Variations in use and timing of hospice and palliative care: Differences across health care payers and cancer type.

132 Background: Cancer societies recommend cancer patients receive palliative care soon after diagnosis of illness and hospice for at least 3 days before death. While studies suggest receipt of hospice in the last 3 days of life is increasing for patients, the timing of first hospice and first palliative care is currently unknown. It is also not known whether fee-for-service versus capitated healthcare systems differ in their provision of supportive care. We evaluated the timing and frequency of palliative care and hospice use across the Department of Veterans Affairs (VA) and Medicare for dually-eligible Veterans, to understand variations in the use and timing of these services across healthcare systems for the same patient population. Methods: A retrospective evaluation of all VA and Medicare administrative data for the population of Veterans aged 65 or older who died with advanced cancer in 2012. Results: The majority of Veterans received supportive care before death: 67% received hospice and 69% received palliative care. On average, patients had 2 encounters with palliative care before death. Patients with melanoma were most likely to receive palliative care (82%); patients with hematologic malignancies were least likely to receive palliative care (58%). Veterans received VA-based hospice on average 35 days before death (SD = 42), while Veterans receiving Medicare-based hospice did so an average of 25 days before death (SD = 24). However, across both systems, 50% of Veterans were receiving hospice 16 days before death. There were substantial variations in timing of hospice enrollment by cancer type. Of Veterans receiving VA- or Medicare-based hospice, 22% cycled in and out of hospice, meaning they dis-enrolled and re-enrolled in such care. 16% of patients were discharged from hospice before death, with VA more likely to discharge Veterans before death compared with Medicare. Conclusions: There are large variations in healthcare system approaches to timing and use of hospice and palliative care, as well variations by cancer type. VA provides hospice to patients earlier in the disease trajectory, while Medicare is more likely to have patients die while enrolled in hospice.