Medicare Coverage Not Aligned with Preferences of Patients with Cancer, Caregivers

Rosemary Frei, MSc

October 2014, Vol 5 , No 8 - Health Policy

A survey of patients with cancer and caregivers about the benefits they would like Medicare to cover in their last 6 months of life uncovered large gaps with the benefits that Medicare currently offers (Taylor DH Jr, et al. J Clin Oncol. 2014;32:3163-3168). Addressing issues related to quality of life and the costs burden of cancer therapy were among the main priorities for patients. The investigators see these results as a basis for a larger discussion of the difficult trade-offs and choices that come with increasing cost and resource constraints.

“We found that those most directly facing cancer, patients and caregivers, were able to talk about difficult things in a reasoned manner. We have to come up with a way to have similar discussions nationally. It will be hard, but it is important,” lead investigator Donald H. Taylor, Jr, PhD, MPA, Associate Professor of Public Policy, Duke University, Durham, NC, told Value-Based Cancer Care.

“Flexibility of the type we note could be a place where ‘strange bedfellows’ could imagine a political deal on Medicare reform—for example, libertarians who value choice and flexibility, and long-term care advocates who understand the lack of long-term care coverage to be the most consequential ‘hole’ in Medicare’s benefit package since the creation of Medicare Part D prescription drug coverage,” Dr Taylor said.

A total of 246 patients and 194 caregivers from North Carolina participated in the study between August 2010 and March 2013. The participants had a wide range of education and income, and 50% said that they had spent ?$2000 out of pocket on medical care in the previous year.

The researchers probed the participants’ choices for which benefits Medicare should cover for patients with cancer near the end of life. All except 1 participant chose some level of cancer treatment, with 6.4% choosing the basic level of cancer treatment, 39.5% the intermediate level, 42.3% the high benefit level, and 11.6% the advanced level.

In addition, at least 80% chose some level of coverage of 5 other benefit types, the most popular, in descending order, being prescription drugs (not including cancer drugs), primary care, home-based long-term care services designed to address disability, concurrent palliative care beyond the current Medicare hospice benefit, and nursing home care. Unrestricted cash was another popular option among benefits not currently covered by Medicare. Home care and palliative care also fell into this category.

“The gap between covered benefits and preferences points toward a subset of patients and caregivers valuing quality of life broadly defined over medical care only,” Dr Taylor and colleagues wrote.

Approximately 50% of the respondents wished for coverage of 1 of the following 3 benefits currently not covered by Medicare:

  • Unrestricted cash
  • Concurrent palliative care
  • Home-based long-term care.
These choices all meant less medical care, such as the most sophisticated and expensive cancer treatment. African Americans were significantly more likely than whites to choose all 3 of these uncovered benefits.

“We view this study as having a primary purpose of agenda setting. We are under no illusions that the type of preferences stated by a substantial minority of participants would be easy to bring about, either politically or technically. However, the first step in reform is to demonstrate gaps in what is covered by Medicare and some of what is identified as important by patients and family members,” concluded Dr Taylor.