Palliative Care in Cancer: When Does the Discussion Begin?

Palliative care discussions are now starting earlier in oncology, as patients and providers realize that palliative care does not equal end-of-life care. A team effort, palliative care requires communication among providers, caregivers, the patient, and the family in order to achieve the patient’s goals for pain and symptom management alongside curative therapy. However, not all clinics or healthcare systems have integrated palliative care into their care plan. While a palliative care physician and nurse might be considered a vital part of the cancer care team at one clinic, a conversation on pain management or end-of-life care may not even occur at others.

A study published 5 years ago in Health Affairs found that nearly one-fourth of Medicare expenditures were made to beneficiaries in their last year of life.¹ Could the integration of palliative care save on these costs? And then there’s the issue of reimbursement. How do you reimburse for the time a palliation consultant spends with the patient?

The American Journal of Managed Care brought together a panel of healthcare experts to discuss some of these questions and challenges during the Oncology Stakeholders Summit, Spring 2015 Peer Exchange. Moderator Bruce Feinberg, DO, vice president and chief medical officer of Cardinal Health Specialty Solutions, was joined by Scott Gottlieb, MD, resident fellow at the American Enterprise Institute; Brian Kiss, MD, vice president of Healthcare Transformation at Blue Cross Blue Shield of Florida; Michael Kolodziej, MD, national medical director for oncology strategy at Aetna; and Ted Okon, MBA, executive director of Community Oncology Alliance (COA).

Feinberg broached the topic of palliative care by narrating the story of a friend whose 93-year-old aunt had a procedure-associated complication and ended up on a ventilator. When the nephew reached the hospital, he was asked how he’d like to continue treatment and handed a list of everything that “do not resuscitate” (DNR) entails. Following an unproductive conversation with the resident physician, a palliative care specialist was called in, which helped ease the process. “Statistics show that only 50% of eligible patients end up in hospice care, with an average length of stay of just 7 days,” said Feinberg, asking, where should the conversation start?

Palliative care discussions need to start well before the end stage of disease or before the patient has intractable pain, according to Kiss. End-of-life care discussions can be initiated in patients who are at an early stage of their disease or even in patients who have enrolled in primary care, he said.

“This is by far the hardest part of the job of being an oncologist,” said Kolodziej. In his opinion, this conflicts with what oncologists are primarily trained to do, and necessitates a systemic change. He also drew attention to the slough of definitions and terms that could confuse anyone trying to come to a decision, including advanced care planning, end-of-life care, and hospice care. Kolodziej believes in leading by example, though, and said that he tells his patients: “I have a healthcare proxy. I have a will. I have made my goals and what I’m interested in known to those I love. I would strongly recommend that we have that discussion and we have it with your family.”

Feinberg suggested that oncologists might push back on adding another specialist to their team, which may already include a radiation, surgical, and medical oncologist. Okon responded by saying that the entire practice, not just the oncologist, would have to adapt and the changes would have to be built into the “fabric of the practice,” echoing Kolodziej. He added that this change would loop back to the patient, ensuring a more patient-centered approach that could enhance the patient’s quality of life and treatment goals.

Feinberg spoke about certain restrictions that CMS has incorporated with reimbursement benefit design, such as the fact that a patient in hospice care cannot get a blood transfusion. This ties the provider’s hands in terms of care delivery, especially for patients with advanced disease. “[The system] has these black-and-white determinants of when things can be done,” he said.

Gottlieb agreed that CMS is very rigid with hospice care, especially since the length of stay in hospice has been steadily increasing. In the subsequent struggle for balance, reimbursement changes are made that don’t work in favor of hospice care providers, he said. He agrees that DNR conversations and decisions should be made early, at the outpatient stage, not when the patient is hospitalized and in need of advanced care.

“If you think about why patients ‘cost’ so much at end of life, it’s because they’re receiving acute care in the hospital,” said Kolodziej, emphasizing that acute inpatient care is the cost driver, in addition to unnecessary chemotherapy administration, and a system that is not adept at managing symptom burden. Do we have a solution, then? Generating a reimbursement code for when a doctor discusses advanced care planning (ACP) with the patient is not going to change the situation, said Kolodziej. “It’s a process, not a 15-minute time slot where you discuss ACP.”

He went on to explain that the current healthcare system needs a makeover with respect to managing patients with advanced disease. Describing Aetna’s Compassionate Care program,² Kolodziej said that specially trained nurses are assigned to address patient concerns and to help them plan and achieve their treatment goals. “The goal is not to enroll them in hospice, and the goal is not to get a DNR. The goal is to have the discussion,” not necessarily with a palliative care physician, because we do not have enough of them, he said.

Kiss said that some of Blue Cross Blue Shield’s cancer accountable care organizations are integrating a palliative care physician and even a palliative care nurse as a part of team-based care. This integration ensures that the patient does not have to endure a change of care from treatment to palliation, and he finds this encouraging.

Gottlieb thinks the integration of palliative care into mainstream cancer care is inevitable given the increasing consolidation in healthcare and practices taking capitated risks. “The incentives on the part of the providers are going to change, too, and that will also impact these decisions.”References

1. Riley GF, Lubitz JD. Long-term trends in Medicare payments in the last year of life. Health Serv Res. 2010;45(2):565-576.

2. Smith A. Q&A on palliative care. Am J Manag Care. 2015;21(6):SP172.

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