benefits magazine march 201514

Is There a role fo In end-of-lIfe

by | William E. Hembree

When a health fund supports planning for end-of-life care and education about wiser use of care, members and their families appreciate the assistance. Fund health care costs also are likely to go down.

Reproduced with permission from Benefits Magazine, Volume 52, No. 3, March 2015, pages 14-19, published by the International Foundation of Employee Benefit Plans (www.ifebp.org), Brookfield, Wis. All rights reserved. Statements or opinions expressed in this article are those of the author and do not necessarily represent the views or positions of the International Foundation, its officers, directors or staff. No further transmission or electronic distribution of this material is permitted. M A G A Z I N E

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r Plan sPonsors Care PlannIng?

B ecause of concerns that plan mem-bers might consider it intrusive, most health and welfare funds to date have not helped members plan for end-of-life

care. But funds that do offer that assistance are likely to reduce health care costs (without shifting costs to members) and meet other goals as well.

In reality, funds already are involved. They are paying most medical costs and probably disability and life insurance. A member who already is in-terested in end-of-life planning is far more likely to appreciate than to resent a plan sponsor’s offer of help. There is a rightful (noncoercive) role for compassionate fund involvement in helping em-ployees learn and act on (voluntary) end-of-life care planning.

Strong prediction for 2015-2016: Many, if not most, plan sponsors will assist their members to learn about end-of-life care planning. This article discusses what is motivating this shift in plan spon-sors’ attitudes and includes practical steps they may want to consider in implementing a highly appreci-ated end-of-life care planning program.

What’s Driving Interest in End-of-Life Care Planning?

For a variety of reasons, people are increasingly becoming interested in end-of-life care planning,

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although many need help understand-ing the possibilities for the final stage of their lives. For one reason, people are learning they can write (and com-municate with family members about) an advance directive that addresses their medical wishes for care when they can’t speak for themselves. They realize this step can help alleviate much of the family’s stress and grief associated with “guessing” and arguing about what forms of care a critically ill or comatose loved one would (and wouldn’t) want near the end of his or her life. Consum-er Reports addressed this issue in the magazine’s December 2014 issue with an article and the results of a reader survey. Among the findings:

• 86% of respondents want to die a pain-controlled death at home surrounded by loved ones.

• Yet, about 70% of U.S. deaths oc-cur in a hospital or nursing home.

• One clear proof of having en-gaged in end-of-life care planning is having completed an advance directive. But fewer than 20-30% of U.S. adults have done so.

Another reason for increasing in-terest is the demonstrable success of a communitywide end-of-life care plan-ning initiative in La Crosse, Wisconsin. Nearly everyone in the city has com-pleted an advance directive. Not coin-cidentally, among 306 regional health care markets across the United States, La Crosse consistently enjoys the low-est average cost.

The third reason interest in end-of-life planning is expanding is the state of Massachusetts has recently issued

regulations giving guidance to a new law requiring physicians to offer volun-tary end-of-life planning conversations to Massachusetts patients who have less than six months left to live. This will have more initial impact on funds and plan sponsors in Massachusetts than in other states, but Massachusetts is just the first of many state-based require-ments on the horizon.

A fourth reason is plan sponsors’ concerns about triggering the “Cadil-lac tax,” which will require payment of a 40% excise tax starting in 2018. Aon Hewitt recently reported a pulse survey showing 40% of U.S. health plans may hit the penalty trigger in 2018. Conse-quently, plan sponsors are seeking in-novative initiatives to effectively control costs instead of using less-effective, “al-ready tried, didn’t work” solutions.

Another very recent reason is the September 2014 release of a landmark 507-page report by the Institute of Med-icine (IOM) entitled Dying in America: Improving Quality and Honoring Prefer-ences Near the End of Life. A summary of the report’s challenges to doctors and payment sources (like trust funds) is:

For patients and their loved ones, no care decisions are more profound than those made near the end of life. For the millions of Americans who work in or with the health care sector . . . providing high-quality care for people who are nearing the end of life is a mat-ter of professional commitment and responsibility. Health system managers, payers, and policy mak-ers, likewise, have a responsibility to ensure that end-of-life care is

compassionate, affordable, sus-tainable, and of the best quality possible.The IOM report shows that funds

as payers have an opportunity to help members, citizens and the nation reach the goals of enhanced quality of life, compassionate care and the best qual-ity possible. By doing so, funds can also help improve the affordability and sus-tainability of health care.

These affordability and sustainabil-ity goals can be accomplished by teach-ing and motivating the most severely ill and terminally ill patients how to buy and use medical care more effectively. Funds could accomplish this by coor-dinating a two- to three-hour wiser buyer/user seminar on using medical care more effectively.

About 80% of a fund’s annual medical and prescription drug costs are attributable to fewer than 20% of members. (In fact, according to a Heal-thentic study of 400,000 patients, as few as 1% of the covered population often create 26% or more of a fund’s cost). This 20% cohort generally is seriously or terminally ill. When these members learn how to use medical care more ef-fectively, they may recover more quick-ly and at a lower cost.

Most critically ill patients exhibit expensive buying and usage behav-iors because they don’t know how to use medical care any differently. They haven’t been taught the right buying/usage behaviors (or they didn’t hear the teaching previously offered because they figured they were “bulletproof ” and wouldn’t need the information). With the onset of serious medical chal-

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lenges, this phase of their life becomes a very teachable mo-ment.

Members with annual claims of $25,000-$50,000 or more are prime candidates for learning how and why to buy and use care more effectively. These members likely have drained sick days and are receiving disability payments from the fund. Many in this cohort will pass away while covered by the fund’s plan after several weeks or months of very expensive care. So life insurance proceeds are often paid for these members as well. Consequently, the educational focus for this cohort is on teaching and motivating wiser buying/usage of medical care and improving health literacy and skills in communicating with providers. Part of the educational emphasis needs to be on why it is advantageous for patients to become as compliant as possible with physicians’ recommendations.

But these members can benefit most by having providers know their preferences for care and, especially, their inter-est in end-of-life care planning, use of advance directives, advanced pain controls and optional use of hospice and/or palliative care in their last days or weeks.

In the most serious circumstances, as a result of the fund’s end-of-life care planning seminar, many if not most of the patients who are terminally ill will become more comfortable with the voluntary alternatives of choosing hospice or pallia-tive care. This decision follows when their physicians counsel that there’s virtually no hope of recovery from their illness/injury regardless of medical interventions.

When members voluntarily choose these alternatives to passing away tubed up and wired to machines in an intensive care unit, cost savings are substantial. Often, highly intensive deaths in the hospital result in costs of $50,000-$100,000. Hospice care fees in the patient’s home usually are less than $10,000. The result—the patient’s death—is the same in ei-ther location.

Patients and families choosing to forgo “heroic but futile” medical interventions, which merely prolong the dying pro-cess at a very high cost, report a significantly improved sense of control over their circumstances, better pain control and improvements in the remaining quality of life in hospice or palliative care. This also results in better engagement, appre-ciation and satisfaction with the health plan sponsor.

One of the most important advantages in engaging fund

members in a wiser buyer/user educational seminar is to re-duce health care costs for the fund and its members. Estimates of funds’ savings vary, but a 5% reduction in first-year costs is a reasonable expectation. This first-year savings would be fol-lowed by larger savings over time. These savings are the result of some high -cost patients choosing reasonable cost alterna-tives at the end of their lives, combined with patients who are buying and using care more wisely while recovering.

Steps to Improve End-of-Life Care Support

Assess Current Plan’s Design for End-of-Life Care Support

This step is simple. List the plan’s current plan design fea-tures and other actions that support end-of-life care plan-ning efforts. Many plan sponsors have no explicit support for end-of-life planning, but more proactive plan sponsors may list the following:

• Plan covers (limited) hospice and palliative care fees.• Vendor conducts telephonic disease management.• Vendor conducts telephonic large-case management.Helpful as these steps are, they may fall short of what’s

needed to support end-of-life care. Often, patients are not aware hospice care is covered or even what hospice care is. Consequently, hospice care is used infrequently. And when used, it often is for only a few days immediately before a pa-tient’s death. In addition, many patients strongly dislike (and often reject) vendors’ telephonic disease management and case management efforts. (See the need for face-to-face com-munications below).

Adjust Plan Design to Fill Gaps

Hospice and palliative care costs are likely paid in the health plan like any other medical charges. Plan sponsors

end-of-life planning

learn more >>EducationHealth Care Management ConferenceApril 13-15, Santa Monica, CaliforniaVisit www.ifebp.org/healthcare for more information.

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end-of-life planning

should consider waiving copays and coinsurance for hospice and palliative care to encourage voluntary use of hos-pice services since they are consider-ably less costly than hospital care.

Savings resulting from use of hos-pice or palliative care are only part of the picture. Almost universally, fam-ily members, caregivers and patients themselves laud the compassionate care and pain-free natural death asso-ciated with hospice or palliative care. Hospice workers are experienced, sen-sitive and adept at helping patients and family members accept the inevitability and nearness of death. Also, hospice physicians are able to dispense levels of pain medication necessary to keep pa-tients comfortable. In contrast, narcot-ics laws and hospital restrictions some-times limit the level of pain medication patients may receive in a hospital.

Plan sponsors should also consider covering payments for specific Current Procedural Terminology codes that

allow a physician to be paid for a lon-ger duration discussion with patients about end-of-life care. The physician would discuss the medical aspects of end-of-life care and the importance of advance directives. This physician visit also should be paid without copays and coinsurance.

Encourage Advance Directives

One of the most important steps in end-of-life care planning is ensur-ing patients have completed advance directives. In essence, advance direc-tives speak for patients when patients can’t speak for themselves. Advance directives contain the patient’s wishes regarding do-not-resuscitate orders, conditions that preclude treatments that simply prolong the dying process, when to insert or remove feeding and breathing tubes, etc. The optimal tim-ing for completion of advance direc-tives is well before patients face final hospitalizations.

What’s the role for plan sponsors in ensuring patients and their families learn about the advantages of an ad-vance directive? Employers can teach members who are seriously or termi-nally ill why completion of an advance directive is valuable. Plan sponsors also can point patients and caregivers/fam-ily members in the direction of vetted resources to allow patients to decide which advance directive prototype best fits their needs.

Use Face-to-Face Communications

Plan sponsors should not rely on written or online communications alone to address this topic.

The optimal face-to-face com-munication is through a seminar en-trusted to a third party that would be seen as a neutral and highly credible information resource. It is important to convey that the purpose of the face-to-face seminar is to help at-tendees use medical care in the most care-effective and personally satis-factory ways possible. There should be no overt focus on saving health plan money. The session will save money because some (maybe many) attendees will change behaviors and use care more effectively. But seri-ously ill patients will see “saving the plan money” as a significant negative. This rationale for the fund’s support of members’ end-of-life planning should be avoided in all forms of communication and seminar presen-tations.

Who could serve as this third-party resource? Start with the fund’s carrier or health plan (it may provide the pre-

takeaways >>•  Despite most people’s wishes, a majority of people die in a hospital or nursing home

rather than at home.

•  Concerns about triggering the Cadillac tax in 2018 are spurring plan sponsors to seek innovative initiatives to effectively control costs.

•  Teaching and motivating severely ill and terminally ill patients how to buy and use medi-cal care more effectively will promote the affordability and sustainability of health care.

•  Plan members benefit by having providers know their preferences for care, their interest in end-of-life care planning, use of advance directives, advanced pain controls and optional use of hospice and/or palliative care.

•  Plan sponsors may want to consider waiving copays and deductibles for hospice or palliative care and paying doctors for longer sessions in which to help with end-of-life planning.

•  A seminar to explain end-of-life planning, which could be recorded for members too ill to attend in person, may be most effective.

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sentation at no cost). Alternatively, some consulting firms and experienced specialty resources may offer these presen-tations for a reasonable fee. The organization chosen should offer a sensitive, empathetic and highly credible and skilled presenter. The presenter should also help plan the program in an implementation planning meeting (possible agenda below).

The seminar presentation should be filmed, since many who will be invited will be unable to attend because of their medical challenges. Plan sponsors or carriers can follow up by mailing the handout materials used in the seminar along with a DVD or other media that can be viewed by patients and caretakers who were unable to attend.

Plan the End-of-Life Care Support Seminar

Ten possible agenda items for an implementation plan-ning meeting are:

1. Where should the seminar be held? When? 2. Who invites patients/caregivers to the seminar? 3. Special steps to ensure patients’ privacy 4. What plan and non-plan design changes should be

made? 5. What metrics should be used to measure the effective-

ness of the program? 6. What are the communications steps? Means? Mes-

sage? Media? 7. Who does what? When? 8. Process for approvals, endorsements by trustees 9. Other discussion 10. Wrap-up.

Implement the Support Program

Implementation steps will follow the actions decided in the planning meeting.

Be sure to communicate thoroughly about the program. Communicating with invited patients and their families/caregivers is obvious. But remember to communicate with specific providers about the fund’s new end-of-life care plan-ning program. Carriers/health plans can identify physicians who are providing most of the care for severely and termi-nally ill patients. Patient-specific letters should be mailed to these physicians. Physicians and their staffs will appreciate

knowing their patients have this new benefit. And because the physician will be paid for the visit to discuss the medical aspects of end-of-life care, he or she will not be surprised by patients seeking this type of visit.

Monitor and Measure Results

Finally, employers should ensure metrics are built in to monitor and measure results of the program. Examples of metrics are per employee per month changes in percentage of illness-specific costs and usage, percentage of generic and mail-order prescriptions, medication and treatment adher-ence, hospitalization and emergency room (ER) usage and ratio of avoidable ER usage. In addition, nonmedical changes in results such as usage of sick days, disabilities, recruiting and replacement costs, life insurance costs, etc., could be measured.

William E. Hembree is the chief executive officer and founder of Health Research Institute (HRI) in Concord, California. The research-based organization

provides health care cost control consulting and health improvement policy planning and implementation assistance as well as data collection and analysis for nationwide private and public employers, unions and coalitions. Hembree previously held positions with a major group insurance company, the nation’s oldest health maintenance organization and Hewitt Associates. He helped Hillary Clinton in developing the Clinton administration’s health plan proposal and also served President George H. W. Bush’s Office of Long-Term Health Planning. Hembree serves as a faculty member for the International Foundation Certificate of Achievement in Public Plan Policy. He received his B.A. and M.B.A. degrees from California State University at Long Beach. He can be reached at hembree_hri@sbcglobal.net.

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