.

Interestingly, patients with cancer comprise a much smaller proportion of patients receiving facility-based hospice services (10%) than those receiving hospice services in the community (42%).7 According to the Medicare Payment Advisory Commission, the percentage of patients with cancer utilizing any hospice services is increasing each year.⁷

In the Next Decade

The aging of the baby boom generation will touch end-of-life care in a big way, Mr Halamandaris believes. “We will see much greater demand from the aging population for hospice and palliative care, for not only cancer, but a variety of diagnoses.” He toldEvidence-Based Oncology, “In the coming years, hospices will continue to expand their scope of services so that they are not only providing care at the very end of life, but are engaged earlier on in the terminal disease process.”

No doubt, more focus will be placed on the completion of advance directives (eg, to forgo extraordinary measures when hope for longer life expectancy with an acceptable quality is vanishing). This may avoid tube feeding, mechanical ventilation, and other life-sustaining measures when the body begins the last phase of life. Mr Halamandaris added, “We are already seeing the beginnings of a very public debate about individual self-determination and making advance decisions about how we—as individuals—want to be cared for toward the end of our lives. Hospices and palliative care organizations will have an important role in educating the public about the options available to them.”

In any case, policy makers will need to engage the public much better than in the past. David Nash, MD, MBA, dean, Jefferson School of Population Health, Philadelphia, thinks “It will become more apparent that our spending is untenable and the trade-offs will become painful. Only then,” he believes, “will the public regard the end-of-life discussion as routine and commonplace.”

Sidebar. Keys to Palliative End-of-Life Care in Cancer

Patients with advanced, terminal cancer should be:

• Regularly evaluated for pain, dyspnea, and depression

• Prescribed treatments proven to be effective in managing pain; these include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates (which may be effective in relieving bone pain in patients with metastatic breast cancer or advanced myeloma)

• Given treatments to effectively manage their dyspnea (eg, opioids in patients with unrelieved dyspnea, and oxygen for short-term relief of hypoxemia)

• Prescribed treatments to treat depression (in patients with cancer, this may include tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention)

• Counseled to complete advance care planning, including advance directives, to address specific issues such as tube feeding, or continuation or discontinuation of chemotherapy

Source:Data from Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the

end of life: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2008;148(2):141-146.Funding Source:None.

Author Disclosures:Mr Mehr reports receiving payment for involvement in the preparation of this article.

Authorship Information:Concept and design; acquisition of data; analysis and interpretation of data; drafting of the manuscript; and critical revision of the manuscript for important intellectual content.1. Emanuel EJ, Ash A, Yu W, et al. Managed care, hospice use, site of death, and medical expenditures in the last year of life. Arch Intern Med. 2002;162(15):1722-1728.

2. Unroe KT, Greiner MA, Hernandez AF, et al. Resource use in the last 6 months of life among Medicare beneficiaries with heart failure, 2000- 2007. Arch Intern Med. 2011;171(3):196-203.

3. Wennberg JE, Fisher ES, Goodman DC, Skinner JS. Tracking the course of patients with severe chronic illness: The Dartmouth Atlas of Health Care 2008. www.dartmouthatlas.org. Accessed September 20, 2008.

4. Kaplan RM: Variation between end-of-life health care costs in Los Angeles and San Diego: why are they so different? J Palliative Med. 2011; 14(2):215-220.

5. Living well at the end of life: a national conversation. The Regence Foundation. http://syndication. nationaljournal.com/events/NJ_Events_ Website/Regence_NationalSurvey_Toplinedata.pdf. Published 2011. Accessed July 12, 2012.

6. Hospice Facts and Stats. National Association of Home Care and Hospice. http://www.nahc.org/facts/HospiceStats10.pdf. Published November 2010. Accessed July 12, 2012.

7. Medicare Payment Advisory Commission, Report to the Congress: Medicare Payment Policy. Published March 2009.

How Can We Get Better Value in End-of-Life Care?