Identifying Patient Preferences for Cancer Care in Medicare: Choosing

Health Plans All TogetherDonald H. Taylor, Jr.

Associate Professor of Public PolicyDuke Sanford School of Public Policy

Duke Cancer Care Research Program, Duke Medical CenterDuke University

Team of ColleaguesFunded by AHRQ 5R01 HS018360, “Hospice to

palliative care: maximizing patient preference and cost savings”

Duke Cancer Care Research ProgramAmy Abernethy, Co-PIYousuf Zafar, Robin Fowler, Lori Hudson, Jordan

Lodato, Krista Rowe, Kris WaldtNIH Department of Bioethics

Marion Danis, Instrumental in developing CHAT approach along with colleagues at U Michigan

Public PolicyPaul Pooley

Purpose and DesignTo provide a rational, patient-defined,

evidence-based recommendation to inform the redesign of Medicare for people with advanced cancer.

Allows patients and caregivers to contribute to healthcare reform conversation

Adapt Choosing Health Plans All Together (CHAT) participatory decision-making tool

Eligible SubjectsPatients who are

·         Medicare beneficiaries age 65 and older ·         Diagnosed with cancer

Family caregivers of any age 18 and older

Enrollment and Conduct of StudyPatients and caregivers approached in Duke

Medical Center Cancer clinicsEnrollment

Pts & caregivers complete CHAT together Those completing study receive $75

CHAT session facilitated by trained personnel

Patient Recruitment (7/10-9/9/10)852 patients pre-screened as eligible129 approached

48 declined40 possible7 yes, not scheduled, not consented9 consented and scheduled (5 pts + 4 family)25 completed study (12 pts + 13 family)

Enrollment Target• Clinics: breast, prostate, thoracic, gyn-onc, GI,

Hem Onc (starting 9/10/10)• Goal: enroll N=600 (300 patients, 300

caregivers) 5 of 25 completed are African-American

• Potential recruitment expansion to inpatient units

Risk/Benefit AssessmentThe greatest participant risk is fatigue

associated with the time required to complete the CHAT exercise process (~2.5 hours)

Patients not likely to directly benefit 

Development of CHAT toolCHAT approach used in numerous contexts in

past work (Danis and others)Key tasks completed

Identifying categories of care choicesProviding an estimate of relative costDeveloping participant materials incl CHAT

toolTraining CHAT leaders to facilitateDeveloping recruitment strategy/materials4 Pilot tests

Cost EstimatesCost estimates from last 6 months of life

Medicare cost from Cancer death cohorts (2008)

Applied mean last 6 months of life Medicare spending as budget constraint (~$35,000)

Developed estimates of mean cost if highest level of care chosen for all categories (~$66,000)

Constraint: participants get 50 stickers; it would take 94 to get highest level in all categories

Participants Task…..The goal of this exercise today is to get

your input into what types of services Medicare should cover.  When you make your decisions, we ask that you take the perspective of a person with advanced cancer (or their family member). Advanced cancer is a cancer that is not generally considered to be curable and is expected to shorten a person’s life…….. 

• Revisions in patient eligibility criteria• Advanced Cancer >>>metastatic>>>all cancer• Changes driven by recruitment realities

CHAT Discussion FormatPre-questionnaireFour rounds

IndividualSmall group consensus (3-4 persons)Large group consensus (10-12 persons)Individual

Post-questionnaireKey questions: Changes in preference due to

discussion? Individual abide by group consensus?

Health Events IntroducedAfter rounds 1 and 2 health events readDiscussion of the event, ‘Are you happy with

your choices?’Facilitated discussionObserved preference changes in pilots

Other Medical CareJulio’s cancer was widespread when it was

first diagnosed. His doctor told him there were not any curative treatments that would be successful. Over the past few months, his vision has become cloudy and he has trouble reading. The standard course of treatment is an ophthalmology visit and cataracts repair if needed.

If Julio chose other medical care, his visits and operation would be covered; if he chose no coverage they would not be.

Cancer Care

Alonzo has had three rounds of chemotherapy and radiotherapy. There is an additional generation of experimental medicines available but there is less than 5 % hope of a cure.

If Alonzo chose the basic or intermediate levels of cancer care this next round of treatment is not covered; if he chose the high or advanced level the additional round is covered.

Vision # 2

Sophia’s doctor recommends new glasses to address her mild double vision.

If Sophia chose dental/vision care then the frames and lenses are covered.

If she chose no coverage this is not covered.

Big PictureAssess patient and caregiver preferences for

CancerRelevant to the expanding discussion of

concurrent palliative care/potential modifications of the Medicare hospice benefit

In later project years, we will use patient preferences to simulate changes in Medicare benefits and impact on cost