Innovation and Evaluation

We urgently need a period of innovation, with thoughtful evaluation and learning, in order to shape the care system and payment arrangements so they will better serve cancer patients coming to the end of life. Here, a list of possibilities is provided. Many agencies and programs should take part, but it seems likely that NCI, AHRQ, HRSA, HCFA, and the VA should be in the lead. In each case, an innovation is listed, but it is essential that each innovation be evaluated and that insights be gained from the trial. These examples are meant to be illustrative, not comprehensive or sufficient. The important conclusion is that innovations such as these should be tried out, in substantial numbers, and soon.

  • If Medicare covers medications, examine effects on end-of-life care.

  • If there is a formulary or purchasing cooperative, evaluate comprehensiveness and efficiency of symptom treatments.

  • If Medicare does not cover medications generally, experiment with coverage for symptoms only.

  • Change enrollment criterion from prognosis to severity (or extent) of illness and allow continuous enrollment from onset of a certain severity to the end of life.

  • Pay more for the first day or two and the last day or two.

  • Carve out certain high-cost treatments or “pay down” their cost to the program to a reasonable cost share.

  • Allow the hospice team to consult on nonhospice patients.

  • Increase the daily rate, tailored to specific diagnoses.

  • Encourage “bridge” and “graduate” programs, with funding beyond home care.

  • Require coverage of hospice in Medicaid.

  • Reward physicians (e.g., with better administrative arrangements) for signing up patients on hospice.

  • Integrate hospice care and nursing home care at a fair rate of pay.

  • Develop regional guidelines on management of common symptoms and advance care planning to ease transfers.

  • Make key consultations for difficult symptoms readily available on-site.

  • Provide incentives so that most residents can live to the end of life in their residence.

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