- The patient experience for end-of-life care may be better for veterans treated by the VA rather than for patients covered by fee-for-service Medicare, according to a group of researchers from Stanford Medicine.
The study, published recently in Health Affairs, investigated the quality of end-of-life care delivered in VA healthcare facilities and by Medicare providers.
The research team, led by Stanford assistant professor of medicine Risha Gidwani-Marszowski, DrPH, measured care quality using metrics from both the American Society of Clinical Oncology as well as the National Quality Forum.
Specifically, Gidwani-Marszowski and team looked at whether patients received chemotherapy, whether they had two or more ED visits, were admitted into the hospital and how long that stay was, whether they died in the hospital, and ICU admissions.
Using these measures and care quality information for over 87,000 veterans over age 66 with solid tumors and who died between 2009 and 2014, the researchers determined that end-of-life care quality was higher at VA facilities than from Medicare physicians.
Medicare patients were more likely to receive unnecessarily intensive care at the end of life including receiving chemotherapy, hospitalization, admission into ICUs, longer stays in the hospital, and death in the hospital.
These results may be the outcome of differing payment structures between VA and Medicare, the research team said. Medicare fee-for-service pays for the total services rendered rather than the quality of care, Gidwani-Marszowski pointed out.
In contrast, VA clinicians are salaried. The base salary pay incentivizes VA providers to deliver holistic quality care rather than a high volume of treatments.
The data did reveal that VA patients were more likely to have two or more emergency department admissions compared to Medicare patients.
This finding may have been the result of limited VA office hours and barriers to accessing clinicians, the research team said. The emergency department may have been the only treatment option after typical office hours, explaining the higher utilization.
Additionally, Medicare patients are often admitted into the hospital for care VA patients must receive in the ED.
These results have considerable policy implications, the research team explained. Currently, the pending Veterans Empowerment Act would alter payment structures at VA, transforming the agency into a payer of healthcare as opposed to a provider of care.
This payment model would largely mirror the one utilized in Medicare, according to senior author Steven Asch, MD, professor of medicine at Stanford.
The study’s results indicate that patients may benefit from the VA’s existing structures.
“The VA has long been a leader in providing patient-centered care at the end of life,” said senior author Steven Asch, MD, professor of medicine at Stanford. “Our study showed that veterans can expect appropriately lower-intensity care as they face late-stage cancer at VA facilities. If they choose instead to use their Medicare benefits outside the VA, they are at greater risk of getting chemotherapy, hospitalization and other services that will likely not help them in their last days.”
Gidwani-Marszowski, who disclosed a position with the VA, said that these findings also have implications for any patient receiving end-of-life care. Patients have the right to have their needs attended to at all times, but especially during palliative and hospice care.
“The findings are not just important for veterans and VA policy, but for anybody who needs medical care at the end of life, which is a majority of us,” Risha Gidwani-Marszowski, concluded. “We as a society need to ensure we are setting up the organization of health care and its financial incentives to ensure that the services patients receive are the ones that are in their best interests at the end of life.”