Dr Thomas LeBlanc: How to Increase Palliative Care Among Patients With Blood Cancer
Thomas LeBlanc, MD, of the Duke Cancer Institute, discusses how palliative care has evolved over the past decade for patients with blood cancers.
What tactics have been used and can continue to be used to increase palliative care and hospice use among patients with blood cancers?
A lot has changed in hospice and palliative care in the last 5 or 10 years. Palliative care is now recognized as a medical sub-specialty. You can do fellowship training, you can get a board certification, and you can engage a palliative care team as part of cancer care. Many studies have been done in the solid tumor realm now very clearly showing that there are benefits for patients and families when you add a specialist palliative care clinician to the cancer care team. It improves symptom management, quality of life, moods, psychological distress. Even in some cases, caregiver outcomes and a few studies have shown a survival benefit which is quite interesting and potentially really important.
Early specialist palliative care may help people better tolerate their cancer treatments for example, and that’s different than hospice care which is end stage, terminal care at the end of life, mostly provided at home and generally requires people to forgo any cancer directed therapies like chemotherapies. The problem here with blood cancers is that usually also means that they have to forgo transfusion support. Part of what we did in the sera-Medicare analysis we presented here at ASH was to look at the association between transfusion dependents and whether or not leukemia patients utilize hospice care and we did see that those who were dependent on transfusions utilized hospice care for a much shorter period of time, suggesting that’s a big barrier to sending these patients to hospice or at least to them utilizing it for a period of time that will help them feel better and live better and spend more time at home at the end of life.
So, one of the things that we think really needs to be looked at in the coming years is a policy solution. So, the way that hospice care is paid for in this country, which mostly is paid for through the Center for Medicare and Medicaid Services under the Medicare benefit is on a per DM rate, where basically hospice care agencies get a small amount of money per day per patient that they are caring for, so there isn’t actually a prohibition in the CMS rules against providing transfusions, or against providing chemotherapies. It’s really more of a practical issue whereby a hospice care agency has a very small margin and cannot afford to provide transfusion support for patients with leukemias and other hematologic malignancies because they cost too much and they would end of going bankrupt and not being able to serve or help anyone.
So, we end up having to make these difficult choices whereby patients don’t often utilize hospice care services when they feel like they are benefiting from transfusions which can have significant palliative care benefits in terms of helping people have less fatigue or less shortness of breath or maybe helping them live a little bit longer and achieve some of their goals and spend time with family at home even if they still die of their disease. Working towards policy solutions there, for example, considering possibly a supplemental payment for blood cancer patients to receive transfusions in addition to the per DM hospice care rate could actually transform our ability to improve the quality of end-of-life care for patients with leukemias and other blood cancers if they could get transfusion support and thereby utilize hospice care earlier. What we found in the sera-Medicare analysis is that Leukemia patients utilize hospice care services, there’s about a $10,000 savings per Medicare beneficiary and the quality of measures all look dramatically better. It’s one of these unusual and nice circumstances where it’s better care, it’s the right care for the person but it also actually costs less.