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Palliative Care
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     To the Editor: The National Coalition for Cancer Survivorship (NCCS), a survivor-led organization that advocates for high-quality cancer care, supports the principles of palliative care outlined by Drs. Morrison and Meier (June 17 issue).1 In 1996, the NCCS published Imperatives for Quality Cancer Care, which states among its principles, "People with cancer should be provided a range of benefits by all health care plans that includes . . . supportive therapies to manage pain, nausea, fatigue and infections, long-term follow-up, psychosocial services, palliative care, hospice care, and bereavement counseling."2 Only when our reimbursement system values and pays adequately for the management of symptoms and other morbidity associated with cancer will the quality of life for people with cancer be measurably improved.

    Ellen L. Stovall

    National Coalition for Cancer Survivorship

    Silver Spring, MD 20910

    References

    Morrison RS, Meier DE. Palliative care. N Engl J Med 2004;350:2582-2590.

    Clark E, Stovall E, Leigh S, Siu A, Austin D, Rowland J. Imperatives for Quality Cancer Care: access, advocacy, action, and accountability. Silver Spring, Md.: National Coalition for Cancer Survivorship, 1996.

    To the Editor: In community oncology practice, anticancer treatment and palliative treatment are a continuum. Unfortunately, the reimbursement dichotomy noted by Morrison and Meier drives a wedge between cancer therapy and palliative therapy, and one size does not fit all. Most systemic cancer treatment is not curative in effect or intention; it is palliative and may be effective temporarily in reducing pain or tumor-related symptoms. On referral to a hospice facility, the information required by the Centers for Medicare and Medicaid Services includes whether the patient is receiving curative treatment and whether such therapy will be continued.

    Often it is deleterious to patient care to propose stopping chemotherapy and referring the patients to hospice care simultaneously. Sometimes the plan is to try a therapy for a limited time. However, it is financially impossible to provide most current systemic treatments of cancer under the hospice Medicare benefit. How do the authors resolve this catch-22?

    Robert C. Kane, M.D.

    Venice Oncology Center

    Venice, FL 34285

    The authors reply: Many regimens of chemotherapy and radiation therapy are palliative, not curative, in intent and outcome. If given for palliation, these treatments can theoretically be covered under the Medicare hospice benefit. The barrier is cost. Hospice care is reimbursed on a per diem basis, and the reimbursement is approximately $100 per day, which prohibits the use of most costly regimens of chemotherapy and radiation therapy. However, there are a growing number of exceptions to this barrier. Larger hospices (typically those with a daily census of more than 200 patients), with the advantages of economies of scale, are often willing to cover not only certain chemotherapies and radiation therapies but also, for example, parenteral nutrition and hematopoietic growth factors. It is important for clinicians to inquire about coverage of specific therapies rather than assume that community hospice partners will refuse to pay for such treatments.1

    In communities where hospices are too small or too financially stretched to provide expensive palliative treatments, the clinician must ensure that high-quality palliative care for symptoms that cause distress, support for decision making, and coordination of care across settings are provided through other routes, including hospital-based palliative care teams and physician and nurse consultants. Such services are growing rapidly (with an increase of 45 percent, to 950 programs, from 2000 to 2002, according to survey data from the American Hospital Association).2 If physicians and their patients continue to demand palliative care services, most communities should have them available for seriously ill patients within the next few years.

    The voice of the consumer is critical for ensuring access to high-quality palliative care. Coordinated consumer advocacy has been central to the recent success of the palliative care movement in this country, as it was for AIDS and breast-cancer research. Similarly, patients and families will have to demand the changes in payment policy that are necessary to compensate providers of so-called cognitive services at least as well as those who provide procedural and diagnostic interventions.

    R. Sean Morrison, M.D.

    Diane E. Meier, M.D.

    Mount Sinai School of Medicine

    New York, NY 10538

    sean.morrison@mssm.edu

    References

    National Consensus Project for Quality Palliative Care. Clinical practice guidelines. April 2004:57-60. (Accessed August 20, 2004, at http://www.nationalconsensusproject.org.)

    Health Forum. Hospital statistics 2004. Chicago: American Hospital Association, 2004.