As more studies link aggressive end-of-life oncology care to problems such as suboptimal cost and quality outcomes, experts are increasingly proposing earlier, more comprehensive palliative care interventions.
Shelley Fuld Nasso
As more studies link aggressive end-of-life oncology care to problems such as suboptimal cost and quality outcomes, experts are increasingly proposing earlier, more comprehensive palliative care interventions. “There is absolutely clear-cut evidence that palliative care enhances clinical outcomes and quality of life for people with advanced malignancy,” said Michael Kolodziej, MD, Aetna’s national medical director for oncology solutions.
As far back as 2012, the evidence was compelling and sufficiently prolific to convince ASCO to issue a clinical opinion supporting the integration of palliative care with conventional oncology treatment.1 “There has been an increasing chorus of voices, in ASCO and outside of ASCO, saying that there really needs to be a better way,” said Lowell E. Schnipper, MD, chair of ASCO’s Value in Cancer Care Task Force and chief of hematology/oncology at Beth Israel Deaconess Medical Center.
In a pivotal recent study, Jennifer Temel, MD, Massachusetts General Hospital, found that early palliative care among patients with metastatic non—small cell lung cancer led to increased survival.2 The palliative group achieved superior outcomes based on median survival and quality of life measures, the study found.
Shelley Fuld Nasso, CEO, National Coalition for Cancer Survivorship, described the Temel study as having initiated a “Big Bang” revolution, predicting that it would eventually “change the way people view palliative care.” Craig C. Earle, MD, director of the Ontario Institute for Cancer Research, said that such findings are taking the pressure off oncologists to go on fighting a patient’s cancer until the very end. “Studies showing that early involvement of palliative care can actually improve hard outcomes like survival are making it more acceptable for oncologists to not always be pushing the most aggressive approach,” he said.
Kolodziej said it’s important to carefully assess the type and value of end-of-life care that patients receive because that is where the costs can really add up. “Look at where the dollars are spent in patients who die of malignancy; the number one cost is not chemotherapy, it’s inpatient care,” Kolodziej said. His view is supported by a 2014 study in Cancer, which linked earlier palliative care referral (>3 months before death vs <3 months before death) with fewer emergency department (ED) visits, fewer hospitalizations, and fewer hospital deaths in the last 30 days of life.3
Even within the hospital setting, earlier palliative consultation has the potential to significantly lower costs. Research published in 2015 showed that in an adult population diagnosed with advanced cancer, palliative intervention within 6 days of admission reduced hospital stay costs by 14% ($1312 per patient)4 and within 2 days by roughly 24% ($2280 per patient).There are strong believers in the value potential of palliative intervention, but there is no consensus on whether a paradigm shift is underway. “There is a mixed picture,” said David Hui, MD, of the Department of Palliative Care and Rehabilitation Medicine, MD Anderson Cancer Center. “People generally have a greater awareness of inappropriate chemotherapy use. National data seem to show some decrease in acute care or hospital stays at the very end of life, but then some other trends show there are a bit more ICU stays.5 This is still evolving.”
The research results Hui mentioned, published in 2013, showed a sharp increase in the percentage of patients who were in hospice at the time of death: 21.6% in 2000 versus 42.2% in 2009.5 Conversely, a study of advanced cancer patient admissions in 2000 (n = 191) and 2010 (n = 141) found that despite poor median survival in both groups (4.7 months median survival post discharge in 2000 and 3.4 months in 2010), hospice was recommended to only 23% of patients in 2000 and 24% in 2010.7
“What we do know is there is plenty more work to do on this score,” Schnipper said.A range of complex factors continues to drive overzealous end-of-life oncology care. One of these is that the era of immunotherapy is generating excitement and contributing to the “focus-on-cure” mentality, Hui said. Similarly, the utility of precision therapies tempts physicians to continue treatment in patients well into advanced-stage cancer. “Targeted therapies, many of which are oral, have made it seem easier to keep treatment going very near end of life. In some situations, this is not unreasonable, but in others, these drugs can still be very toxic, not to mention incredibly expensive, for very modest potential benefits,” Earle said.
According to Hui, patient age, attitude, degree of awareness regarding their condition, and beliefs toward risk taking can also have a profound impact, as can general cultural taboos, shared by both patients and providers alike, which discourage candid conversations regarding end-of-life related topics. “It’s easier to talk about the next line of therapy than death,” Earle said.
In addition, Hui said, portions of the healthcare system that should be working together are siloed. “There is a dichotomy between the acute care system and the hospice care system, and some of the reimbursement policies may contribute to more aggressive chemotherapy use at end of life.”Fee-for-service reimbursement models can reward nonproductive treatment and fail to adequately compensate for comprehensive palliative care. “It’s an unfortunate by-product of our system that probably has an unconscious effect at skewing decisions,” Schnipper said.
The Centers for Medicare & Medicaid Services (CMS) has undertaken a number of efforts to explore alternative oncologist payment methods perceived as more compatible with the promotion of end-of-life care optimization. The federal agency has supported numerous programs experimenting with compensation mechanisms, such as episode-based “bundling,” and has provided millions of dollars in grant funding to further the oncology medical home (OMH) concept, which emphasizes physician accountability, enhanced patient services, and expanded care accessibility to decrease inappropriate hospitalization and nonproductive therapy. “As of 2016, CMS is now going to pay for advanced care planning discussions,” said Fuld Nasso.
OMH programs also are being used by the private payer community to incentivize improved end-of-life care. “I’ve been a big proponent of the oncology medical home. Within that delivery model, we pay practices for having advance care planning visits and end-of-life discussions,” Kolodziej said.
Schnipper added that when an OMH is successful with end-of-life issues, patients get a quick response to their needs and they are able to remain at home rather than in an ED, “which is otherwise the default position.”
Consultants in Medical Oncology and Hematology (CMOH), a 9-physician group practice outside of Philadelphia, established a delivery model focus that is earning respect for its handling of end-of-life patients. In 2010, CMOH became the first oncology practice to meet all National Committee for Quality Assurance criteria required for recognition as a Level 3 Palliative Care Medical Home.8 “They are doing a better job of talking to patients earlier and getting them into hospice care earlier,” Fuld Nasso said.
Results of the CMOH effort include a 68% decrease in ED visits, a 51% drop in hospital admissions per patient treated with chemotherapy per year, and a 21% reduction in length of stay for admitted patients.8 Cost savings yielded by the group’s OMH program are estimated at roughly $1 million per physician annually.