Improving Palliative Care for Cancer (2001) / Chapter Skim
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Part 2 2 Reliable, High-Quality, Efficient End-of-Life Care for Cancer Patients: Economic Issues and Barriers
Part 2 2 Reliable, High-Quality, Efficient End-of-Life Care for Cancer Patients: Economic Issues and Barriers
Pages 65-95
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Part 2
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This chapter addresses the contribution to the shortcomings made by the financial arrangements covering care for people with advanced cancer. Changes in financing and coverage will not, on their own, change the standards of care (VIadeck, 1999)
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At. FIGURE 2-1 The population with advanced cancer.
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Since we are focused upon those at the end of life, this chapter does not deal with the costs of diagnosis or initial treatment, and since the focus is on cancer care, it does not deal with the effects of comorbidities, although the economics of both earlier care and care of other conditions profoundly affect the economics of cancer care.
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, and durable medical equipment. Medicare also offers hospice; indeed, Medicare pays for 65 percent of all patients receiving hospice care in the United States (National Hospice and Palliative Care Organization, 2001~.
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of the days that Medicare pays to hospice providers can cover continuous nursing care, inpatient respite stay, or inpatient symptom management. The services that hospices provide include many elements that are not typically part of Medicare coverage: for example, interdisciplinary team, care planning, personal care nursing, family or patient teaching and support, chaplaincy, medication (with a small copayment)
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. skilled nursing home stays Is high enough that the tew patients who do qualify are not even offered the opportunity to enroll in hospice (only either skilled nursing home care or hospice can be in effect at one time)
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Is the " just barely qualified" patient just "more likely than not" to die within six months, or should that patient be "virtually certain to die"? This may sound like an arcane issue, but the population that includes everyone who is more likely than not to die from a chronic disease within six months is probably two to three orders of magnitude (100 to 1,000 times)
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However, these patients are being served by only about a score of hospice organizations. The other 3,100 hospices mostly serve less than 50 patients on any given day (Stephen Connor, National Hospice and Palliative Care Organization, personal communication, Tuly 13, 2000~.
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Gap Between Hospice and Home Care Many patients simply have no Medicare-covered services for a part of their course when they are quite needy but are neither so sure to die within six months that hospice is available (or they are otherwise ineligible for their local hospice) nor so housebound as to qualify for the limited help from Medicare home care (which requires being unable to leave the home except for physician visits)
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Advanced Lung Cancer (Non-Small Cell Cancer of the Lunge In contrast to breast, prostate, and colorectal cancers, very little progress has been made in early diagnosis and long-term remission in lung cancer. Furthermore, as the most common cancer among men and women in the United States, lung cancer accounts for approximately 20 percent of all cancer care costs (Desch et al., 1996~.
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Smith suggests that a fairer comparison would be average total health care costs, rather than limiting it to hospital charges. Advanced Colorectal Cancer Evaluating the costs of treating patients with advanced colorectal cancer has been the subject of various research endeavors, most of them outside the United States.
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Hospital charges for breast cancer patients who died in 1992 in a Connecticut hospital averaged $42,000, while the costs for those who died at home or in hospice care averaged $20,000 (Polednak and Shevchenko, 1998~. Advanced Prostate Cancer Finding the most effective therapy, both medically and financially, for relieving pain related to metastatic prostate cancer has been a major focus of recent research (Beemstrober et al., 1999; Bennett et al., 1996; McEwan et al., 1994; Shah et al., 1999~.
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In 1991, the total Medicare payments for prostate cancer care from diagnosis to death (seven years) averaged about $49,000 (Riley et al., 1995~.
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One example of this is second-line chemotherapy for metastatic lung cancer, which entails the use of fairly expensive drugs and a number of toxicities. On the other hand, we know very little about the most efficacious, least costly treatment for the full spectrum of advanced cancers.
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Current NCCN guidelines call for switch to hospice or palliative care when chemotherapy has been tried and failed, and provide a starting point for "stopping rules." For instance, current NCCN guidelines call for 2 types of chemotherapy in breast cancer, then switch to hospice care. The average patient receives far more types of chemotherapy.
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The metric for measuring the subjective components of caregiver burdens is quite unsettled. The complexity of human situations seems hard to capture in a single scale that would allow comparisons, for example, of the burdens incurred by an elderly wife caring alone for her aged husband who is dying slowly of metastatic prostate cancer with the burdens felt by a large extended family supporting a younger man dying with very difficult suffering from lung cancer.
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From page 83... ...
Researchers and clinicians are beginning to identify as end points the distressing symptoms of advanced cancer. The National Cancer Institute provides a comprehensive list of the six different categories of clinical trialstreatment, prevention, diagnostic, genetic, screening, and supportive care on its Web site (http://cancernet.nci.nih.gov/cgi-bin/srchcgi.exe)
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From page 84... ...
Complex Role of the Patient's Setting As an alternative to aggressive, often futile, expensive therapy requiring repeated hospitalizations, increasing numbers of terminally ill cancer patients are enrolling in hospice or other home care. By opting for hospice or extensive home care, patients commonly remain at home among loved ones, receiving care that is focused on their symptoms, emotions, spiritual concerns, and family.
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Very little research has described the costs to caregivers of terminally ill cancer patients. One study of cancer patients who were undergoing active treatment reported that the average cancer home care costs for a three-month period were not much lower than the costs of nursing home care (Stomme!
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From page 86... ...
However, if good palliative care extends life by a few months or if nursing home placement shortens life, these effects have not been assessed. Thus, since patients' length of life varies substantially anyway, it would be hard to notice whether interventions or patterns of care altered survival time by a few months.
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Making plans requires envisioning the patient's situation comprehensively, effectively communicating about the situation and its possible treatments with patient and family, and having the capability to implement plans where the patient lives (including home, assisted living, or nursing home)
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Modifications to hospice seem to be an obvious target for improving end-of-life care for patients with cancer (President's Cancer Panel, 1999~. Hospice could be made available on the basis of the extent of illness or disability and then be lifelong, rather than requiring a confident prediction of death within six months.
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POSSIBLE STRATEGIES TO IMPROVE FINANCING FOR CARE OF PATIENTS COMING TO THE END OF LIFE WITH CANCER Reshaping the financing of end-of-life care for those with cancer requires attention to three elements: serviceable methods, adequate description and monitoring, and innovation with evaluation. Many organizations bear responsibility for addressing these needs, some of which are noted (in parentheses)
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for signing up patients on hospice. NURSING FACILITY OR LONG-TERM CARE · Integrate hospice care and nursing home care at a fair rate of pay.
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CAPITATED PLANS · In PACE, the payment rate for Medicare is set at the nursing home rate and Medicaid makes up the rest. The Medicare rate is almost certainly too low for cancer patients, forcing Medicaid to make up more of the overall rate and thereby making PACE care of cancer patients unattractive for the states.
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A comparative analysis of Medicare home care cost savings for the terminally ill. Home Health Care Services Quarterly 1989a; 10:79-96.
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Pamidronate in prevention of bone complications in metastatic breast cancer: a cost-effectiveness analysis. Journal of Clinical Oncology 2000;18:72-79.
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Journal of the National Cancer Institute. Integrating economic analysis into cancer clinical trials: the National Cancer Institute-American Society of Clinical Oncology Economics Workbook.
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Stommel M, Given CW, Given BA. The cost of cancer home care to families.
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