What is managed care's part in end-of-life care?
What is managed care’s part in end-of-life care?
Health plans explore ethical issues, role of hospice
As major health care institutions such as the Robert Wood Johnson Foundation in Princeton, NJ, and the American Medical Association in Chicago turn their attention to end-of-life issues, a few managed health care plans have started exploring how their internal policies and protocols impact on their terminally ill members and how this situation might be improved.
In some cases, local hospice representatives have participated in these conversations. However, hospices hoping to work with managed care on end-of-life problems will need to understand the overriding issue of public mistrust of managed care’s motives, which will shape any policies health plans develop to address the end of life.
The Hospice Federation of Massachusetts in Norwood recently established a managed care task force to work with managed care organizations in the state. Representatives from this task force met in November with case managers from the managed care organizations to explore common concerns and the lack of mutual understanding. One outcome from this dialogue will be educational forums for the two groups. Several HMOs in the state, including the Harvard-Pilgrim, Fallon, and Tufts health plans, are also looking internally at end-of-life issues.
In Minnesota, the Allina Foundation, the charitable arm of the mega-corporation created by the merger of the Allina health system and the Medica health plan, has identified four strategic priorities for its philanthropic efforts, including "the limits of life," explains Foundation executive director Mike Christenson. Phase one of the Foundation’s Project, Discussion of Evolving Choices in Dying and Ethics (DECIDE) began with focus groups of dying patients, family members, and health professionals and a 1994 survey conducted by Louis Harris and Associates, summarized in The 17 Minute Report published by the Foundation.
"We learned about dying patients’ attitudes toward health care’s role in their care. They weren’t just unsettled; we’re talking about outrage here. We’re talking about terminal diagnoses communicated over the telephone and a complete lack of space for family grieving," Christenson explains.
"One of the first things we learned 31¼2 years ago was that many insurers in the state did not offer the Medicare hospice benefit model for people under 65 and we were one of them. That changed quickly," he adds.
"The [Study to Understand Programs and Preferences for Outcomes and Risks of Treatment] demonstrated that massive clinical interventions did not change the system. That tells all of us that we need to take a new course. We believe hospice is part of the solution and needs to be studied more," he says. "We think it’s probably too much to ask of physicians, or for that matter nurses, to deliver the same quality and quantity of care as a hospice. And we’ve done something about it; we’ve developed a more organized educational program for physicians about hospice and moved the hospice model front and center."
Phase two involved funding a dozen practically oriented end-of-life projects, including the publication of a physician manual on hospice care by the Minnesota Hospice Organization in St. Paul.
During Phase three, the medical director of Allina’s HealthSpan home care and hospice program, Ed Ratner, MD, and HealthSpan hospice director Karen Harrison will work with Christenson and the Project DECIDE team. Their goal will be to develop a systemwide model for addressing end-of-life care and suffering, creating opportunities to deepen the connection to hospice throughout the system.
"Integrating hospice in a huge system like this one is a huge opportunity," Harrison says. Christenson also sees the current state and national interest in end-of-life care as an opportunity that hospices should seize. "Hospices have legitimate criticisms about the health care system, but there are ways to take it on," Christenson says. "Hospice people are amazing caregivers very rich, very deep," he adds. "But sometimes heroes should think strategically. They also need to be advocates. Our responsibility from the systems’ side is to shine a spotlight on the heroic work they do."
The FHP health plan in Denver is looking at similar issues through its ethics committee, formed in 1996. The committee has a dozen members including health plan senior managers, community physicians, a member and employer representative, ethicists, and community representatives, as well as ad-hoc members, reports Deb Van Houten, RN, CCM. Van Houten is FHP’s vice president for medical management and quality improvement and is president of the board of Pike’s Peak Hospice in nearby Colorado Springs.
In educating itself about ethics and exploring its role, the committee decided not to evaluate specific cases but instead to focus on certain ethical challenges faced by managed care organizations. One of these, to be explored in at least three bimonthly meetings of the ethics committee during 1997, is end-of-life care.
"At our first meeting, we gave folks the opportunity to talk through their personal feelings. One physician said managed care should not have any role in end-of-life care because it is certain to be misunderstood. I went in with a strong belief that there’s a lot we can do, even just to educate case managers about end-of-life care and hospice or to make sure they understand our hospice benefit and where to go for resources such as pain management specialists," Van Houten says.
"At FHP we have a very rich hospice benefit, but we need to make people aware of it. Whether we also have a role in improving, for example, the number of people who have advance directives, I’m not so sure," she adds.
The committee is still in the information gathering stage, but will explore issues such as outcomes measurement and "other quality initiatives we might implement. Even hospice is struggling with the outcomes issue, but there are measures we might be able to find even just surveying physicians to see if we have improved their knowledge about hospice and hospice referrals. Our initial conversation also [addressed] the fact that people aren’t being referred to hospice. Society is not comfortable with the issue, and physicians don’t do that conversation very well."
These are sensitive issues, in light of the bad press managed care now receives, Van Houten says. "There is a fine line between what we believe is right as a health plan and how the media will interpret what we do. I’m asking this committee to help me plan how to address these issues in a way that is not viewed skeptically. My key message is that managed care organizations, at least here at FHP, are very interested in our role in end-of-life care and in how to make that a quality setting for patients, as well as how we balance that with how we’re viewed from a marketing or public relations standpoint. To me, that’s a real dilemma. How do we get people to believe we’re doing it for the right reasons?" she asks.
"There’s a lot of activity out there happening in this area. Managed care organizations realize they have to pay attention to these issues. We need to participate because we are a spoke in the health care wheel."
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