Improving End-of-Life Care: Making Hospice and Home Support Accessible

Maureen Canavan and Dr. Kerin Adelson, healthcare executive, chief quality and value officer, and professor of Breast Medical Oncology at MD Anderson Cancer Center, sat down with us to discuss critical issues in end-of-life care.

In this interview, they explore the urgent need for policy and system-level changes to improve access to hospice and supportive home care, highlighting how current reimbursement structures often fail to meet the needs of patients and families at the end of life.

Canavan is an epidemiologist at Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center (COPPER) and affiliated faculty at Yale Institute for Global Health. Adelson is healthcare executive, chief quality and value officer, and professor of Breast Medical Oncology at The University of Texas MD Anderson Cancer Center, in Houston.

Transcript

Given what we know about end-of-life care, what policy or system-level changes do you think are most urgently needed to improve access to hospice and supportive home care?

Canavan: You know, one thing that we've come across, really, is the limited reimbursement for both hospice and home care, specifically supportive home care at the end of life. I think this is something, and they talk about the carrot or the stick, and this is a very positive thing. If we have improved reimbursements for hospice care or home supportive care, this goes back to what Karen was just saying.

Patients can be at home, they can be with their family, and they can still be receiving care that helps them. We currently are very good about reimbursing for high-cost immunotherapy, but seeing these much less costly things, like reimbursement for hospice and home care, I think would definitely be a policy-level change that could have far-reaching positive effects. I think also in terms of tying it, potentially, to performance, when we think about the use of systemic therapy.

One thing Karen was noting that they're doing at MD Anderson is that need for justification of this high-cost systemic therapy, so making sure that if you are proceeding in that capacity, it's really prognostically appropriate and also appropriate for the patient's wants and needs.

Adelson: One to make is that, as an oncologist, I could give $35,000 worth of combined immunotherapy on the day a patient dies and be reimbursed for it, but I cannot, for the most part, get a patient with Medicare or commercial insurance a home attendant for $15 to $20 an hour. Dying is hard, and it's hard on families, and it's scary, and many, many families can't afford to take time off work to take care of their loved ones.

When you look at our payment incentives when it comes to end-of-life care, they are truly perverse. Many, many patients can't afford to die at home because there's nobody to look after them, and they end up staying in the hospital, a much higher-cost environment, because they can't get out of bed and toilet or have their pain managed, or help with that. Definitely looking at our payment system and enhancing the benefits to help patients essentially die at home and get the support they need in that environment.

In addition, the hospice benefit pays terribly. If you think that somebody has to travel to the house and give that patient care, very, very little can be done for the patient within the hospice benefit. That's something that should be looked at as well.

More generous reimbursement for hospices would allow them to do more for patients, including providing more support in the home than most hospices can do with what they're reimbursed today.

Transcript has been edited for clarity and conciseness.

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