Medicare to Try a Blend of Hospice Care and Treatment


Medicare to Try a Blend of Hospice Care and TreatmentMost older Americans close to death have to make a difficult choice: continue with traditional medical treatment or switch to hospice care, which focuses not on a cure but on easing their remaining days.

Now, Medicare is testing a third alternative: both.

The new pilot program, designed to affect the care of about 150,000 Medicare patients over the next four years, will allow patients with terminal diseases to receive hospice care to manage suffering and counseling to plan for the end of life — but still see doctors and get medical treatments, like chemotherapy or hospitalization, intended to fight their illnesses.

The test program is based on research that shows that patients with access to both so-called palliative care and traditional medicine often end up with a better quality of life and less expensive, intense medical treatment. The approach may even offer the patients a longer life span than those treated with traditional medicine alone.

That surprising result came from a type of study that is unusual in evaluating services for patients: a randomized controlled trial. Such trials, which randomly assign patients to get different sorts of care, are common for studying new drugs, but rare when it comes to health care policy. But they are becoming more popular, as The Upshot reported last year, because randomized trials can provide definitive, and counterintuitive, results.

The question of how to mix palliative care, intended to manage patients’ symptoms, and curative care to fight disease has been studied in three randomized trials of cancer patients. All showed benefits to the approach.

Dr. Jennifer Temel, an author of a randomized study of patients with lung cancer, said she was sometimes asked why such a trial was needed for an idea that seemed intuitive. But doctors are evidence oriented, she said, and the studies have provided a strong basis for changes in medical practice and payment policies from insurers like Medicare.

The speed with which cancer treatments are changing, for example, can lead to confusion. “It is harder for patients to decide that ‘I don’t want more chemotherapy,’ ” said Dr. Temel, clinical director of thoracic oncology at Massachusetts General Hospital. “I think we need more of a gray zone where patients can get the benefits of hospice care but still receive chemotherapy to help them live longer.”

The Medicare pilot program will itself be a kind of randomized trial. So many hospices wanted to participate in the program that Medicare was able to randomly select half to start the program in 2016 and the rest to start two years later. Comparing the outcomes between the two groups, and a third group of hospices that never applied, will allow for a more robust evaluation of whether the policy makes sense for all of Medicare, said Dr. Patrick Conway, the principal deputy administrator and chief medical officer at the Centers for Medicare and Medicaid Services.

“If it’s successful, and we think it will be, it’s a strong evidence base to potentially scale it to the entire Medicare population,” he said.

There are risks with the new approach. As reporting from The Washington Post has shown, hospice care is a part of Medicare where unscrupulous providers can commit fraud by signing up healthy patients for services. In cases in which patients will not have to sacrifice more traditional medical care, there is a risk that hospice providers may sign up patients who do not really want or need their services.

Dr. Conway said the pilot program would be set up to limit which patients would be eligible and to carefully monitor the providers for fraud.

Medicare will also monitor the cost of patients in the trial program and those who get the traditional medical benefit. The randomized trial will teach the government how to achieve the best health outcomes for dying patients. But it will also show which approach is more costly.


Related Online CEU Courses:

End of Life: Helping with Comfort and Care is a 1-hour online CEU course that takes a respectful look at the end of life, what might be expected, and offers practical suggestions on how to bring comfort.

Death and Dying: The “Butterflies are Free” Program – Dying isn’t a subject that Americans like to think about. Our national character is vibrant, optimistic, life-affirming. These qualities have been a great advantage to us as a people, but they have a down side.

The Grieving Self is a 3-hour online continuing education (CE/CEU) course that looks at stories of the bereaved to determine the major issues to address to reconnect those who grieve to a stable sense of self.

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Mapping Your End-of-Life Choices


Mapping Your End-of-Life ChoicesRobert H. Laws, a retired judge in San Francisco, and his wife, Beatrice, knew it was important to have health care directives in place to help their doctors and their two sons make wise medical decisions should they ever be unable to speak for themselves. With forms from their lawyer, they completed living wills and assigned each other as health care agents.

They dutifully checked off various boxes about not wanting artificial ventilation, tube feeding and the like. But what they did not know was how limiting and confusing those directions could be.

For example, Judge Laws said in an interview, he’d want to be ventilated temporarily if he had pneumonia and the procedure kept him alive until antibiotics kicked in and he could breathe well enough on his own.

What he would not want is to be on a ventilator indefinitely, or to have his heart restarted if he had a terminal illness or would end up mentally impaired.

Nuances like these, unfortunately, escape the attention of a vast majority of people who have completed advance directives, and may also discourage others from creating directives in the first place.

Enter two doctors and a nurse who are acutely aware of the limitations of most such directives. In 2008, they created a service to help people through the process, no matter what their end-of-life choices may be.

The San Francisco-based service, called Good Medicine Consult & Advocacy, is the brainchild of Dr. Jennifer Brokaw, 46, who was an emergency room physician for 14 years and saw firsthand that the needs and wishes of most patients were not being met by the doctors who cared for them in crisis situations.

“The communication gap was huge,” she said in an interview. “The emergency room doctor has to advocate for patients. I felt I could do that and head things off at the pass by communicating both with patients and physicians.”

Sara C. Stephens, a nurse, and Dr. Lael Conway Duncan, an internist, joined her in the project. Ms. Stephens flew to La Crosse, Wis., to be trained in health care advocacy at Gundersen Lutheran Health System. Through its trainees, tens of thousands of nurses, social workers and chaplains have been taught how to help patients plan for future care decisions.

“People often need help in thinking about these issues and creating a good plan, but most doctors don’t have the time to provide this service,” said Bernard Hammes, who runs the training program at Gundersen Lutheran. “Conversation is very important for an advance care plan to be successful. But it isn’t just a conversation; it’s at least three conversations.”’

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