Because of concerns about veterans' access to care, it has been suggested that the U.S. Department of Veterans Affairs (VA) should shift from providing health care to veterans to a Medicare-like role as a purchaser of care. In a retrospective study, researchers evaluated the quality of end-of-life cancer care provided to veterans by the VA and by traditional fee-for-service Medicare.

The quality of care received by veterans during the last 30 days of their lives was evaluated by assessing the proportion of patients who experienced two or more ED visits, chemotherapy, an ICU stay, a hospital admission, or death in the hospital, as well as the number of days spent in the hospital. Higher proportions of patients with these experiences was indicative of poor quality of care. The study cohort included more than 87,000 veterans who died of solid tumors; a little more than half of these were Medicare reliant. Compared with VA-reliant patients, those who relied on Medicare received end-of-life care that was of a lower quality with respect to chemotherapy, hospital admission, ICU admission, number of days spent in the hospital, and death in the hospital. On the other hand, Medicare-reliant patients were less likely to have multiple ED visits in the last 30 days of life.

In VA-reliant patients, palliative care penetration-defined by the researchers as "the ratio of unique patients receiving palliative care [to] the total number of deaths among patients who received the majority of their care at a facility"-had no effect on the quality of end-of-life care. The researchers could only assess for palliative care penetration among VA-reliant patients because palliative care is not identified in Medicare administrative data.

The authors conclude that the shift toward the VA becoming more of a purchaser than a provider of health care may improve access to care for some veterans; however, based on the results of this study, they suggest that the VA monitor the quality of end-of-life care and coordinate with community providers to ensure veterans receive the best care at the end of their lives.

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