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A recent study by Vince Mor published in JAMA Oncology found that veterans with advanced lung cancer treated in Veterans Affairs (VA) Medical Centers with high hospice use were more likely to receive concurrent cancer care and also less likely to receive aggressive care. On top of that, veterans treated at facilities with high levels of hospice use also incurred lower costs of care.

This is a strong case for the concept of concurrent care in which individuals can avoid the “terrible choice” between hospice and life prolonging therapies. On this weeks podcast, we interview the lead author, Vince Mor, about this study and whether concurrent care is ready for prime time outside of a integrated health care system like the VA.

We also put a plug in the end for the NIA Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratorythat Vince is helping to lead. If you want to learn more about the collaborators, click here.

by: Eric Widera

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: Alex, who is our special guest today?

Alex: Today our special guest is the esteemed Vince Mor, who is a Senior Health Research Scientist at the Providence VA Medical Center, and professor in the Department of Health Services, Policy and Practice at the Brown University School of Public Health. Welcome to the GeriPal podcast, Vince.

Vince: Thank you very much.

Vince: My pleasure.

Eric: I’m super excited to have you on. We’re going to be talking about one of your papers you just published in JAMA Oncology on Concurrent Care, which is hospice care while you’re still getting things like chemotherapy.

Eric: But before we do, we have one other person to introduce in this room. Alex, who else is in our studio office?

Alex: We also have Joe Lin, who is a fellow in our palliative care program here at UCSF. Welcome to the GeriPal podcast, Joe.

Joe: Thank you.

Eric: Before we jump into this paper, we always ask, is there a song request that you have, Vince?

Vince: Yeah, I thought Bridge Over Troubled Waters would be very appropriate for this discussion.

Alex: Terrific.

Alex: (singing).

Joe: (singing).

Alex: All right Joe, with the harmony.

Eric: Joe just found out today he was joining our podcast.

Alex: Joe worked that up two minutes before we started. That was awesome, Joe.

Eric: You didn’t expect this when you woke up in the morning, did you Joe?

Joe: I expect this every day.

Eric: Why did you choose that song, Vince? Why do you think it’s appropriate for where we are right now?

Vince: When a person with, in the last stages of oncology, or cancer, is trying to hold on to their hope and to also then begin to acknowledge the fact that they’re likely to die, the notion of this bridge over troubled waters actually made sense. And because that’s what in some sense is what concurrent care is. It’s a bridge that allows you to go from active treatment to palliative care.

Eric: Oh, I love that analogy right there. We’ll hear more of that song at the end.

Eric: I guess first of all, I’d love to hear how you got interested in this topic of concurrent care. But maybe before we do, can you actually define what we’re talking about when we say concurrent care?

Vince: Concurrent care – there have been a number of papers published in the last decade or so about this. It’s basically the ability to get care from a registered hospice under the Medicare Hospice Benefit, while at the same time getting treatments that are still potentially curative, or at least focused on arresting the rapid progression of the disease in the end stages.

Vince: Whether those treatments actually extend life or just make you somewhat more comfortable, what they do do is under the Medicare Hospice Benefit, which is quite restrictive, you can’t, the hospice has to pay for everything. Which means if they have to pay for chemotherapy or radiation therapy, which is thousands of dollars, it’s far more than they get paid for a day of hospice care. So it’s basically not done.

Vince: This notion of “Can you have your cake and eat it too, at the same time?,” is really great.

Eric: Common things in concurrent care is like chemotherapy for patients with advanced cancer, or dialysis for people who also may be dying of something related to their kidney disease, or the kidney disease was related to something else. Those types of things, right? While you’re also getting hospice care.

Vince: Right. What we studied was just cancer. Each disease, as you can imagine, presents its own clinical and policy issues. That’s really important to take into consideration. Your analogy is quite correct, but the implications are broader.

Alex: This concurrent care model, it seems like … a few organizations, there are few spaces to study this concurrent care model. In fact, I believe the VA is one of the only. Are there other examples of states or organizations or programs that allow concurrent care?

Vince: It’s really a function of the payment system, the reimbursement system, which is why under VA, it’s completely separate. So it’s perfectly appropriate.

Vince: If you’re commercially insured; if you’re, let’s say, you have somebody in your family, you’re working, somebody in your family is insured from Aetna, or your commercial insurance company, it’s perfectly possible for the commercial insurance company to say, “Yeah, we’ll pay for hospice. But we’ll also pay for chemotherapy at the same time.”

Vince: There have been a few descriptive studies showing that that’s viable, it works. But it does not work under Medicare, the way Medicare is paid for.

Eric: That’s because like you said earlier, the hospice agency, when they enrolled, they’re responsible for everything that’s related to the terminal illness. If the terminal illness is advanced cancer, they have to pay everything that’s related to the terminal illness.

Eric: If they need chemotherapy or want chemotherapy, the hospice agency has to pay for it despite them just getting what, like $150 a day?

Vince: That’s correct. You’re absolutely right. That’s the challenge.

Vince: … that’s the terrible choice.

Vince: Yep.

Alex: The terrible choice, right. That was, I think, David Casarett’s term for it. The terrible choice between hospice care and expensive care that may be slightly life prolonging, but also may be very palliative in nature.

Alex: When I think about radiation for people with advanced lung cancer, for example, that’s often palliative radiation. Sure, it may prolong life by some small amount. But often, the primary intent when people are nearing the end of life is symptomatic relief.

Alex: Somebody with spinal cord metastasis, for example, radiation to the brain for somebody who has confusion and swelling from brain metastases, et cetera.

Vince: That’s correct.

Eric: But shouldn’t hospices … I always think about this, like if it’s from a symptomatic standpoint; I’m having worsening dyspnea cough, radiation from hospice if it’s focused on symptom. It’s like getting radiation for a malignant process in the spine that’s causing weakness.

Eric: Should hospice … doesn’t hospice cover that already?

Vince: They … Imagine, you said it perfectly. Right now the home care rate is about $150, $160 a day. You go to a radiation therapy session; there’s almost never just one. Four or five days of significant radiation therapy, for whatever palliative purpose, is going to cost thousands and thousands of dollars.

Eric: Yeah.

Vince: That was never envisioned when the Medicare Hospice Benefit was first designed.

Alex: In fact, this gets to the point of your article. The fear was that if you allowed people to receive concurrent care; both hospice care as well as very expensive treatments, aggressive treatments, as we might call them, like radiation; that costs would rise. And that we needed to constrain those costs.

Alex: So they designed the benefit with those costs partly in mind, thus forcing people to make that terrible choice. Is that sort of … I mean, I don’t know if you know what the thinking was around the time when they designed the original Medicare Hospice Benefit. But I assume that was part of the reason for that, the way it was written.

Vince: I’m now going to give you a little surprise. I actually helped design the original Hospice Benefit.

Alex: Oh!

Eric: Oh!

Vince: Because I did the National Hospice Study in 1982. So I was, yes. We had long discussions about some of these issues.

Vince: At the time, hospice was only for cancer care. At the time, there was far less chemotherapy for this advanced stage, because there had not been the evolution of palliative chemotherapies that actually had less in the way of side effects about them.

Vince: And radiation therapy was delivered almost exclusively for palliative purposes on an inpatient basis for patients who were in a hospice inpatient setting. Or an oncology wing.

Vince: Since the last 40 years, there’s been a huge transformation of oncology care from inpatient-centric to outpatient-centric. The world has changed; the benefit has not.

Alex: Wow, we should get to, at the end, we will ask you if you could redesign hospice policy from the ground up, or maybe change it from where we are now; what would you do differently? Should we first talk about the article?

Eric: We should talk about the article.

Alex: We should talk about the article. In this article, again, in JAMA Oncology, titled Association of Expanded VA Hospice Care with Aggressive Care and Cost for Veterans with Advanced Lung Cancer. You used data from the VA, veterans newly diagnosed with stage IV non small cell lung cancer, from 113 VAs between 2006 and 2012.

Alex: The methods you used are somewhat complex analytically. I wonder if there’s a way you could simplify it for our readers so they understand what the, for our listeners and readers, what the difference is between the concurrent care group and the people who were not as likely to have received concurrent care.

Vince: What we did was we first divided all of the medical centers into those medical centers that changed over the course of 2006 through 2012, and began to add a lot of hospice care to all of their cancer patients in general. Not just their lung cancer patients, but all of their patients.

Vince: Those facilities that embraced the hospice idea, in their own setting. Both by having hospice, their own hospice inpatient unit, but also by referring lots of their dying cancer patients that they were taking care of in their own oncology service to a local hospice.

Vince: This is sort of a natural experiment. Then for each medical center, we looked at how they changed over time, and then how newly diagnosed stage IV lung cancer patients from, let’s say, 2006 in medical center A, compared to those diagnosed in 2012 in the same medical center. So you have within medical center change.

Vince: That’s how we were able to say what difference did it make, the increasing adoption of hospice in the face of the policy that allows for concurrent care.

Vince: Because in VA, there is no prohibition on doing hospice and chemotherapy radiation.

Eric: Why not just look at, you have low utilizers of hospice, you have high utilizers of hospice in different medical centers. Why just look at them instead of looking at this difference over time?

Vince: Because the medical centers that have chosen to adopt hospice are probably different in many many ways than medical centers that don’t. And for those of your listeners that know anything about the VA, when you’ve seen one medical center, you’ve seen one medical center.

Alex: That’s right.

Vince: The same is true for the patients who would elect hospice. Patients who elect hospice are really quite different than those who don’t.

Eric: In your paper, you have something called the Hospice HEQ, which was Hospice Exposure Quintile.

Vince: Yep.

Eric: You separated facilities based on this. Can you just describe Hospice Exposure Quintile one more time?

Vince: Okay. We looked at 113 hospices, and we saw which ones changed a lot between 2006 and 2012-

Vince: … and which ones changed virtually not at all, with respect to the bulk of their patients adopting hospice.

Vince: Then we took that distribution and divided it into five groups.

Alex: So 113 medical centers, and you looked at their use of hospice within each of these years, 2006 to 2012.

Vince: Yep.

Eric: So if you’re in the top quintile … Wait, let’s say I’m a medical center with a high use of hospice in the past, and a high use right now, versus one with a low use in the past, and a low use right now. Do I fall in the same quintile? Or is that separate quintiles?

Vince: That never happened.

Eric: All right.

Vince: That’s one of the reasons we did it that way. There were no facilities that were high-high. There were some facilities that were middle, and then they became high. So it’s every facility year was assigned to a given quintile.

Eric: Did anybody go down in hospice use?

Vince: They may have intermittently gone down, but not consistently over time.

Eric: One last question from me, around methods. One of the challenges in the VA is the VA could be the hospice payer, the home hospice payer? Or you could go to inpatient hospice and the VA may pay for inpatient hospice facility at a VA. Or you could go to a skilled nursing facility, and that could be VA paid. Or, Medicare-paid hospice or some other hospice.

Eric: One of the challenges I have as a VA provider is I never really know, I never can get data on who are the Medicare-paid hospice folks, because that’s not through our system. Are you capturing both VA-paid hospice and Medicare-paid hospice?

Vince: We have all the data.

Eric: You have everything.

Vince: Yeah. We have all the data. Whether it’s Medicare only, fee basis; that is, that the medical center is buying it for their patient from the local hospice; or whether the person is getting inpatient hospice provided at the VA. We have all of it.

Eric: See Alex, you just need to design the system and then you can get all the data from it.

Alex: That’s right.

Vince: Oh no no, your data, you could only get the data you have on your clinical patients from the VA. You have to wait for two years to get the Medicare data.

Eric: Okay. Yeah. All right, Alex.

Alex: Okay, great. What were the major outcomes that you looked at in this study?

Vince: We wanted to ask the question, first off, does a person entering hospice with newly diagnosed, very late stage lung cancer, with an average survival of only about four to six months, what’s the likelihood that they’re actually getting chemotherapy or radiation therapy?

Vince: We found that actually in the high quintile places, they’re getting more of this stuff. They’re getting much more hospice. 15, 17, 18% are getting one of those – either radiation or chemotherapy. The idea was right. There is more individual-level concurrent care happening in the places that made the bigger investment in hospice.

Eric: The high quintile, again, is those who went from a lower use of hospice to a higher use of hospice.

Vince: Right.

Alex: One might expect, then, that if there’s more hospice and there’s more concurrent care, meaning radiation, chemotherapy, that those patients would be more expensive.

Vince: You would expect that. But guess what? What happens is there’s a huge reduction in the number of days in the inpatient setting. Whether on the Medicare hospital side or in the VA medical center.

Vince: You get this perfect balance of substitution, so that where hospice is actually substituting for inpatient hospital care, which is the most expensive. All of our cost savings came from a reduction in inpatient days.

Alex: Interesting. On average, were these patients who received concurrent … or I should say, in the highest quintile of hospice use, who also had higher rates of concurrent care, on average cost less than patients in lowest quintile hospice use?

Vince: I don’t have the number off the top of my head, but it was statistically significantly less in the context of a lot of heterogeneity.

Alex: Yeah.

Vince: I think it was several thousand dollars worth.

Alex: Yeah. Wow. Having both was less expensive than having one. Isn’t that interesting?

Vince: Well, it’s having the option for both.

Alex: Right.

Vince: Only a minority of people actually got it. But-

Eric: Well, six percent, if I remember right, somewhere in the low, it’s in the single digits, right?

Vince: No, it was in the teens for that highest quintile group.

Alex: Yeah. It’s also, when you think about the, I guess one of the challenges for policy folks is you think, “Oh, it must be more expensive if we’re going to let them get hospice and radiation and chemotherapy.” Yet that’s not the whole universe of costs.

Alex: The whole universe includes things like hospitalization, acute care service use, ICU stays-

Vince: Right.

Alex: Incredibly expensive care that is reduced for those patients who are allowed, have the option of receiving concurrent care.

Vince: Right. This is consistent with several small single-institution trials that were done five, eight years ago. Which is really great, because our data are population based, from a very specific and special population, but nonetheless special.

Eric: Yeah, 13,000 people in this study. I mean, it’s a big population. It is interesting, though, because in … the nice thing about the VA, it’s one healthcare system. ICU costs, outpatient costs, chemotherapy, it’s all going to the same place.

Eric: But for most large academic medical centers or other centers, in the older model of fee for service, if you reduce my ICU stay, or if you’re not admitted to my hospital in the last two weeks of life, I actually may not see some money coming in to my hospital. I don’t really care what happens to them as an outpatient because I don’t need to pay for that.

Eric: Does this work in those other types of settings?

Vince: Thank you very much for that question. In the discussion section, we’re pretty clear to suggest that the reason this works is because the VA is an all-encompassing, all-payer combined system. Even though there’s leakage into the Medicare world, these patients are managed by the local medical center and the oncology practice, et cetera.

Vince: In the private sector, everybody’s got their finger in the pot. It’s really different. So the incentives are all different, et cetera.

Eric: Yeah. It definitely sounds like things are moving towards incentives. I think one of the really interesting things is, even for hospitals, read some evidence that while hospital stays, generally in a fee for service, like people are making money at that last hospital stay? Everybody loses money. Doesn’t matter who you are, what system you’re in.

Eric: I wonder if it even would work in those types of settings as well, just by preventing that last very expensive hospital stay.

Vince: I don’t know. That’s a really good question. The last expensive hospital stay is actually, depending on the age of the person, is dropping. The very old people are spending less time in the last hospitalization, in general. But for, say, somebody around 70 to 80 plus, that last hospitalization tends to be expensive.

Vince: On the hospice side, what happens frequently in the Medicare world is patients are discharged from the ICU directly to hospice, they spend 24 hours in the inpatient hospice unit, and sort of it’s “This plus this plus this plus.”

Alex: Right. Well, this is a great segue into the question we were at before, which is, how should we redesign hospice policy? Should we redesign it? Should we change … or is the better question, how should we redesign it, given where we are? Or is it, how would you design it from the ground up if you could start again?

Vince: I’m going to first answer that question in relation to Medicare Advantage, okay? Or managed care. Medicare Advantage, people are paid per member, per month. Medicare pays them a per member, per month.

Vince: Right now, the policy is that once somebody elects hospice, who’s a Medicare Advantage member, they go to the Hospice Benefit, and there’s really not much continuity between their Medicare Advantage membership and the hospice. It’s sort of a … they’re kind of disrupted.

Vince: The first thing what should happen is that Medicare hospice should be part of the Medicare Advantage benefit. The Medicare Advantage plans should be fully accountable. Then they have the freedom to do whatever they want; then we can all watch to see what happens.

Alex: Yeah.

Vince: Because it may well be that once you have the all-encompassing incentive of a per member per month, then those people will figure out the right way to do it. And there might be some concurrent care; it might work quite well.

Vince: But on the strict fee for service with no per member per month cap, at this juncture it would not work. Not in our current healthcare system.

Alex: Right … and it would not work because the costs would rise-

Vince: Yeah. Yeah, I mean 60 plus percent of all hospices in the United States are now for profit. The individual physicians and radiation practices and the hospitals, hospital outpatient departments; everybody wants to have their piece of the pie. If you just allow concurrently more pieces, more people to have access to that pie, the total pie gets bigger and bigger.

Alex: Right. Each of those services wants all of the reimbursement that the insurance will pay for.

Vince: It’s one way to say it.

Eric: The reason we don’t see that within your, the VA system?

Vince: Because the oncologists in the VA are saying, “Are you sure you want … Is this sensible? Yeah; clinically, it makes sense. This is the right thing for you.”

Eric: Because there’s no direct financial incentives of doing more.

Vince: Right. There’s no direct; the only rationale for doing more is clinical.

Alex: Is there talk of instituting the change that you just talked about for Medicare Advantage; changing health policy so that Medicare Advantage plans are responsible for hospice services, and they don’t essentially switch to fee for service hospice?

Vince: I believe so. There has been a lot of discussion in Medicare; the politics of this get complicated. Not all of the hospices, hospice advocacy organizations or lobbying groups want this to happen, because they think they would be constrained in some way by the Medicare Advantage plans.

Vince: And not all of the Medicare Advantage plans want to take on that added liability, because they don’t think Medicare will increase their per member per month proportionately, et cetera.

Alex: Interesting.

Eric: What about healthcare systems like Kaiser Permanente? Is there an incentive for them to do things like concurrent care? They have the oncologists on their staff, they have the radiation oncologists; sometimes they have hospice or they fee out hospice. It starts looking a lot like the VA.

Vince: Kaiser Permanente – they have their hospital division. Then they have their doctor division.

Vince: Then they have their insurance company on top of it. Now, there is a lot more binding together in Kaiser than in many just insurance-based plans. But it’s not a fully encompassed system the way the VA is.

Alex: Interesting. So, are there things that our readers, our listeners and readers should do if they want to advocate for change in this area? Because I think most, maybe all of our listeners would agree that concurrent care is the best care for patients because it doesn’t force that terrible choice.

Eric: But it also sounds like the system is set up in a way, outside of the VA, where more will beget more, maybe. Because there is, in instances, very strong incentive, financial incentive to do more. Maybe; am I hearing this right? Maybe in a regular Medicare world, may not be the right thing.

Vince: It would be difficult for me to envision under a standard fee for service system, where there are all of these disparate actors functioning, that I think more will beget more. That’s certainly what history has taught us.

Vince: I’m much more sanguine about some form of bundle, whether that’s some kind of Medicare Advantage plan or some kind of all-encompassing plan where the budgets have to be managed as an overall; and you deal with how you reimburse the doctors and the hospitals, slightly separately. And you could put those all together.

Alex: Vince, should we have Medicare Advantage for All?

Vince: That would be my strong preference. As much as there are lots and lots of horror stories that one hears about Medicare Advantage companies, a lot of those are largely attributable to what one would say, incomplete and inadequate regulatory oversight.

Vince: It is possible to do a better job with the regulatory oversight, and still have a cap in that sense.

Eric: I’ve got to know, a fascinating paper in JAMA Onc; I encourage all of our listeners to read it. What’s next for you around this topic?

Vince: We’re actually looking at dialysis now within the Veterans Administration, and how big changes in the way in which dialysis was purchased by the VA over, about the same period we looked at here. What effect that had on access to dialysis, and so on.

Vince: We’re again bringing all the data together, and asking about a very important clinical, very frail, vulnerable population, and what adverse effects or positive effects policy changes, particularly around purchasing, have.

Eric: Then the other question I have for you is, the nice thing about the VA, integrated healthcare system, you’ve got one payer. But the problem is, when we start including hospice, now we have these other entities outside of the VA.

Eric: As a VA provider, there’s a lot of confusion out there on the hospices too. There are some hospices that fully understand concurrent care and some that just don’t want to do it because they’re worried about … would Medicare come after them? Did you see similar things in your research?

Vince: Yeah, we had a wonderful, Cari Levy, who’s at Denver, at the VA there, did some great qualitative studies going out and talking to hospices, medical centers, oncology practices, oncologists within the VA.

Vince: The level of confusion, you’re absolutely right. It’s very hard, it’s a complex question of; it’s sort of a “Yes, but.” And whenever you have a “Yes, but,” things could be misunderstood.

Vince: Yes, you can do what you want, but you need to check in. Or yes, but; and so people, if the answer doesn’t go in just one direction. That makes the veterans exceptions to what their normal Medicare counterparts are getting.

Vince: It’s really hard to practice that way because you know one standard of practice. We’re not very smart, us humans, sometimes.

Alex: That’s great. Okay, last question from me. Vince, am I right? Did you receive a gigantic NIH grant with Susan Mitchell to study dementia?

Vince: We did. It’s all about, we have bench to bedside. Ours is, can you take a study that works when researchers do it? Let’s say concurrent care when researchers are really studying it in one place.

Vince: And can you actually embed that in a healthcare system, and make it work with people with dementia, serious dementia? Whether it’s in a doctor’s office, in an emergency department, in a nursing home, or assisted living. We’re funding pilots all around the country now.

Alex: She emailed me and asked if we could do a GeriPal podcast about it. I said, “It’s not really a full podcast topic, but if there is a plug that you wanted to make, we could make it.” So maybe this is our plug, to consider pilots…

Vince: It’s called IMPACT, and it’s basically a collaboratory funded by the National Institute on Aging, focused on dementia. It’s trying to fund pilots and support pilots to basically take an idea that we believe works, and try to actually engineer it so that it’s delivered within the healthcare system.

Eric: And if they’re interested in it, they have a good idea, what should they do?

Vince: We have a website; it’s IMPACT, but I don’t know exactly ww whatever it is. But IMPACT ADRD would do it, if you just Google it or what have you.

Eric: Great.

Alex: Great. We’ll put a link to that in the blog post associated with this podcast.

Vince: Terrific. Thank you.

Eric: I think with that, I want to give you a big thank you for joining us today. I learned a ton, just about concurrent care, and where we are with our healthcare system. It seems like a great idea, but it’s complicated. So thank you for joining us, Vince.

Vince: My pleasure.

Eric: Maybe we could just end with a little bit more of the song? Joe, you ready?

Alex: Joe’s getting ready. He’s back at the mic. Let’s start from the beginning this time. Thank you so much, Vince. Really appreciate you coming on the GeriPal podcast.

Vince: My pleasure. Thank you.

Alex: (singing).

Joe: (singing).

Eric: Instead of “I will lay you down,” I thought you were going to say, “Hospice will lay you down.” [laughing].

Eric: Vince, again, a very big thank you for joining us.

Eric: To all of our listeners out there, thank you for joining us for this podcast. If you haven’t already, please take a moment to rate us on your favorite podcasting app. Or send an email to a friend, and tell them how much you like GeriPal, and encourage them to listen to it.

Eric: With that, thanks everyone.

Alex: Thanks everyone. Bye.

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