Krakauer eol policy

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  • Terminally ill patients are forced to choose between life prolonging treatment and palliative support
  • Members need to weigh the relative merits of one type of care versus another and choose what is best for them in consultation with their family, physicians and spiritual advisors. Our responsibility is to provide members with information and support so that they are able to make a well-informed decision. NHPCO – hospice and palliative care involve a team-oriented approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the person’s needs and wishes. Support is provided to the persons loved ones as well.
  • This program is a unique offering in the industry. It follows Aetna’s goal of providing greater access to care and information, and places us as ‘Best in Class’ on this issue
  • With the success of the ACCP program launched in 2004, Under the guidance Of Dr Rowe, there was a pilot conducted in 2005 with 13 large employers that expanded the definition of terminal illness from 6 months to 12months. allowed for curative care while in hospice and removed all day and dollar limits on inpatient and outpatient hospice benefits. This program is a unique offering in the industry. It follows Aetna’s goal of providing greater access to care and information, and places us as ‘Best in Class’ on this issue. This program is a unique offering in the industry. It follows Aetna’s goal of providing greater access to care and information and putting the member at the center of everything we do. Case Management Services - Helping members understand options, nurses were trained to : Assess and manage members’ care in a culturally sensitive manner Identify resources to make members as comfortable as possible, addressing pain and other symptoms Help coordinate medical care, benefits and community-based services Inform the member about treatment options, continuity of care, and advanced care planning Provide personal support 2) Enhanced Benefits Pilot Program* - Helping members access optimal care by eliminating barriers to hospice: Allow curative treatment Liberalize hospice entry requirement to 12 month terminal diagnosis (from 6) Remove day and dollar limits from hospice benefit 3) Website - Helping members understand care options, the Aetna Compassionate Care program website provides: Information on the dying process, the grieving process, hospice and palliative care support Information about decisions to be made, a checklist of important documents to compile, plus printable Advanced Directives and Living Will forms for several states Tips for beginning a discussion with loved ones about end-of-life wishes www.aetnacompassionatecareprogram.com
  • Case management Aetna’s nurse case managers have long provided end-of-life care coordination as part of their responsibilities. However, our vision for the Aetna Compassionate Care program took these capabilities to the next level. All of our nurse case managers received additional training on issues specific to the challenges raised by these clinical situations, transforming support in this context into a core competency that is now an Aetna standard. To develop and deliver this training, Aetna has worked with the National Hospice and Palliative Care Organization, America’s oldest and largest nonprofit membership organization representing hospice and palliative care programs and professionals across the country
  • In order to effectively do this you must always be aware of the members/families level of understanding-each situation is unique and you must make it a priority to know the literacy or emotional state of your audience (member, family, and caregiver) in order to have a discussion with them that is meaningful and understood. During a highly emotional time comprehension can be difficult especially when dealing with a life limiting illness... If the member agrees it is very helpful to have another family member present to hear the message you need to deliver.
  • For the participants who had just the specialized case management program: The percentage using hospice and respite increased from 30.8% to 71.7% the average length of time in hospice increased from 15.9 days to 28.6 days The percentage with acute hospital admissions decreased from 42.9% to 22.7%
  • For the pilot participants who had both the specialized case management program and the enhanced benefits : The percentage using hospice and respite increased from 37.9% to 69.8% the average length of time in hospice increased from 21.4 days to 36.7 days so the pilot program helped members use hospice services more and access hospice benefits at an earlier point in time relative to death The percentage with acute hospital admissions decreased from 40.3% to 16.8% [If question comes up on what was the cost associated with the providing more robust hospice benefits in the pilot, or whether any savings was achieved by a shift of costs from acute care to hospice, here is our answer…] The cost of the pilot program was low. We liberalized the benefits to remove barriers to optimal care at the end of life, we presented the care choices to the member through our case management, and as a result, members in the pilot chose hospice over other more expensive acute type care. Researchers found that hospice reduced Medicare costs by an average of $2,309 per hospice patient . The new study from Duke University appears in the October 2007 issue of the professional journal “Social Science & Medicine.” Additionally, Medicare costs would be reduced for seven out of 10 hospice recipients if hospice has been used for a longer period of time the study found. “ Given that hospice has been widely demonstrated to improve quality of life of patients and families...the Medicare program appears to have a rare situation whereby something that improves quality of life also appears to reduce costs,” - Don H. Taylor, Jr., assistant professor of public policy at Duke’s Sanford Institute of Public Policy
  • First comment cont’d… She also wanted to thank Aetna for not thinking of them as a statistic and that it was nice to know that the insurance company was there for them.  She did not expect such compassion from such a big insurance company.  She does not hear that from other people.  She was curious about our little unit and what we did. 
  • If customers are insterested in offering the expanded benefits now: At this time, we can work with self insured customers to follow the expanded hospice benefit model until we roll it out on a broader basis. For fully insured customers, we are currently reviewing state filing requirements to determine if any additional filings are necessary.
  • Krakauer eol policy

    1. 1. Ready Today for The Future of Health Care and Optimal Hospice Care Aetna Compassionate Care SM Program
    2. 2. ©2009 Aetna “ There is a great divide separating the kind of care Americans say they want at the end of life and what our culture currently provides . Surveys show that we want to die at home, free of pain, surrounded by the people we love. But the vast majority of us die in the hospital, alone, and experiencing unnecessary discomfort.” - Bill Moyers, PBS Commentator End of life care – current state
    3. 3. Historic Human Mortality Rates Hamourabi Codex Hipocrates Galen Koch Pasteur Sanitation Antibiotics
    4. 4. Geriatric Conditions and Quality Scores <ul><li>The ACOVE (Rand) Study identified significant quality and care gaps and opportunities that might be addressed in managing care in Medicare populations </li></ul><ul><li>Opportunities to improve care, especially for terminal illness, were clearly demonstrated </li></ul>©2009 Aetna
    5. 5. End of life care – current state ©2009 Aetna Lack of Knowledge about Care Options: Unfortunately, discussions with patients and families regarding terminal care and available options happen too late, or not at all. “ Acceptance of one’s mortality is a process, not an epiphany.” - Randall Krakauer, MD, Head of Medicare Medical Management, Aetna
    6. 6. End of life care – current state ©2009 Aetna <ul><li>Barriers to Care: </li></ul><ul><ul><li>To enter into hospice and receive palliative care, the patient must: </li></ul></ul><ul><ul><ul><li>discontinue curative care, or stop treatment of the illness </li></ul></ul></ul><ul><ul><ul><li>be terminal within life expectancy of six months or less to live </li></ul></ul></ul><ul><ul><li>Often there are coverage limits on hospice care that apply to both number of days in hospice and maximum dollar coverage allowance </li></ul></ul>
    7. 7. <ul><li>The focus of hospice is based on the belief that each of us has the right to die pain-free and with dignity, and that our loved ones will receive the support to allow us to do so. </li></ul><ul><li>Hospice care provided to patients and families includes: </li></ul><ul><ul><li>pain management </li></ul></ul><ul><ul><li>symptom control </li></ul></ul><ul><ul><li>psychosocial support, and </li></ul></ul><ul><ul><li>spiritual care </li></ul></ul>Hospice care philosophy ©2009 Aetna
    8. 8. Aetna Compassionate Care SM <ul><li>To provide additional support to terminally ill members and their families, and help them access optimal care . </li></ul>©2009 Aetna Goal of the Program:
    9. 9. <ul><li>Specialized Case Management Services </li></ul><ul><li>Enhanced Hospice Benefits* </li></ul><ul><li>Aetna Compassionate Care SM Website www.aetnacompassionatecareprogram.com </li></ul>©2009 Aetna Aetna Compassionate Care SM Program addresses barriers to optimal care This program provides support to terminally ill members and their families, and helps them to access optimal care . *Pilot Program with enhanced hospice benefits (2005)
    10. 10. Case Management Services <ul><ul><li>Assess and manage members’ care in a culturally sensitive manner </li></ul></ul><ul><ul><li>Identify resources to make members as comfortable as possible, addressing pain and other symptoms </li></ul></ul><ul><ul><li>Help coordinate medical care, benefits and community-based services </li></ul></ul><ul><ul><li>Inform the member about treatment options, continuity of care, and advanced care planning </li></ul></ul><ul><ul><li>Provide personal support </li></ul></ul>©2009 Aetna Aetna Compassionate Care SM - Helping members understand options, nurses were trained to :
    11. 11. Case Management <ul><li>Case Managers trained and experienced in care and management of terminal illness </li></ul><ul><li>Engage members, family and caregivers and physicians to help initiate discussions on options and planning and present alternatives. </li></ul><ul><li>Provide and facilitate emotional and psychosocial support – culturally sensitive </li></ul><ul><li>Facilitate palliative care and pain relief </li></ul><ul><li>Also support family and caregivers </li></ul><ul><li>Retain in contact as long as we can be helpful </li></ul>©2009 Aetna
    12. 12. I Don’t Understand <ul><li>Establishing a level of understanding is critical at any level of case management for optimal outcomes </li></ul><ul><li>Elderly? </li></ul><ul><li>Hearing Impaired? </li></ul><ul><li>Language Barrier? Cultural Barrier? </li></ul><ul><li>Poor Comprehension? </li></ul><ul><li>Too upset to talk? </li></ul>©2009 Aetna
    13. 13. What is the impact? <ul><li>Three groups </li></ul><ul><ul><li>Medicare </li></ul></ul><ul><ul><li>Commercial </li></ul></ul><ul><ul><li>Commercial pilot groups with enhanced hospice benefit </li></ul></ul><ul><li>Each group with previous year (2004) non randomized case control match </li></ul><ul><li>Three year run period – death is end point (2005-2007 Q1) </li></ul><ul><ul><li>Control group tracked for same amount of time </li></ul></ul><ul><li>Compare key parameters </li></ul>©2009 Aetna
    14. 14. Matched Study Cohorts ©2009 Aetna Aetna Compassionate Care SM
    15. 15. Results ©2009 Aetna Aetna Compassionate Care SM
    16. 16. ©2009 Aetna Results Commercial Case Management Group Commercial Members p<.0001 for each comparison Source: Evaluation of Aetna Compassionate Care Program, Aetna Inc., Aetna Health Analytics, September 2007, internal document.
    17. 17. Aetna Compassionate Care SM ©2009 Aetna Commercial Enhanced Benefits Pilot Group p<.0001 for each comparison Source: Evaluation of Aetna Compassionate Care Program, Aetna Inc., Aetna Health Analytics, September 2007, internal document . Results
    18. 18. Compassionate Care Feedback: cm note ©2009 Aetna Wife stated member passed away with Hospice. Much emotional support given to spouse. She talked about what a wonderful life they had together, their children, all of the people's lives that he touched - they were married 49 years last Thursday and each year he would give her a piece of jewelry. On Tuesday when she walked into his room he had a gift and card laying on his chest, a beautiful ring that he had their daughter purchase. She was happy he gave it to her on Tuesday - on Thursday he was not alert. She stated through his business he touched many peoples lives, and they all somehow knew he was sick, and he has received many flowers, meals, fruit, cakes, - she stated her lawn had become overgrown and the landscaper came and cleaned up the entire property, planted over 50 mums, placed cornstalks and pumpkins all around. She said she is so grateful for the outpouring of love. Also stated that Hospice was wonderful, as well as everyone at the doctors office, and everyone here at Aetna. She tells all of her friends that &quot;when you are part of Aetna, you have a lifeline.&quot; Encouraged her to call CM with any issues or concerns. Closed to case mgmt.
    19. 19. ©2009 Aetna
    20. 20. Results of our three-year study of program participants show: <ul><ul><li>Significant increase in hospice use </li></ul></ul><ul><ul><ul><li>The proportion of members using hospice increased dramatically -- to 71% for Commercial members and 77% for Medicare members (now over 80%).  In addition, the average number of days in hospice nearly doubled. </li></ul></ul></ul><ul><ul><li>Significant decreases in acute/critical care utilization </li></ul></ul><ul><ul><ul><li>There were 82% fewer acute hospitalization days (Medicare) and considerable reductions in emergency room visits for all program participants (77% reduction for Medicare). ICU stays also showed dramatic (88% - Medicare) reductions. </li></ul></ul></ul>©2009 Aetna
    21. 21. ©2009 Aetna <ul><li>&quot;(Family Caregiver) was happy that he was able to die at home with hospice services because this is what he wanted. He died comfortable with his family.” - Family Caregiver of ACCP Member </li></ul><ul><li>“ You make the unbearable a little more bearable. God Bless you. You are credits to your profession.” – Widower of ACCP Member </li></ul><ul><li>&quot;I hope you guys keep the program because I think others would find it beneficial also. The nurses that I dealt with helped me with several different issues and, without them, I would have had a lot more trouble.&quot;  - Family Caregiver of ACCP Member </li></ul>Aetna Compassionate Care SM Program - feedback
    22. 22. ©2009 Aetna <ul><ul><li>The specialized case management had a critical impact on the care sought by the participant -- members were more aware of the care options available to them and many more sought hospice care. </li></ul></ul><ul><ul><li>The enhanced benefits allowed pilot participants not only to seek optimal care, but also to take full advantage of it . </li></ul></ul>Aetna Compassionate Care SM Summary
    23. 23. ©2009 Aetna <ul><ul><li>Specialized Case Management and benefits liberzlization is now the standard medical plan for commercial members. </li></ul></ul><ul><ul><li>Seek to liberalize the Hospice benefit for Aetna Medicare Advantage members at our risk </li></ul></ul><ul><ul><ul><li>Change definition of “terminal” from six months expectation to 12 months </li></ul></ul></ul><ul><ul><ul><li>Allow concurrent curative care </li></ul></ul></ul><ul><ul><li>This program enables Aetna to continue to take a position in helping our members, and to influence the industry’s approach to palliative care and care at the end of life. </li></ul></ul><ul><ul><ul><li>Incorporate into ACO plans </li></ul></ul></ul><ul><ul><ul><li>Through our experience participate in opportunities to improve care of Advanced Illness on a large scale (through opportunities such as C-TAC). </li></ul></ul></ul><ul><ul><li>Continue to support and train our nurse case managers so that end-of-life case management remains a core proficiency. </li></ul></ul><ul><ul><ul><li>Incorporate into comprehensive Palliative Care Plans </li></ul></ul></ul>Aetna Compassionate Care SM Next Steps

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