Death (Panels), Be Not Proud…


All sales final?

All sales final?


Good morning, ProviderNation. Death panels, be not proud: Terminally ill patients who don’t go into hospice are dying just as quickly but are much more likely to visit emergency rooms, be admitted into hospitals, even have surgery for unrelated conditions than those who enter hospice, the fine folks at the Journal of the American Medical Association are saying.

In a new study, researchers found that Medicare had to pay an average of nearly $9,000 more to treat non-hospice, terminally ill cancer patients in their last year of life than it cost to treat patients in hospice over the same time. Those who declined hospice had “significantly more hospitalizations,” more trips to intensive care, and even more “invasive procedures … largely for acute conditions not directly related to cancer,” the researchers found.

Nearly three-quarters of those who refused hospice care wound up dying in hospitals or skilled nursing centers, versus a scant 14 percent of hospice patients who did, JAMA researchers say.

Rethinking End-Of-Life Care

What’s important about this study is that it’s comparing like with like: Researchers scoured tens of thousands of records and matched cases of people whose died after roughly the same length of time. The findings come in the midst of what appears to be a wave of critical rethinking about end-of-life care. Many in this profession are working hard to change the way they, and we, and you and I think about death, dying, and grief.

But wherever the other ironic points of light flash out, the team behind Thursday’s JAMA report say that Medicare has some thinking to do, too.

“First, the Medicare administration monitors and prosecutes hospices with inappropriately long hospice stays, creating a perceived disincentive for physicians to make early hospice referrals that are more likely to produce long stays,” the report says. “Second, Medicare does not reimburse physicians for discussions to elicit patients’ preferences for end-of-life care. Third, Medicare requires patients to formally renounce curative care before enrolling in hospice, which is thought to limit demand.”

“This Last Issue”

“This last issue,” the team says, “is particularly relevant to cancer care since patients often wish to continue active treatment irrespective of prognosis—an area of concern to payers as use of costly new targeted therapies, often oral and less toxic, becomes widespread at the end of life.”

This is a toxic issue, of course: Follow the implications down one way, and you might well find yourself feeling like a villain from a sword-and-sandals movie.

Dr. Ira Byock argues that patients shouldn't have to choose between disease treatment and palliative care.

Dr. Ira Byock argues that patients shouldn’t have to choose between disease treatment and palliative care.

But help is on the way. Dr. Ira Byock, whom many of you met in our September cover story on death, dying, and grief, argues that palliative care and disease treatment don’t have to be mutually exclusive.

“In the past,” he tells me, “skeptics questioned whether cost savings associated with hospice were predetermined by preferences of those who choose hospice to eschew aggressive treatments. This study’s matching strategy, exclusion criteria, and analyses show otherwise. Prior to enrollment, hospice users were at least as likely to choose active disease treatments as the matched controls.”

‘Welcoming Arms… Reluctant Arms’

For Byock and other advocates like him, the math isn’t all that difficult.

“The lower costs among hospice patients likely resulted from better care,” he says. “It’s not hard to understand how the mundane components of hospice care—meticulous management of pain, breathing, and bowels; crisis prevention and early crisis management; supportive counseling regarding the natural course of illness and development of an endgame; and 24-hour access to help—result in less calls to 911 and less time spent in hospitals and ICUs.”

For Byock, the answer is straightforward: Medicare should scrap its “arbitrary requirement” that people waive disease treatment in order to have palliative care, because “the terrible choice” currently on offer only leads “to higher costs and lower quality.”

Byock makes a living at this, of course (and he’s literally written the book on it), but for him and many others, dying well isn’t just a matter of dignity for individual souls.

“In healthy societies,” he tells me, “people are born into the welcoming arms of a community, and they die from the reluctant arms of a community.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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