Compared to Medicare, Veterans with VA-Financed Care are More Likely to Receive Dialysis and Hospice for Kidney Disease

BACKGROUND:
The Medicare Hospice Benefit is intended to improve quality of care for patients near the end of life and serve as a less costly alternative to curative care. The requirement to forfeit Medicare coverage for treatments related to one’s hospice diagnosis in order to receive hospice services may be particularly challenging for patients with a terminal diagnosis of end-stage kidney disease (ESKD). In contrast to Medicare, VA – as part of its Comprehensive End-of-Life Care Initiative launched in 2009 – is committed to ensuring that Veterans have access to hospice services regardless of whether they are still receiving disease-modifying treatments. This retrospective cross-sectional study sought to answer the question: Does the frequency of concurrent hospice and dialysis (“concurrent care”) among Veterans with ESKD vary by hospice payer? Using VA data, investigators identified 70,577 Veterans who initiated maintenance dialysis and died between 2007 and 2016. They then examined the percentages of hospice users who received concurrent care, by hospice payer as well as by dominant dialysis payer, along with hospice length of stay.

FINDINGS:

• Rates of concurrent care were substantially higher among Veterans receiving VA-financed, compared with Medicare-financed, hospice services.
• The proportion of Veterans receiving concurrent care was lower for those receiving Medicare-financed hospice (25%) than for those receiving VA-financed hospice, either under VA Community Care (42%) or in VA inpatient hospice (55%).
• Regardless of hospice payer, VA paid for the majority (87%) of dialysis treatments after Veterans were enrolled in hospice.
• Veterans who received concurrent care had a median hospice length-of-stay of 43 days, compared with 4 days for those who did not.

IMPLICATIONS:

• Findings suggest that there is probably a substantial unmet need for concurrent care among the large majority of Veterans with ESKD receiving hospice services under Medicare.

LIMITATIONS:

• Patients were not randomized to receive Medicare- or VA-financed hospice services, and this observational design cannot support causal inferences about whether liberalizing Medicare hospice eligibility requirements and payment policies would increase rates of concurrent care.
• Data comparing the quality of care for seriously-ill patients with ESKD who receive concurrent hospice and dialysis vs hospice alone vs no hospice are not currently available.

AUTHOR/FUNDING INFORMATION:
Dr. Wachterman is part of HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR); Ms. Corneau and Dr. Mor are part of HSR&D’s Center of Innovation in Long-Term Services and Supports for Vulnerable Veterans (LTSS); and Dr. O’Hare is with HSR&D’s Center of Innovation for Veteran-Centered & Value-Driven Care.

Wachterman M, Corneau E, O’Hare A, Keating N, and Mor V. Association of Hospice Payer with Concurrent Receipt of Hospice and Dialysis among US Veterans with End-Stage Kidney Disease. JAMA Health Forum. October 21, 2022;3(10):e223708.