By Brenda L. Mooney
PROVIDENCE, RI — An intense effort by the VA to improve end-of-life care is paying off, with hospice use increasing more among veterans than nonveterans.
A new report found that hospice use for nonveteran Medicare beneficiaries rose 5.6% between the pre-initiative period—fiscal years 2007 and 2008—and the post-initiative period—fiscal years 2010 to 2014.
At the same time, however, the increase was 7.6% among veterans who only used VA care, 6.9% among those who were dually enrolled in Medicare but used VA care, 7.6% among veterans who received healthcare from both VA and Medicare and 7.9% among dually enrolled veterans who used Medicare.
The recent study in the journal Health Affairs found that a VA program, the four-year Comprehensive End-of-Life Care (CELC) initiative beginning in 2009, successfully led to more hospice use among military veterans and at a higher growth rate than Medicare.1
As part of the initiative, the VA funded new inpatient hospice units, palliative care staff and palliative care training, while promoting mentoring for leaders and staff, a systematic quality monitoring program, and outreach to community providers outside VAMCs through the “We Honor Veterans” campaign.
Researchers from Brown University and the VA, including the Geriatrics and Extended Care Data Analysis Center, evaluated the effort at the agency’s request. They analyzed the trend in hospice use among more than a million male veterans age 65 and older between 2007 and 2014, and compared that rate of growth to demographically similar Medicare beneficiaries not enrolled in VA care.
“Compared to enrolled veterans’ hospice use in the years before CELC began, their use of hospice after the initiative increased substantially, and rates of increased use were approximately two percentage points higher than the increases observed for Medicare beneficiaries not enrolled in V.A. health care,” explained lead author Susan Miller, PhD, a professor of health services, policy and practice in the Brown University School of Public Health. “Based on population data, we estimated that this increase resulted in an additional 17,046 veterans receiving hospice care in fiscal years 2010 to 2014.”
Miller pointed out that the VA began establishing a healthcare system-wide hospice and palliative care program in 2002.
“Palliative care, in the form of palliative care consults and visits and hospice care, has been found to improve care at the end of life and to result in care more aligned with patient and family preferences,” she said. “Thus, palliative care results in less aggressive (and undesired) care such as emergency room visits and hospitalizations near the end of life. The VA’s efforts to improve veterans’ end-of-life care arose from the recognition that improvement was needed and the belief that greater access to palliative care and hospice could help to achieve this improvement.”
The study noted that, in 2008, 30% of inpatient deaths in VA facilities were in hospice beds, increasing to 44% by 2011. Recognizing that hospice use also was increasing in the general population, the study team designed the research to determine whether the CELC drove growth beyond the larger trend.
The difficulty was that older veterans are eligible for Medicare as well as VA benefits.
“Some veterans receive care in their last year of life reimbursed by the V.A. or Medicare or both,” Miller said. “So our evaluation compared differences in changes in hospice use for groups of veterans with differing combinations of health care use.”
“Additionally, we did a sub-analysis including only veterans and nonveterans with any hospitalization in the last year of life because we believed that if indeed the CELC initiative drove the observed two percentage point population-level differences, we would see even greater effects for veterans with exposure to VA medical centers since most of the CELC investments occurred in these settings,” she noted. “The validity of our findings was supported as we found that veterans who used only V.A. health care and had V.A. hospital exposure, compared to similar Medicare beneficiaries, had a greater increase in hospice use of four percentage points.”
Although the small VA-only population of veterans increased their hospice use, that 1% of the study group was about 10 percentage points less likely than veterans who were also enrolled in Medicare, the study found.
While socioeconomic issues might have played a role, Miller also said the study was unable to determine if another payer—such as Medicaid—was funding hospice care.
“Research has shown that African Americans and lower-income individuals use hospice less and since this [V.A.-only] group of veterans tend to have lower incomes and are more often African American, this is likely part of the reason for lower use,” she suggested. “However, there are likely other factors at play that need to be identified.
A facility-specific survey found that 138 of 140 VA facilities reported shortages of medical officers, with psychiatry and primary care positions being the most frequently listed.
When Terrence O’Neil, MD, retired as chief of nephrology at the James H. Quillen VAMC in Johnson City in December 2016, he left in his wake decades of work treating kidney disease—nearly 35 years in the Air Force and DoD, plus 11 more at VA.