Palliative Care and Pain Management at the End of Life ___________________________________________
individual hospice programs offer. Hospice care may be denied to patients receiving palliative chemotherapy or radiotherapy, and this may result in many people not choosing hospice. Although oncology experts have noted that radiotherapy is an important component of palliative care for many people with metastatic cancer, only 3% of people receiving hospice care receive radiation therapy; expense and the need to transport patients were the primary barriers [77; 78; 79]. Other pallia- tive interventions, such as chemotherapy, blood transfusions, total parenteral nutrition, and intravenous medications, may not be economically feasible for small hospice units but may be possible at larger ones [80; 81; 82]. Many have suggested that the hospice model should change to allow for integration of disease-directed therapy [83; 84]. The Affordable Care Act of 2010 stipulates that the Centers for Medicare & Medicaid Services (CMS) implement a three-year demonstration project to evaluate concurrent hospice care and disease-directed treatment [84]. This project represents a significant change to the eligibility criteria and, while the change has the potential to improve access to hospice care, care- ful assessment of the effect of concurrent treatment on use of hospice as well as on quality of life, quality of care, survival, and costs is needed [84]. Phase 2 of the project, the Medicare Care Choices Model (MCCM), became a six-year study (2016–2021) to assess whether offering Medicare beneficiaries the option to receive supportive, palliative care services through hospice providers without forgoing Medicare payments for treatment of their terminal conditions would improve beneficiaries’ quality of life, increase their satisfaction with care, and reduce Medi- care expenditures. In all, 89 of141 (63%) Medicare-certified hospices participated in MCCM; however, only 44 (31%) participated for all six years [85]. Of 7,253 Medicare beneficiaries who enrolled in the MCCM program, all qualified for hospice and met other eligibility crite- ria, including having cancer, heart failure, chronic pulmonary disease, or HIV/AIDS [85]. Enrollees received supportive and palliative care services through MCCM while continuing to receive Medicare coverage for disease-directed treatment of their terminal condition. Specific MCCM-directed services included assessment of health and health-related social needs, care coordination and case management, access to healthcare professionals, person- and family-centered care planning, shared decision-making, and management of symptoms. Length of enrollment varied (median: two months) and 89% of enrollees died before the end of the MCCM program. Surveyed MCCM enrollees and caregivers reported high levels of satisfac- tion with their quality of life, shared decisions, and receiving care consistent with individual wishes. MCCM enrollees had 12% fewer outpatient emergency department visits, 26% fewer inpatient admissions, and lower net Medicare expenditures when compared to a matched group of non-participants [85].
Deceased enrollees were less likely than comparison benefi- ciaries to receive aggressive life-prolonging treatment in the last 30 days of life and spent more days at home before death. The Medicare Hospice Benefit criterion of a life expectancy of six months or less has also affected the timeliness of referral to hospice because of the aforementioned challenges in predict- ing prognosis. Many hospices were accused of fraud and were assessed financial penalties when government review found documentation of patients who received hospice care for longer than six months. As a result, many clinicians delayed hospice referral because of their lack of confidence in their ability to predict survival within six months. However, the six-month regulation has been revised, and a penalty is no longer assessed if a patient lives beyond six months if the disease runs its normal course [34]. Unfortunately, reimbursement for end-of-life care discussions is not as straightforward as for hospice care. An effort to establish government reimbursement for discussions of end-of-life care options, including hospice care and advance directives, sparked a political storm that led to the removal of the proposed reim- bursement from the healthcare reform bill of 2011. However, beginning in January 2016, the CMS introduced two Current Procedural Terminology (CPT) reimbursement codes for advance care planning visits [86; 87]. Despite a national increase in advance care planning claims, the overall claims rate remains low. Two-thirds of hospice and palliative medicine specialists did not use the new CPT codes in 2017, despite working with seriously ill patients [87]. Difficulty in Prognostication To make appropriate referrals to hospice, clinicians must be able to determine accurate prognoses, at least within the six-month timeframe required for reimbursement. However, prognostication is a complex issue and is a primary barrier to hospice use [88; 89; 90; 91; 92; 93; 94; 95]. Studies have found that physicians typically overestimate survival, and one study found that physicians overestimate prognosis both in determining it and in communicating it to the patient [93; 96; 97]. The difficulty in determining the risk of death within a specific time period not only affects the ability of clinicians to make appropriate referrals to hospice but also impedes the ability of patients and families to make necessary end-of-life decisions, with many patients not fully understanding the severity and progressive nature of the disease [98]. Several factors contribute to physicians’ difficulty in prognos- tication, including a desire to meet the patient’s needs (for a cure or prolongation of life) and a lack of reliable prognostic models [81; 97; 99]. Perhaps the most important factor con- tributing to prognostic difficulty is the variations in disease trajectories, which have been characterized as a short period of evident decline, long-term limitations with intermittent seri- ous episodes, and a prolonged decline ( Figure 5 ) [9; 32; 100].
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MDCA1525
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