The study published in JAMA Network Open examines the use of palliative care (PC) among Medicare beneficiaries with a poor prognosis of cancers. The increased involvement of advanced practice clinicians (APCs) and the adoption of telehealth, particularly during the coronavirus disease 2019 (COVID-19) pandemic. It has the potential to shift the patterns of PC delivery. The scientists aimed to investigate how these evolving dynamics were affected by the use of specialty PC in the final stage of life among this vulnerable population.
A retrospective cohort design was utilized to analyze the data from 1,508,103 Medicare fee-for-service beneficiaries aged 66 and older who died between 2018 and 2023 from cancers with poor prognosis, like rare cancers with high mortality and metastatic solid tumors. Data were collected from Medicare claims for outpatient, inpatient, and professional services with a specific focus on outpatient and hospital-based PC interactions. PC specialists were identified as clinicians who either had 80% or above of their evaluation and management (E&M) services coded as PC-related (International Classification of Diseases [ICD]-10: Z51.5) or who self-identified with a PC specialty code. Only encounters that occurred in the year preceding death were included. Hospice-related visits were excluded to specifically focus on early and concurrent PC delivery.
The primary outcome was the proportion of decedents who had at least one encounter with a PC specialist in their last year of life. Secondary outcomes included the frequency of encounters, care setting (hospital vs. outpatient), type of clinician (APC, self-designated PC physician, or other physician), and use of telehealth. Regression models with clinical variables, geographic, and demographic factors were used to determine the changes over time and identify subgroup variations. Statistical analysis included linear and logistic regression with covariate adjustment.
From 2018 to 2023, the number of decedents receiving any specialty PC increased to 37.21% from 29.84%. It marks a 24.2% relative increase (95% confidence interval [CI] 6.30 to 8.12, adjusted change: 7.21% points). The most notable growth occurred in outpatient settings, increasing to 20.56% from 10.66% with a relative increase of 88.2% (95% CI: 8.33 to 10.48). The average number of PC encounters per user increased slightly from 3.79 to 3.45 per decedent. APCs become the most prevalent PC providers, with an increased share of 22.84% from 15.57% (45.4% relative increase). It surpasses self-designated PC physicians to 15.60% from 14.06% and other physicians. Telehealth also played a growing role, accounting for 18.2% of all outpatient PC visits in 2023, with a peak of 28.5% in early 2021 during the pandemic.
Despite overall improvements in access, inconsistencies remained. Older adults (≥90 years), rural residents, and low-income people (dual Medicaid and Medicare participants) had significantly lower odds of receiving specialty PC. The odds of accessing PC were 16.3% in people aged≥90 years or older, which was lower compared to those aged 66-69 years in 2023. Among dual-eligible beneficiaries, the PC was 2.82%, and among rural people, it was 13.3%. In contrast, Asian American women and patients with more comorbid conditions were more likely to utilize PC services.
The models demonstrated that the evaluated PC involvement was not solely due to compositional modifications, but also related to real-world shifts in clinical practice. This study has many limitations. The use of billing codes may underrepresent PC specialists and encounters, specifically when the Z51.5 code is not required. The analysis excludes hospice care and focuses exclusively on services delivered in the last year of life. Additionally, selection bias may exist due to enrollment differences between traditional Medicare and Medicare Advantage plans over time.
In conclusion, while the use of APCs and telehealth has helped expand PC access for patients with poor-prognosis cancer, overall utilization remains inadequate. Persistent disparities based on age, geography, and socioeconomic status highlight that increasing clinician supply or expanding virtual care alone is insufficient. System-level interventions and customized policies are needed to address persistent imbalances and improve high-quality PC access for all patients.
Reference: Chua IS, Huskamp HA, Mehrotra A, Wilcock AD. Palliative Care Specialist Use Among Medicare Decedents Who Had Poor-Prognosis Cancers. JAMA Netw Open. 2025;8(7):e2522886. doi:10.1001/jamanetworkopen.2025.22886
