A Q&A with Diane E. Meier, MD, FACP, Director, Center to Advance Palliative Care; Professor of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai; New York, NY; firstname.lastname@example.org
Originally published November 8, 2017
Q: You wrote in MedGenMed in 2007 that palliative care was the job of all hospitals. In October 2017 you were honored at the National Academy of Medicine for your achievements in this field. How fully has your charge to hospitals in 2007 been realized?
A: Palliative care is a fairly new medical specialty devoted to reducing suffering and improving quality of life for people living with serious illness-whether the disease is curable, chronic, or life threatening and progressive. Palliative care teams work alongside disease treatment specialists to provide an added layer of support in service of pain and symptom management, family support, attention to the social determinants of health, and skilled communication about what to expect and what matters most to the patient in the context of the reality of the illness. Multiple studies demonstrate palliative care’s contribution to achievement of the triple aim: better experience of care, better care outcomes (including survival in several studies), and as an epiphenomenon of better care, much lower unnecessary utilization of 911 calls, ED visits, and hospitalization. Continue reading…
“Uninsured cancer patients are paying anywhere from 2 to 43 times what Medicare would pay for chemotherapy drugs, according to a new study from the University of North Carolina at Chapel Hill. These findings were published by Dusetzina et al in Health Affairs.
“Uninsured patients who did not negotiate the billed amounts could expect to pay $6,711 for an infusion of the colorectal cancer drug oxaliplatin. However, Medicare and private health plans only pay $3,090 and $3,616 for the same drug, respectively.”
“One in five Medicare patients with melanoma experience delays in getting surgery, a Yale study found. The research was published April 8 in JAMA Dermatology.
“Melanoma, a type of skin cancer, is a leading cause of new cancer diagnoses in the United States. A delay between diagnosis and surgery to remove melanomas may cause patients psychological harm and affect health-care quality. Using the national Surveillance, Epidemiology, and End Result-Medicare database, the Yale team conducted the first population-based analysis of delay of surgery among Medicare patients with melanoma.
“The researchers reviewed data on more than 32,000 Medicare patients diagnosed with melanoma. They found that 22% of patients waited longer than 1.5 months for melanoma surgery, and 8% were delayed more than 3 months. Although no gold standard exists, a timeframe of less than six weeks between diagnosis and surgery has been recommended.
” ‘Delay for melanoma surgery in this population is more common than we expected,’ said Jason Lott, M.D., who was first author of the study as postdoctoral fellow in the Robert Wood Johnson Foundation Clinical Scholars Program at Yale School of Medicine.”
“Results of clinical trials evaluating chemotherapy regimens for advanced pancreatic cancer and lung cancers “tended to correctly estimate survival for Medicare patients aged 65 to 74 years, but to overestimate survival for older Medicare patients by 6 to 8 weeks,” Lamont et al reported in the Journal of the National Cancer Institute. “These ‘real world’ results may help inform treatment discussions between older patients with these common advanced cancers and their oncologists,” the researchers wrote.
“In the United States, ‘patients who enroll in chemotherapy trials seldom reflect the attributes of the general population with cancer, as they are often younger, more functional, and have less comorbidity,’ the investigators observed. ‘We compared survival following three chemotherapy regimens according to the setting in which the care was delivered (ie, clinical trial vs usual care) to determine generalizability of clinical trial results were to unselected elderly Medicare patients.’ ”
The gist: New research shows that four or more PET/CT scans can help guide care for patients who have been treated for lung cancer. This is significant in the light of a recent announcement from Medicaid and Medicare Services that only three FDG PET/CT scans would be routinely covered after treatment.
“New research from Johns Hopkins School of Medicine reveals a high value of scans which could lead to future change of reimbursement policies for follow-up positron emission tomography/computed tomography (PET/CT) studies in lung cancer. The study, featured in the February 2015 issue of the Journal of Nuclear Medicine, establishes the value of fourth and subsequent follow-up PET/CT scans in clinical assessment and management change in patients with the disease.
“According to the American Lung Association, lung cancer is the leading cancer killer in both men and women in the United States. Approximately 402,326 Americans living today have been diagnosed with lung cancer. In 2014, diagnoses of an estimated 224,210 new cases of lung cancer were expected, representing about 13 percent of all cancer diagnoses.
“In the retrospective study, a total of 1,171 patients with biopsy-proven lung cancer who had positron emission tomography with a radioactive tracer (18F-FDG were identified at a single tertiary center from 2001 to 2013. Among these, 85 patients (7.3%) had four or more follow up PET/CT scans with a total of 285 fourth and subsequent follow up PET/CT scans. Median follow up from the fourth scan was 31.4 months. The follow-up PET/CT scan results were correlated with clinical assessment and treatment changes.”
“As in the draft plan, individuals must still have a 30 pack-year history of smoking to qualify and must either be smoking currently or have quit in the past 15 years.
“Also, beneficiaries must obtain a written order from a physician for the first screening, stipulating that the patient underwent counseling on lung cancer screening and that it involved a shared decision-making process. Subsequent annual screenings will also require similar written orders.
“The counseling sessions must emphasize the importance of continued abstinence for ex-smokers and cessation for current smokers.”
“The Centers for Medicare & Medicaid Services (CMS) has made a preliminary decision to cover lung cancer screening with low-dose computed tomography (LDCT) for eligible patients.
“The decision was welcomed by a number of professional societies, including the American Thoracic Society, the Lung Cancer Alliance, and the American College of Chest Physicians.
“In April, the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) voted against recommending national Medicare coverage for annual screening for lung cancer with low-dose CT in high-risk individuals. Although the MEDCAC vote isn’t binding, their ruling ignited intense pushback from healthcare professionals, patient advocates, and professional associations. More than 40 medical societies have urged CMS to provide coverage for older adults. Even politicians have entered the fray, with members of the US House and Senate asking CMS to reimburse for screening.
” ‘LDCT has been shown to reduce mortality when used to screen individuals who are at high risk for developing lung cancer because of their age and smoking history,’ Charles Powell, MD, chief of pulmonary, critical care, and sleep medicine at Mount Sinai Hospital in New York City and chair of the American Thoracic Society’s thoracic oncology assembly, said in a statement.
” ‘While there is some risk of overdiagnosis, it is outweighed by the mortality benefit that has been demonstrated with screening targeted groups of high-risk patients,’ he said.”
“A federal prescription-subsidy program for low-income women on Medicare significantly improved their adherence to hormone therapy to prevent the recurrence of breast cancer after surgery.
” ‘Our findings suggest that out-of-pocket costs are a significant barrier’ to women complying with hormone therapy, said Dr. Alana Biggers, assistant professor of clinical medicine at the University of Illinois at Chicago College of Medicine, and lead investigator on the study. Programs that lower these costs can ‘improve adherence—and, hopefully, breast cancer outcomes—for low-income women,’ she said. Biggers presented the results of the study at an Oct. 14 press conference in advance of the American Society for Clinical Oncology Quality Care Symposium in Boston.
“Breast cancer is a leading cause of cancer-related deaths for women of all races, but survival rates differ by race and socioeconomic status, with African American women and women of low income having higher rates of death.”
“Low-dose computed tomography (LDCT) is a low-cost and cost-effective strategy for screening Medicare beneficiaries for lung cancer, according to a study published in the August issue of American Health & Drug Benefits.
“Bruce S. Pyenson, from Milliman Inc. in New York City, and colleagues estimated the cost and cost-effectiveness (cost per life-year saved) of LDCT lung cancer screening in the Medicare population at high risk for lung cancer. Medicare & Medicaid Services (CMS) beneficiary files (2012) were used to establish Medicare costs, enrollment, and demographics. CMS and U.S. Census Bureau projections were used for forecasts to 2014.
“The researchers found that approximately 4.9 million high-risk Medicare beneficiaries would meet criteria for lung cancer screening in 2014. Without screening, Medicare patients newly diagnosed with lung cancer have an average life expectancy of approximately three years. The average annual cost of LDCT lung cancer screening is estimated to be $241 per Medicare person screened. For Medicare beneficiaries aged 55 to 80 years with a history of ≥30 pack-years of smoking and who had smoked within 15 years, assuming a 50 percent screening rate, LDCT screening for lung cancer is low cost, at approximately $1 per member per month. This screening demonstrates highly cost-effectiveness, at <$19,000 per life-year saved.
” ‘If all eligible Medicare beneficiaries had been screened and treated consistently from age 55 years, approximately 358,134 additional individuals with current or past lung cancer would be alive in 2014,’ the authors write. ‘LDCT screening is a low-cost and cost-effective strategy that fits well within the standard Medicare benefit, including its claims payment and quality monitoring.’ “