Trends in Provision of Palliative Radiotherapy and Chemotherapy Among Hospices in the United States, 2011-2018

Abstract

This case series study uses Medicare 2011-2019 Hospice Cost Report Data to analyze trends in the proportion of freestanding hospices in the United States providing radiotherapy and chemotherapy, as well as the expenses incurred for providing these therapies.

Hospice is central to end-of-life care. Yet to receive hospice services, Medicare beneficiaries need to forgo treatments related to their terminal conditions.¹ Thus, patients with cancer cannot receive radiotherapy or chemotherapy, such as single-fraction radiotherapy for painful bone metastasis, for palliative purposes. To alleviate this constraint, some hospices have developed open-access programs that allow patients to receive care for their terminal conditions.² These hospices, however, encounter an increase in costs without an accompanying increase in reimbursement. In 2016, the Centers for Medicare & Medicaid Services initiated the Medicare Care Choices Model (MCCM), which allows participating hospices to provide care for beneficiaries’ terminal conditions and receive a higher payment rate.³ Despite this, very few hospices participate in the MCCM. To date, little is known about trends in hospices providing palliative radiotherapy and chemotherapy. This topic is particularly important now, as hospices may be reluctant to provide new, expensive immunotherapies.

Methods

In this case series study, we analyzed the 2011-2019 Hospice Cost Report Data, which cover costs for freestanding hospices in the US from 2011 through 2018 to calculate expenses for radiotherapy and chemotherapy.⁴ Medicare-certified institutions are required to submit annual cost reports, including detailed expense information to the Centers for Medicare & Medicaid Services. Aggregated institution-level data are publicly available; thus, no institutional review board approval was required based on the Common Rule. Data management was done in SAS statistical software, version 9.4 (SAS Institute Inc).

Results

The number of Medicare-certified freestanding hospices rose from 2404 hospices in 2011 (total expenses: $1.2 billion) to 2948 hospices in 2018 (total expenses: $15 billion). From 2011 to 2018, radiotherapy expenses decreased from $6.3 million to $1.6 million, and chemotherapy expenses decreased from $12.3 million to $1.3 million (Figure 1A). Approximately 307 hospices (12.8%) incurred radiotherapy expenses in 2011, but only 159 (5.4%) did so in 2018; 113 (4.7%) and 92 (3.1%) hospices incurred chemotherapy expenses in 2011 and 2018, respectively (Figure 1B).

Figure 1. Total Expenses and Provision of Radiotherapy and Chemotherapy Among Hospices in the United States, 2011-2018.

A, Total expenses of radiotherapy and chemotherapy among freestanding hospices. B, Percentage of freestanding hospices providing radiotherapy and chemotherapy.

Mean monthly chemotherapy expenses among nonprofit hospices that provided chemotherapy fell dramatically, from $17 029 in 2011 to $2322 in 2018 (Figure 2A). Mean monthly radiotherapy expenses among nonprofit hospices that provided radiotherapy also decreased. From 2011 to 2018, the percentage of hospices that provided radiotherapy decreased substantially for both for-profit (157 of 1780 [8.8%] to 71 of 2462 [2.9%]) and nonprofit hospices (147 of 576 [25.5%] to 86 of 473 [18.2%]) (Figure 2B). The proportions that provided chemotherapy fell by only 1% and 2% in for-profit and nonprofit hospices, respectively.

Figure 2. Monthly Expenses and Provision of Radiotherapy and Chemotherapy Among For-profit vs Nonprofit Hospices in the United States, 2011-2018.

A, Mean monthly expenses of radiotherapy and chemotherapy. B, Percentage of freestanding hospices that provided radiotherapy and chemotherapy, by for-profit vs nonprofit status.

Discussion

From 2011 to 2018, hospices decreased their radiotherapy expenses by 75% and chemotherapy expenses by 90%. Because Choosing Wisely guidelines are against the provision of systemic chemotherapy for patients with terminal-stage cancer,⁵ the decreased chemotherapy utilization in hospices may be appropriate. However, the dramatic reductions in radiotherapy expenses and in the proportion of hospices providing radiotherapy are alarming. Our findings highlight the concern that patients with cancer in recent years might have postponed enrolling in hospice until the very end of life so that they could continue to receive palliative treatments.⁶

Our analyses have several limitations. Our findings, limited to freestanding hospices, cannot be generalized to hospital-affiliated hospices. Because of data constraints, we could not calculate radiotherapy and chemotherapy expenses per patient with cancer. Additionally, we were unable to determine the factors causing the observed decrease in radiotherapy and chemotherapy expenses. Future research surveying for-profit and nonprofit hospices regarding their practices in these therapies is warranted.

Radiotherapy and chemotherapy can relieve symptoms for patients with cancer with terminal illness; yet, over time, fewer hospices were able to offer these expensive treatments. The decreasing trend in palliative treatments indicates that the current MCCM may not provide sufficient incentives for hospices to provide appropriate palliative care for patients with cancer at the end of life. To improve the quality of end-of-life cancer care, it is important for policy makers to identify the barriers hindering the provision of palliative radiotherapy. Intensified efforts to facilitate hospices in providing appropriate palliative treatments for patients with cancer may be needed.