Blue Cross expands benefits for end-of-life care
“We don’t want anyone to be concerned they may not get the care they need,” said Andrew Dreyfus, chief executive of Blue Cross Blue Shield of Massachusetts.
By Priyanka Dayal McCluskey Globe Staff December 28, 2015
The state’s largest health insurer this week will begin offering some of the newest and most comprehensive end-of-life benefits in the nation, aiming to prod patients and health care providers to discuss death openly and expand services to help people live out their last days.
The move by Blue Cross Blue Shield of Massachusetts comes as a growing number of health organizations put more emphasis on how patients are treated at the end of life by providing and paying for care that is more in line with patient wishes. Most Americans, for example, say they want to die at home, but most still die in hospitals and other institutions, according to several studies.
And while the primary goal is not cost control, the effort also has the potential to lower health care spending by giving patients more options to replace hospital care with less expensive — and often preferable — alternatives, such as hospice and home care. Medical care at the end of life can be expensive; a 2010 study found that 25 percent of all Medicare payments go toward the 5 percent of people in the last year of their lives.
“The industry is now starting to take this seriously,” said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center. “The industry now not only understands the issues [around death and dying], but understands there are concrete things they can and need to do, and Blue Cross is showing us how to get started.”
As of Jan. 1, Blue Cross Blue Shield of Massachusetts, with 2.8 million members, will pay for more counseling sessions between providers and patients to discuss end-of-life care and expand access to hospice services. It is also developing a home care program that will be launched later in 2016.
Other insurers, including Medicare, the government program for those 65 and older, have decided to cover the cost of end-of-life discussions between doctors and patients. (Medicare’s change takes effect in 2016.)
Blue Cross is taking this a step further. It will also cover costs of visits with psychologists, social workers, and other mental health workers, where patients can ponder questions such as how they want to die, where they want to die, whether they would want doctors to take all possible measures to keep them alive — or whether they prefer to forgo intensive medical treatments to be more comfortable at the end.
Specialists in end-of-life care say people should begin such conversations with providers and loved ones well before they become seriously ill. Blue Cross plans to cover end-of-life counseling sessions for any member who chooses to have one, not just for those who are sick.
“All patients should be thinking about it,” said Andrew Dreyfus, chief executive of Blue Cross.
The insurer’s efforts to expand end-of-life benefits were inspired in part by Dreyfus’s experience of watching his parents and 61-year-old brother die from illnesses, which he detailed in a recent essay in the Globe.
“Each of these losses was excruciating, but my grief was softened because my parents and brother made decisions about their care and died gently, free from invasive medical treatment and touched by loved ones until the very end,” he wrote. “Unfortunately, their experiences are not typical.”
Efforts to improve end-of-life care are gaining traction, though. Massachusetts General Hospital is preparing to launch an initiative in 2016 to train clinicians who treat serious illnesses to help patients plan for death. The hospital also plans to hire more specialists in palliative care, the branch of medicine that treats the symptoms and stresses of disease for the seriously ill, so more patients can receive such care.
Beth Israel Deaconess has revised its electronic health records system to help emergency doctors retrieve information about patients’ end-of-life wishes. Starting early next year, every patient admitted to the hospital will receive a guide outlining options for people with serious illnesses.
Among insurers, several health care specialists said, Blue Cross is leading the field on end-of-life care. But others are focused on the issue, too.
‘We don’t want anyone to be concerned they may not get the care they need.’
Andrew Dreyfus, Blue Cross Blue Shield of Massachusetts chief executive
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Tufts Health Plan, an insurer based in Watertown, said it will work with some of its sickest members to put their end-of-life wishes on paper, so they can be shared with primary care physicians and the patients’ health care proxies.
Medicare and many health plans limit hospice coverage to people with six months or less to live, but Harvard Pilgrim Health Care, of Wellesley, said it has no such restrictions for terminally ill patients, as long as physicians believe hospice is appropriate.
Blue Cross said it will expand hospice eligibility to patients expected to live 12 months or less, from the current six months.
Dreyfus said Blue Cross’s new benefits may reduce some costs: For example, if a terminally ill patient with shortness of breath gets help at home, instead of going to the hospital. But he said that providing hospice and home care to more patients means costs might also increase. The goal of end-of-life benefits is to improve care for dying patients, he said: “We don’t want anyone to be concerned they may not get the care they need.”
Dr. Vicki Jackson, chief of palliative care at Mass. General, said insurers play a key role in the movement to increase patient-doctor discussions about end-of-life care and help patients decide how they want to spend their remaining time.
“Reimbursement is one important piece,” she said. “That there is a way to be able to bill for it says how important this is. That adds a certain validity.”
Ellen Goodman, a former Boston Globe columnist who now directs The Conversation Project, a campaign to promote end-of-life planning, said that efforts such as the one at Blue Cross show the progress in addressing issues surrounding death and dying.
“We’ve already seen a big culture change in the number of people who recognize that it’s important to have conversations with their families, as well as their providers, to talk in advance about how they want to live the end of their lives,” said Goodman.
“This is about quality of care,” she said. “This is about helping people to live the way they want to at the end of their lives.”
Priyanka Dayal McCluskey can be reached at priyanka.mccluskey@globe.com. Follow her on Twitter @priyanka_dayal.
Filed under: General Problems
If you haven’t guessed, this is definitely one if my soap boxes….
If you have damage to your spinal cord (SCI)above the T-8 to T-10 level you are at risk for autonomic dysreflexia. Essentially your body perceives a sensation below the injury but the feedback mechanisms cause you body to overreact – even if the person doesn’t have sensation to perceive the stimulus. Everything from a full bladder to an ingrown toenail can trigger it. Pain and already high blood pressure from withdrawal were what killed my friend. The doctor treating him retired and the one that replaced him put him on a five day taper from a pretty high dose of morphine, despite the fact he was doing really well. If someone has dysreflexia, the HR and BP increase to dangerous levels. Usually get headache, sweating flushing above injury, and pallor below it. The main thing is to sit them up and try to figure out cause. If it can be fixed easily (i.e. go to the bathroom, shift weight), it’s usually goi g to pass quickly. If an infection is present or they have a pressure ulcer or other cause that can’t be relieved quickly, most people have nitroglycerin paste on hand that will drop BP quickly. Untreated patients can have a heart attack or stroke.
Does this condition affect those who suffer from spinal stenosis?
Not usually….you’d need a decent amount of damage to your spinal cord for that to to happen, but it’s possible just like paralysis from stenosis is possible.
Thanks again, Anne.
IF this is actually done RIGHT, AND APPLIED CORRECTLY, it’s a very good thing that would actually promote quality of life AND save financial resources. The danger is of course that cost savings will be the primary endpoint and not a secondary effect of this policy. End of life in an ICU when the body is shutting down, but doctors and nurses are doing their damnedest to prolong life is an awful experience for the individual if they are remotely conscious and something that loved ones can never forget. Being delerious or in severe pain intubated and restrained is horrible. In an ICU, the focus is on prolonging life, getting the person extubated, and maintaining oxygen status once extubated. Even in the best circumstances, pain control surffers as opioids and other sedatives must be minimized or held to effect this goal. Insurers and limited bed space exert pressure on clinicians to get patients through this process faster than slower. The ICU environment itself makes patients, especially the elderly prone to a frightening condition called ICU psychosis. The assurance that patient won’t remember all this doesn’t mean much when they are suffering horribly and often patients DO remember this experience. There’s emerging evidence that this can cause PTSD in both patients and families. If a patient with essentially a terminal prognosis DOES make it out of the ICU, floor staff are often still in the awful position of holdings pain meds to maintain respiratory status. The same conditions that promote delirium and ICU psychosis are still present on the floor though to a lesser extent. It’s common for these patients to have new cognitive deficits from hypoxic damage to the brain. These deficits make coping with all this suffering even more difficult for patients. The likelihood of an elderly patient (or even a younger patient) with multiple systemic issues like cardiovascular disease, respiratory illness, renal/hepatic compromise and / or metastatic cancer getting discharged is VERY LOW and not requiring skilled nursing home care (or relatives providing the equivalent) is even less. Their quality of life during this time is almost always very low.
When a patient foregoes a DNR, staff must resuscitate them. This causes family to be ushered from the room when arrest is impending or has already occurred. The likelihood of successful resuscitation (re-establishing cardiac activity isn’t great in any patient and extremely low in a elderly patient with multiple systemic issues (or a younger patient with metastatic cancer or no possibility like transplant for correcting these issues) is EXTREMELY LOW. When successful, it generally only brings suffering if they regain consciousness. It’s pretty much expected that there will be rib fractures. This compounds the difficulty and pain associated with extubating the patient.
The alternative to all this is comfort care in the hospital, nursing home, or family home. Foregoing aggressivechemotherapy in a patient who is not responding to it after multiple efforts or using drugs with few side effects that may still prevent tumor incursion in particularly painful areas. These patients actually tend to live longer because their bodies do not have the strain of chemotherapy. Platelets and transfusions can also benefit some patients and allow them quality time with family. Palliative radiation can decrease pain from bony metastasis and delay or decrease tumor burden from obstructing the bowel. IV bisphosponates (same class of drugs used in osteoporosis) can dramatically reduce pain related to bone metastases while also preventing pathological fractures that result from tumor destruction of bone.
Early diagnosis and staging and treating aggressively when it can cure or extend life should always be the goal. If you have an elderly patient with serious health issues, aggressive treatment is more likely to hasten death and take the patient’s quality of life. If this patient has breast or prostate cancer that is growing slowly, this is particularly true.
I don’t want anyone to be deprived of aggressive treatment that they truly want. I do think reimbursement for end-of-life counseling is needed along with education about how to approach this subject. So many people have unrealistic hopes from TV shows. Miracles do happen and I would never want someone who truly wanted more than anything to survive to be deprived of aggressive treatment. Unfortunately we are mortal and can only live so long. If you have active 90-year-old woman who is starting to become symptomatic from something a pacemaker can treat, that may be just what she needs to keep playing bridge and enjoying her grandkids. A quadruple bypass on a 75 year old man who has a smoked 2 packs of a day for 50+ years, is a retired miner with black lung disease and is oxygen dependent is not going to have the same effect barring divine intervention, but stuff like this goes forward all too often without an honest discussion about reasonable expectations. When I was sitting in the ICU with my friend that died from a heart attack after withdrawal-induced autonomic dysreflexia, there were way too many patients like that. I don’t think all of them would have wanted this if they really knew what to expect.
Right now there is so much distrust of our health care system after all the talk of death panels that patients, patient with limited means fear being allowed to die unnecessarily so much that they often make decisions out of fear that end up robbing them of time AND quality of life. It’s the distrust, that’s often warranted, that really scares me about all this.
This is one of the few times that actually doing the RIGHT thing in healthcare actually costs LESS. The problem lies in greed though. If cost cutting measures lead to patients being pushed, or worse forced to choose comfort care – whether they are the 70 something retired miner oxygen that needs bypass surgery or the 78 year-old who was running marathons up until last month and now needs a complicated valve repair that’s absolutely wrong. It will only lead to fearful patients demanding heroic measures that rob them of time with family and inflict suffering. On top of that we’ll have more costs and more suits related to denial of care. Looking for the source on this but a documentary and several other articles I’ve read cited that -focused care for those who truly wouldn’t benefit and only suffer more would reduce costs to the extent that most of the Medicare/Medicaid cuts being rolled out would not be necessary. I worked as a hospice nurse years ago and I’ve seen more people die than I want to count. Home or a hospital or nursing home unit that’s geared towards hospice/palliative care is definitely the place to be when the time comes imho. I’ll never forget the kids I on hem/onc that were so far beyond medicine’s reach, but then a researcher with a phase one drug would say just the right thing to get the parents to hope again…or the grandmother with bad lungs, bad kidneys, and a failing heart of gold. What helps the kidneys causes edema and fluid in the lungs. Then she can’t breathe. Morphine would get rid of the air hunger, but they hold off not wanting to supress her respiratory rate because her CO2 is high. Medicine can either play musical chairs with this lady or let her enjoy her family for however long and not let noisy alarms and vital signs every few hours disturb her.
Thanks so much, Anne, for all of this great information. Well, not great, but very educational. I am particularly grateful for the information on autonomic dysreflexia, as I’ve never heard of this condition before and I’m guessing I have the potential to suffer from it. It’s good to know the signs, just in case.
First, I’m sorry about your friend. But I’m confused about your describing the heart attack as having been withdrawal-induced. Is that withdrawal from pain medications? Don’t mean to pry, but I think I may have gone through something like that when I was forced into a cold-turkey detox. Hard to remember the specifics of such a horrific experience, but I was wondering if this would mean I need to be extra careful about watching out for these symptoms in the future?
Sorry to make this about me, and I understand all the fears that other patients are worried about. I can see this system being abused, but I also know that there aren’t enough palliative care systems in our health care. Thanks again, Anne.
You might look at this as a type of genocide — and it’s obviously all about saving money for health insurance companies — but it’s important for patients to have these kinds of options.