NEWS

Managed Care Groups Urged to Take the Lead in Addressing End-of-Life Issues

Judith Randal

Although managed care organizations come in many forms — staff model health maintenance organizations, independent practice organizations, point of service plans, and preferred provider organizations to mention but a few — all of them are intent on shaping provider behavior with institutional arrangements and organizational controls.

That being the case, argues a new report, managed care organizations would do well to enlist such tools as clinical guidelines and continuous quality improvement reviews in the ongoing struggle in the United States to upgrade the care of the terminally ill.

The report, published in May, is the work of an interdisciplinary task force assembled by the Education Development Center, a Newton, Mass., think tank. Funded by the Robert Wood Johnson Foundation, Princeton, N.J., the project surveyed all the managed care organizations in the United States that provide capitated services to Medicare beneficiaries and interviewed those of them that have already started to experiment with new ways of delivering care to patients in the final phase of life.

"Problems with end-of-life care in this country predate the managed care era and have largely been intractable," noted Mildred Z. Solomon, Ed. D., director of EDC's Center for Applied Ethics and Professional Practice, one of the 23-member task force, and the project's principal investigator.



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Dr. Mildred Z. Solomon

 
"Regardless of their many forms, managed care organizations provide opportunities to intervene at the systems level to make changes for the better."

Short Shrift

Listing some of the panel's concerns at a Washington, D.C., press conference on the report, Solomon began with the short shrift often given to the control of pain for many dying and other patients in the United States. To help correct this problem, the task force wants managed care organizations to institute clinical guidelines which treat pain as, in effect, a vital sign — monitoring pain at every patient encounter and entering the findings (including the effectiveness of any analgesics that have been prescribed) in the patient's chart. The requirements would make pain a hard issue for health professionals to duck.

Another concern, Solomon noted, is the tendency of U.S. medicine to lump all patients nearing the end of life together. The task force advocates different patterns of supportive care for different patient populations, depending on their disease. As an example, its report favorably cited a case management program that Kaiser Bellflower in Los Angeles County, Calif., has developed for patients with congestive heart failure.

Patients in the program are taught how to pace themselves and to recognize and manage symptoms of fluid overload so that they can live more fully with less disability for whatever time remains to them. Becoming active partners in their own care turns out to be good for them, their families, and Kaiser Bellflower. The data show that patients empowered with these skills require fewer hospitalizations and emergency room visits in the final phase of their lives than would be expected otherwise.

Also a factor that managed care organizations should consider is that their interpretation of what coverage will include can profoundly affect the quality of a patient's death, according to the report. The task force used the stories of two HMO patients with metastatic cancer to illustrate its point.

One died at home, as he had wished, because his HMO was willing to incur the expense of having the Visiting Nurse Service step in when his deteriorating condition became too much for his wife to handle alone. The other patient, too, had wanted to die at home, but was denied registered nurse services because it was her HMO's judgment that she did not have "skilled nursing needs."

While this was technically true, it was also true that her husband and daughter felt incapable of looking after her whenever she or they were frightened by her symptoms, which happened more frequently as her disease progressed. Ultimately, the husband and daughter became so overwhelmed that they called an ambulance to take her to a hospital. She died there the next day.

As both these patients were Medicare beneficiaries, enrollment in a hospice program would have been an alternative way for them to get palliative care at home. However, hospice benefits have their own problems, according to the new report.

One problem is that Medicare rules stipulate that any patient referred to a hospice program must have a maximum life expectancy of 6 months. Because many physicians mistakenly believe that there can be financial penalties for a patient who fails to die "on time," they tend to play it safe by waiting until patients are virtually moribund.

A key factor here, the panel noted, is that, except for patients with certain cancers, survival times are notoriously hard to predict.

Nor is it just that. Having a doctor certify in writing that a patient will be dead within 6 months is something that many patients and their families find so psychologically distressing that they reject the hospice option out of hand.

For all these reasons, the task force believes hospice eligibility, whether or not a dying patient is elderly, should be based on the demonstrable criterion of severity of need instead of the iffy issue of life expectancy.

Although the task force's criticism of the Medicare hospice benefit may seem to depart from its focus on managed care, the panel did not look at it that way. Rather, it perceived the benefit's shortcomings as being of a piece with other barriers to more humane and more effective end-of-life care that — given their leverage — managed care organizations and purchasers of their plans in both the private and public sectors are in the strongest position to correct.

This was perhaps said best in the new report by task force member Ira Bycock, M.D., of the University of Montana, Missoula.

Wrote Bycock, "I hope one day to see a billboard advertising a local managed care plan that has on its left an image of proud parents beaming at a newborn baby, in the center a middle-aged man on a treadmill or a woman having a mammogram during a thorough health maintenance evaluation, and on the right an elderly person at home in a hospital bed. The caption will read, `From Home Birth to Hospice. Promoting Wellness Throughout Life.' "

(Free copies of the task force report, "Meeting the Challenge: Twelve Recommendations for Improving End-of-Life Care in Managed Care," can be obtained from Mildred Solomon, Education Development Center, Inc., 55 Chapel St., Newton, Mass. 02458-1060 or email mcare{at}edc.org.)



             
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