Study Author Comments On Financial Incentives That Affect End-of-Life Care Quality

The author of a study published in the Journal of the American Medical Association (JAMA) on February 5, 2013, commented that many patients continue to receive aggressive treatments at the end of life, with on average three transitions in the site of care in the last three months of life. An interview with Joan M. Teno, MD, of Brown University, summarized the conclusions she draws from the data produced by the study.

Findings of the Study

Based on an analysis of Medicare data for more than 800,000 patients aged 66 years or older who died in 2000, 2005, or 2009, the study found that fewer individuals are dying in acute care hospitals than in the past and that more are receiving hospice care. A growing number are receiving care in an intensive care unit in their last month of life, and individuals are facing more transitions between different care sites in their final three months.

Financial Incentives

There are financial incentives to provide more care in fee-for-service care, Dr. Teno commented. We don’t get paid to talk with patients about their goals or care or probable outcomes of care, she said, but we are paid for hospitalizations, and there are financial incentives for nursing homes to transfer patients back to acute care. She suggested “we need to restructure how we pay hospital systems” and she is hopeful about the potential of bundling of Medicare payments through accountable care organizations.

Although some advocates have proposed using the site of death as a measure of the quality of care patients receive at the end of life, Dr. Teno said that we “need to go beyond site of death and look at health care transitions.” Such transitions are difficult on a dying patient and family, she said. One transition that often occurs is from an acute care hospital to a nursing home. When that happens, the nursing home has to “represcribe” all the patient’s medications, she explained. There is often a delay in getting medicine to the patient. Patients may not get effective palliative care when you move them, especially in the last three days of life, she concludes.

Advice for Clinicians

Hospice care, for many patients, “is an add-on to aggressive care,” said Dr. Teno. “We need to talk with patients about goals of care,” she said, and offered the following advice to clinicians: “Don’t wait until a patient is actively dying to refer to hospice.” She suggested that the clinicians get a palliative care consultation and talk with patients about their goals for care early on. “We have to thoughtfully navigate care at the end of life to give the right care at the right time and in the right location, she said, …”honoring the patient’s right to choose.”