Rounding out the Moon Shot

It was a great honor for Vice President Biden to visit Duke to discuss the cancer “Moonshot” initiative that he is leading. The language of curing all cancer has given way to more realistic, though plenty bold talk:

Biden said he was not naïve enough to think that all cancers can be cured but pointed out there’s a growing consensus among scientists that “we really are at an inflection point.”

“The science is ready, it seems to me,” Biden said. “Much more has to be done, but I believe we can make much faster progress.”

Our culture will always gravitate to metaphors of war, victory and complete triumph, and so we need to make sure we round out the moonshot to include other places where the science is also likely at an inflection point. Key issues:
  • How to we improve communication of options to patients and families so they can have a role in deciding what therapies and care are best for them?
  • Developing a more coherent system of providing high touch, low tech care that can help patients and families live best. There is some evidence patients are ready to engage treatment tradeoffs. And if we wiped cancer off the face of the earth….there will be an explosion of heart disease and stroke morality, and the caring needs of humans will always be central to our life experience.
  • There was lots of discussion yesterday at Duke about information sharing and determining when the federal government does and does not have a role. A practical information expansion where the federal government does have a role is making available claims data from Medicare Advantage plans to researchers. They are now generally unavailable, so that means the claims data for around 3 in 10 elderly persons in the U.S. cannot be included in research. Making the data available won’t cure cancer, but it could make data sharing efforts like the one described by UNCs Stephanie Wheeler more readily replicable nationally.

I don’t know the correct mix of how the Moonshot resources should be invested. We just need to make sure we round out the discussion of the choices facing our nation: basic science, innovation in treatments, clinical investigation, how to communicate to patients, and how to provide systems of caring that will be needed by patients and families regardless of what disease(s) people eventually die from.

Talking Medicare End of Life Policy Changes

I was on WUNC’s program The State of Things yesterday talking about changes to Medicare end of life policy. About 12 minutes.

Right to Die Debate

Most of my research focuses on hospice and palliative care–so I think, study and talk a great deal about death. Invariably when I give a talk about hospice and palliative care policy, someone asks about physician assisted suicide. This surprises me because I see them as quite different, but I guess it shouldn’t since it keeps happening, especially if non researchers (normal people) are in the audience.

A flip response by someone (me) who feels quite morally muddled about physician suicide is to say something like “if we have better hospice and palliative care, then no one would be interested in physician assisted suicide.” I have said this in response to questions about physician assisted suicide and the right to die movement, but I don’t really think I fully believe this to be true.

I remain muddled on this issue, however, I do think this piece by Kevin Drum is the most coherent and honest thing I have ever read on the topic and I commend it to you.

 

Evaluating Medicare End of Life Changes Coming 1/1/2016

We have a post at Health Affairs blog on 3 changes to Medicare end of life policy that are taking place on January 1, 2016:

  • First change in how Medicare pays hospice providers in 32 years
  • Payment for Advance Care Planning
  • The Medicare Choices program (test of concurrent hospice care)

Any one of these would arguable be the biggest end of life policy change for Medicare since the creation of the hospice benefit in 1983; combined, they make for huge shift, and evaluating their impact is a top policy priority.

Should Hospice be put into Medicare Advantage?

The bipartisan Chronic Care Working Group of the Senate Finance Committee outlines this as an option they are considering (see p. 8 h/t to Brad Flansbaum). I have blogged about the oddity of hospice being carved out of Medicare Advantage plans before (here, here, and here). Several points:

  • There is no actuarial reason to carve hospice out.
  • Putting hospice into the Medicare Advantage benefit package will almost certainly lead to hospice aggregation and driving out small providers in some areas, because hospice is now any willing provider in Part A. If we put it into Med Advantage plans, they will contract and in some markets this will have big impacts. This might be good and might be bad depending on the market (competition v quality trade-off).
  • There is now a huge business opportunity produced by this carve out that is just now being leveraged. Any palliative care company that can (1) get more Medicare Advantage patients to elect hospice and (2) do so earlier will improve Med Advantage plan profitability. If a patient goes out of Med Advantage to hospice 30 days before death versus dying in a hospital, the Med Advantage plan losses ~$1,500 in premiums, but avoids $15,000+ in claims. They likely improve patient quality/experience as well, but these profits now could at least partly be going back into the system.

My guess is that hospice goes into the Medicare Advantage benefit package within the next few years, driven finally by the rise of palliative care on a more widespread basis.

Beyond this issue, the working paper is filled with what interests a bipartisan group of staffers + members of the Senate Finance Committee (they key committee) in the area of chronic care, so this is a great place to start when thinking about what you should be studying/writing a dissertation or grant on.

Five Most Pressing End of Life Science Policy Needs

A colleague from a federal funding agency asked me last week for a “10,000 foot view of what you feel are the five most pressing science policy issues for palliative, hospice, end-of-life areas?”

Here goes.

  • How to better represent uncertainty (prognosis, treatment effectivenss, etc) to patients and families
  • Aligning patient/family wishes and preferences with treatment options offered (at both a micro level—as patients go through illness trajectory as well as in structuring what is offered to patients in benefit packages)
  • Improving methods of non experimental inference, which includes reaching a societal consensus on ‘how much evidence is good enough?’ to make policy decisions based on observational demonstration evidence
  • Improving prognosis methods, and including morbidity/disability states as both an outcome of interest, as well as using same to better predicting survival
  • Harvesting and providing data on cost, quality and patient/family preferences in near real time so that it can be used to inform treatment decisions

A Beautiful Death

That is the name of the Duke Sanford Schools newest “Ways and Means” podcast that discusses one families struggle with brain Cancer, with some extended comments from me on the subject of what Medicare does and does not cover for persons facing the end of their life.

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