ASH Statement in Support of Palliative Blood Transfusions in Hospice Setting

Jun 25, 2019

The American Society of Hematology (ASH) represents approximately 17,000 physicians, scientists, and medical trainees committed to the study and treatment of blood and blood-related diseases. As an organization of physicians and scientists who care for desperately ill patients, including those with blood cancers such as leukemia, lymphoma, and myeloma, as well as those with non-malignant conditions such as sickle cell disease, thalassemia, hemophilia, thrombophilia, and various anemias, ASH is supportive of efforts to ensure patients have access to appropriate care throughout the course of their disease, including those receiving hospice care.

Background
The Medicare hospice benefit was established to provide terminally ill Medicare beneficiaries with access to high-quality end-of-life care. Unlike traditional care that seeks to cure the disease, hospice care focuses on maximizing the quality of life by providing comfort and support services. Hospice care is associated with less symptom distress, fewer hospitalizations, and makes it possible for the patient to die at his/her preferred location. When a beneficiary chooses the Medicare hospice benefit, they agree to forego coverage for conventional treatment of the terminal illness and related conditions. Hospices receive a per diem payment for each patient enrolled and are required to cover all items, services and medications for the palliation and management of the terminal illness and related conditions, including blood transfusions.1 Transfusions offered to palliate symptoms, including fatigue or bleeding, are very much aligned with the philosophy of hospice care to improve the quality of life for patients at the end of life. Yet, in practice, many hospices are forced to choose not to provide treatments such as palliative blood transfusions because of their cost, relative to the daily reimbursement rate for hospice care services.

Consequently, patients with hematologic malignancies, many of whom need blood product transfusions to control their symptoms, are less likely to use hospice services than patients with other cancers.2 Studies show that in the last 30 days of life, patients with hematologic malignancies, when compared to patients with solid tumors, have a greater number of emergency room (ER) visits, hospital admissions, intensive care unit (ICU) admissions, hospital deaths, and deaths in the ICU. These adverse events at the end-of-life are linked to lack of hospice care.3

Transfusions can address palliative needs related to breathlessness, bothersome bleeding, and profound fatigue. Relieving these symptoms should be arguably a goal similar to treatment of pain, constipation, or obstructive symptoms typical for patients with solid tumors.4 Expanding access to Medicare hospice services for those that require transfusions has the potential to offer cost savings through the avoidance of acute hospitalization or aggressive end of life care and to improve quality of life for the patient.

ASH Recommendations
Hematologic oncologists agree that they would refer more patients to hospice if blood product support was more readily available to patients, who require transfusions for symptom management.5 Recognizing the need to ensure patients receive the best and most appropriate care throughout the course of their disease, ASH recommends the following:

  • The Centers for Medicare and Medicaid Services (CMS) work with hospice agencies and administrators to clarify that palliative transfusions are a covered benefit and should be symptom-based and performed in collaboration with hematologic oncologists.
  • CMS work with hospice agencies to create innovative reimbursement models to promote the provision of palliative transfusions, such as allowing them to be paid for separately under Medicare Part B.
  • CMS work with hospice providers and other stakeholders to explore novel ways to access transfusions, such as at-home transfusions.6

References

  1. Department of Health and Human Services, Centers for Medicare & Medicaid Services. Medicare Program; FY 2020 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Federal Register, vol. 84, no. 8, April 25, 2019.
  2. Howell, Debra A., et al. “Haematological Malignancy: Are Patients Appropriately Referred for Specialist Palliative and Hospice Care? A Systematic Review and Meta-Analysis of Published Data.” Palliative Medicine, vol. 25, no. 6, Sept. 2011, pp. 630–641, doi:10.1177/0269216310391692.
  3. Odejide, Oreofe O. “A Policy Prescription for Hospice Care.” Journal of the American Medical Association, vol 315, No. 3 (2016).
  4. LeBlanc, Thomas W., Pamela C. Egan, and Adam J. Olszewski. "Transfusion dependence, use of hospice services, and quality of end-of-life care in leukemia." Blood, 132.7 (2018): 717-726, doi: 10.1182/blood-2018-03-842575
  5. Odejide, Oreofe O et al. “Why are patients with blood cancers more likely to die without hospice?” Cancer, vol. 123, 17 (2017): 3377-3384
  6. Fridey, Joy L. “General Principals of home blood transfusion.” UpToDate