VA bests Medicare in end-of-life care for cancer patients, study reports

January 8, 2018, Stanford University Medical Center

Cancer patients treated by the Department of Veterans Affairs are less likely to receive excessive end-of-life interventions than those treated through Medicare, according to a study led by researchers at the Stanford University School of Medicine and Veterans Affairs Palo Alto Health Care System.

The study will be published online Jan. 8 in Health Affairs.

"The findings are not just important for veterans and VA policy, but for anybody who needs medical care at the end of life, which is a majority of us," said Risha Gidwani-Marszowski, DrPH, a consulting assistant professor of medicine at Stanford. "We as a society need to ensure we are setting up the organization of and its financial incentives to ensure that the services receive are the ones that are in their best interests at the end of life."

Gidwani-Marszowski, the lead author, is also a health economist at the VA Health Economics Resource Center. The senior author is Steven Asch, MD, professor of medicine at Stanford.

Many Americans say they would prefer to die at home and forgo intensive medical care at the end of their lives. Yet in the last month of life, many studies have shown that the use and cost of health care accelerates. Approximately 4 percent of the entire federal budget is spent on care for Medicare patients in their last year of life, according to some estimates.

In addition, changes are afoot at the VA. Several efforts, including the proposed Veterans Empowerment Act, would change the VA so that it mostly funds medical services, along the lines of Medicare, rather than providing all the care itself.

Those changes could expose veterans to any effects a Medicare-like funding approach has on end-of-life care, Gidwani-Marszowski said.

Testing a funding model

The researchers tested whether the way that care is organized affects the provision of end-of-life services for veterans dying of cancer. The study looked at 87,251 veterans older than 66 who had solid tumors and died between October 2009 and September 2014.

The researchers based the analysis of care quality on guidelines developed by the American Society of Clinical Oncology and the National Quality Forum, as well as on research that has shown patients consider some services undesirable or burdensome at the end of life. Specific criteria included whether patients received chemotherapy; whether they had two or more visits; whether they were admitted to the hospital and, if so, how many days they spent there; whether they died in the hospital; and whether they were admitted to intensive care. In the study, higher numbers of veterans receiving these services indicates lower quality of care.

The researchers then compared the use of these services by veterans with cancer who used VA health care with veterans with cancer who received their care through Medicare. More than 90 percent of older veterans are enrolled in Medicare as well as the VA, so the population that is eligible for both programs is ideal for evaluating differences in care due to health care system factors, Gidwani-Marszowski said. Researchers accounted for several characteristics that could affect which system veterans choose for care, including the distance they live from medical facilities, Gidwani-Marszowski said.

The study showed that Medicare patients were more likely to receive unduly intensive care at the end of life including chemotherapy, hospitalization, admission to the unit, longer stays in the hospital and death in the hospital than those who received care through the VA.

Gidwani-Marszowski said the study's findings that Medicare patients receive lower-quality, higher-intensity end-of-life care make sense given the different financial incentives of the two systems. VA physicians are salaried, while Medicare-funded physicians bill according to the services provided, which is known as fee for . Therefore, additional services provided through Medicare generate funds for physicians and health care organizations.

Emergency department use differs

The researchers also found that the VA patients were more likely than the Medicare patients to have two or more emergency department visits. One possible explanation, Gidwani-Marszowski said, is that extended hours or access to appointments are not available at all VA facilities and that veterans may instead need to go to the emergency department for their care. Another is that Medicare patients may be hospitalized for care that VA patients get in the emergency department.

"The VA has long been a leader in providing patient-centered care at the end of life," Asch said. "Our study showed that veterans can expect appropriately lower-intensity care as they face late-stage cancer at VA facilities. If they choose instead to use their Medicare benefits outside the VA, they are at greater risk of getting chemotherapy, hospitalization and other services that will likely not help them in their last days."

The work is an example of Stanford Medicine's focus on precision , the goal of which is to anticipate and prevent disease in the healthy and precisely diagnose and treat disease in the ill.

Explore further: Palliative, hospice care lacking among dying cancer patients, Stanford researcher finds

Related Stories

Palliative, hospice care lacking among dying cancer patients, Stanford researcher finds

May 27, 2016
Medical societies, including the American Society of Clinical Oncology, recommend that patients with advanced cancer receive palliative care soon after diagnosis and receive hospice care for at least the last three days of ...

Aggressive care at end of life for advanced lung cancer patients linked to poorer outcomes

May 25, 2017
For patients with advanced cancer, aggressive care—chemotherapy, mechanical ventilation, acute hospitalizations and intensive care unit admissions—at the end of life is commonplace. Yet until now, little is known about ...

Study examines home health care in medicare beneficiaries

October 4, 2017
According to an analysis published in the Journal of the American Geriatrics Society, Medicare beneficiaries receiving home health services who are dually enrolled in Medicaid, live in a low-income neighborhood, or are Black ...

V.A. campaign to increase hospice care showing results

July 5, 2017
A new study in the July issue of Health Affairs finds that a U.S Department of Veterans Affairs (V.A.) initiative to improve care at the end of life led to a substantial increase in the use of hospice among U.S. veterans.

VA commission on care: Eliminate VA medical centers

April 11, 2016
(HealthDay)—A radical proposal has been suggested for eliminating all Veterans Affairs (VA) medical centers and outpatient facilities in the next 20 years, floated by seven of 15 members of the VA Commission on Care, according ...

Repealing ACA would leave more veterans uninsured, increase pressure on VA

September 14, 2017
Proposals to repeal or replace the federal Affordable Care Act would likely increase the demand for service in the Veterans Affairs medical system, while also increasing the number of veterans who have no insurance coverage ...

Recommended for you

Fasting diets reduce important risk factor for cardiovascular disease

March 19, 2018
Intermittent energy restriction diets such as the 5:2 diet clears fat from the blood quicker after eating meals compared with daily calorie restriction diets, reducing an important risk factor for cardiovascular disease, ...

Small changes in diet can have a big impact on health

March 19, 2018
How's that New Year's resolution coming along? Getting ready for summer and want to look your best? Just want to feel better physically? Whatever your motivation, Mercedes Sotos-Prieto, an assistant professor of nutrition ...

Multiple screen use affects snack choices

March 19, 2018
Using multiple screen devices simultaneously while snacking may influence food choices, according to a new Michigan State University study.

Exposure to low levels of BPA during pregnancy can lead to altered brain development

March 17, 2018
New research in mice provides an explanation for how exposure to the widely used chemical bisphenol A (BPA) during pregnancy, even at levels lower than the regulated "safe" human exposure level, can lead to altered brain ...

The coffee cannabis connection

March 15, 2018
It's well known that a morning cup of joe jolts you awake. But scientists have discovered coffee affects your metabolism in dozens of other ways, including your metabolism of steroids and the neurotransmitters typically linked ...

Smoking linked with higher risk of type 2 diabetes

March 15, 2018
The prevalence of diabetes has increased almost 10-fold in China since the early 1980s, with one in 10 adults in China now affected by diabetes. Although adiposity is the major modifiable risk factor for diabetes, other research ...


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.