This is a very important study that brings good news. The key is how we move to expand access to palliative care throughout the system, particularly in the Medicare program.
Currently, the hospice benefit in the Medicare program requires patients to 'unelect' curative care before they can begin receiving hospice care. Hospice is not synonymous with palliative care, but hospice is an inter-disciplinary approach through which patients who are believed to have 6 months or less to live do receive palliative care services. [Palliative care is care that address the physical and psychosocial symptoms of serious life limiting illness and helps patients deal with the complex issues inherent with such an illness] This study demonstrates that early provision of palliative care benefits patients in terms of life span and quality of life and appears to reduce intensive end of life costs. It is important to note that the mean survival time for both treatment and control in this study was longer than 6 months, the presumptive period of hospice eligibility in the Medicare program.
There are several good reasons why the hospice benefit, which has been generally unchanged since the early 1980s should be changed. First, this study, and one published looking at a demonstration tested by Aetna in its non-Medicare (younger) business, show that opening up eligibility for palliative care (before there has been a certification of someone being in their last 6 months of life) improves patient benefit and reduces cost. Second, it is very difficult to accurately predict death, and this uncertainty likely hinders access to/choosing of hospice, which practically limits palliative care. In turn, this harms patients and likely increases costs. Third, in spite of great improvement in the availability of hospice and an increase in knowledge of this option in the Medicare program, 1 in 4 Medicare decedents who die while using hospice only do so for 5 days or less, and the median is still less than 3 weeks. Patients are not getting the maximum benefits they might from hospice, and certainly not from palliative care. Fourth, the image of hospice, especially as it relates to 'unelecting' something in the Medicare program is likely unpalatable to a substantial segment of the population. The length of hospice use figures appears to be stalled at current levels, and new approaches are likely needed to deliver the needed palliative services. The current Medicare hospice benefit structure simply imposes a choice that does not seem necessary either from the perspective of helping patients or conserving the resources of the Medicare program.
The PPACA allows for concurrent care demonstration projects in which access to palliative care would be granted to patients without their 'unelecting' any type of care treatment. These demonstrations seem to have been conceived of with the Aetna study in mind, but this latest study should provide even more impetus to move ahead aggressively and quickly in carrying out these demonstrations and to then begin moving toward policy changes in the Medicare program fairly rapidly.
Policy/implementation questions I have about this study and how it can be applied broadly are as follows:
- will patients choose early palliative care if offered the choice? Put another way, how important (if at all) is selection bias in explaining these results, meaning were those who consented to the study very different from the typical patient?
- will these findings hold up/will this choice be replicated in more ethnically diverse patients? There were only 6 of 151 patients in this study that were not white. This is not a criticim of the study, merely a fact that must be kept in mind from a policy perspective since their are many differences in care use across race and ethnic groups.
- will doctors and other providers offer or 'sell' early palliative care to their patients? Both doctors and patients need to learn the message that palliative care improved quality of life and extended life. How threatening of a message will this be to oncologists? Other doctors?
- Can other studies replicate similar results in other disease groups, like congestive heart failure, or COPD?
- In one sense, all of these points above hinge on the fact that while RCTs are ideal for assessing internal validity, they can be wanting for external validity (how broadly applicable are their findings). The concurrent care demonstrations in Medicare should focus on nailing down these issues of how this expanded/early palliative care approach can be most broadly implemented to local conditions given the mounting evidence that expanded palliative services without patients having to 'unelect' curative services seems to benefit both patient and the Medicare program.