Involving the Patient in End-of-Life Care Decisions: Aetna’s Oncology Strategy

July 2012, Vol 3, No 5

Houston, TX—Payer-sponsored programs that promote appropriate end-of-life care are beneficial to all stakeholders, according to Ira M. Klein, MD, MBA, Chief of Staff to the Chief Medical Officer, Aetna Oncology Strategy.

At the Second Annual Conference of the Association for Value-Based Cancer Care, Dr Klein discussed advancedcare directives and emphasized that the patient and family “should be at the center of what you do.”

Studies have shown that although 70% of Americans express the wish to die at home, only 25% actually do. And 90% of terminally ill patients with cancer cite their homes as their preferred site of death, yet only 33% actually die there, Dr Klein noted.

“It is not a mystery to us when death is approaching. We have more than adequate clinical signals,” he said. “So, what is going on?” Among Aetna members, only 1% generate 33% of its claim costs. When these patients develop terminal conditions, he noted, “We know who they are, their families know, yet they do not end up in the right place.”

“Just having a signed advanced-care directive does not mean that all parties have ‘done their duty,’” Dr Klein pointed out. “Unfortunately, discussions with patients and families regarding terminal care and available options happen too late or not at all.”

Lacking a more structured approach to end-of-life care, patients are treated within the traditional and expensive framework that is not beneficial, Dr Klein concluded.

Aetna’s Approach to End-of-Life Care

Aetna offers an “innovative and member-centric” case management program that combines patient support with benefit design. Key components are the use of an outsourced vendor for patient counseling on end-oflife issues, an insourced high-intensity complex case management program, and transition to “compassionate care” that allows patients interventions to improve functional status.

The outsourced Vital Decisions Living Well Program was founded on the knowledge that end-of-life interventions increase feelings of empowerment for the patient, reduce hospital admissions and emergency department visits, and reduce costs.

“If you employ these services, you do not shorten patients’ lives; you in - crease patient satisfaction, you improve patients’ attitudes, you resolve conflicts within families, and you use fewer resources,” Dr Klein said. “We knew this, we saw end-of-life discussions as an unmet need, and we decided to do something.”

Figure 1
Vital Decisions Living Well Program Goal and Strategy.
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The Vital Decisions Living Well Program acts as a catalyst for planning and decision-making. The vendor, Vital Decisions, is a bioethics services company staffed by highly trained social workers. For Aetna, the goal is to create members who proactively participate in their care by identifying, communicating, and incorporating their priorities into current and future care decisions (Figure 1). The counselor helps patients become empowered through understanding and choosing among options for care, and developing a plan they can take to their physicians.

“Patients are often in the back passenger seat in this journey, and they tell their physicians to ‘just drive.’ When patients have no directions for where the journey is going, they do not always get the best plan for care. Under our program, this changes. The patient says ‘I have a plan,’ and the physician treats in a manner consistent with this.” Physicians as well as patients appreciate the clarity inherent in this process, Dr Klein added.

From claims data, patients are identified for the Vital Decisions program on the basis of end-of-life clinical triggers. For patients with cancer, it is usually when metastasis develops that performance status (Eastern Cooperative Oncology Group Per formance Status ≥2 or Karnofsky Performance Status ≤70) declines or that patients become dependent in activities of daily living. The timing is such that patients can be engaged in discussions when there is “some certainty about the finality of mortality yet the functional status is still high,” he said.

Vital Decisions is given the patient’s name, and the company then obtains the physician’s approval and the patient’s consent to initiate the service.

Figure 2
Identification of the Most Highly Fragile Members Earlier in the Process.
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The second component—the highintensity complex case management program—is also part of Aetna’s goal of early identification of fragile members and referral to the compassionate care program (Figure 2). The program is a member-centric model with high-touch and face-to-face patient assessment by staff with intensive training in motivational interviewing, end-of-life issues, and cultural competency.

When appropriate, patients are entered into the compassionate care program, which “gives patients and their families a landing place where they do not feel abandoned as they sometimes do going into hospice,” he said. The program provides traditional hospital measures of support, pain management, and symptom control, with psychologic and spiritual support as well.

“We now have the right benefit for the right condition. We are matching the solution to the problem,” Dr Klein commented.

Results of a 3-year study of program participants show a >70% increase in hospice use, and an almost doubling in the average number of days in hospice; for Medicare patients, an 82% reduction in acute hospitalization days and an 88% reduction in intensive care unit stays; and considerable reductions in emergency department visits for all program participants.

Lessons Learned about End-of-Life Care

Dr Klein shared lessons learned from Aetna’s experience with structured end-of-life counseling services:

  • Physicians should direct end-of-life care, not payers, but payers can facilitate care by providing tools for patients to be “proactive”
  • Payers should create an environment in which bioethics discussions happen, in an “opt-in” permissive manner
  • Physicians welcome assistance in engaging patients in end-of-life care discussions
  • Patients value the availability of skilled and focused bioethics counseling services
  • The guiding principle for these services is 2-way communication
  • A dedicated hospice benefit removes barriers and improves the delivery of needed services.

“What we are doing is empowering patients, not directing them. When they see their oncologists, they are ready to have these discussions and they value this,” Dr Klein pointed out.

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