JOURNAL OF PALLIATIVE MEDICINE Volume 12, Number 9, 2009 ª Mary Ann Liebert, Inc. DOI: 10.1089=jpm.2009.0089
A Comprehensive Case Management Program To Improve Palliative Care 1 1 Claire M. Spettell, Ph.D., Wayne S. Rawlins, M.D., M.B.A.,2 Randall Krakauer, M.D.,3 Joaquim Fernandes, M.S., 2 2 2 Mary E.S. Breton, B.S., J.D., Wayne Gowdy, B.S., Sharon Brodeur, R.N., B.S., M.P.A., Maureen MacCoy, B.S.N., M.B.A.,2 and Troyen A. Brennan, M.D., M.P.H.4
Objective: The objective of this study was to evaluate the impact of comprehensive case management (CM) and expanded insurance beneﬁts on use of hospice and acute health care services among enrollees in a national health plan. Study Design: Retrospective cohort design with three intervention groups, each matched to a historical control group. Methods: Intervention groups were health plan enrollees who died after 2004: 3491 commercial enrollees with CM; 387 commercial enrollees with CM and expanded hospice beneﬁts; and 447 Medicare enrollees with CM. Control groups consisted of enrollees who died in 2004 prior to the start of the palliative care CM program. The main outcomes measured were the proportion using hospice, mean number of hospice days, and number of inpatient days measured through medical claims. Results: Hospice use increased for all groups receiving CM compared to the respective control groups: from 30.8% to 71.7% ( p < 0.0001) for commercial members with CM and from 27.9% to 69.8% ( p < 0.0001) for Commercial members with CM and enhanced hospice beneﬁts. Mean hospice days increased from 15.9 to 28.6 days ( p < .0001) and from 21.4 to 36.7 days ( p < 0.0001) for these groups, respectively. Inpatient stays were lower for all groups receiving CM services compared to their respective control groups. Conclusions: Comprehensive health plan CM and more liberal hospice beneﬁt design may help to break down barriers to hospice use; beneﬁts might be liberalized within the context of such case management programs without adverse impact on total costs.
Introduction ospice care helps to meet the needs of patients with advanced illness by providing effective pain and symptom management and support for the emotional and spiritual needs of patients and their caregivers. Such care allows patients to achieve a sense of control over dying, many of whom would prefer to die at home. Hospice utilization among Medicare decedents increased dramatically in the last decade, to approximately 40% in 2005.1 However, the current rate is considered less than ideal to fully meet the needs of those with advanced illness, and there is substantial variation in the use of hospice by age, race, diagnosis and geographic location.2–5 Many individuals enter hospice shortly before death, substantially limiting the beneﬁt they might obtain 1 2
from hospice services. In 2006, the median length of stay in hospice was 20.6 days, down from 26.0 days in 2005, and little changed from the 2001 rate of 20.5 days.6 Among Medicare decedents, the median length of stay was 15 days in 2005.1 Barriers to election of hospice care include preferences for aggressive curative treatment among patients, families, and physicians, physician’s discomfort and difﬁculty in initiating conversations about advanced illness choices, Medicare regulations requiring the patient’s physician to certify that the patient has a life expectancy of 6 months or less, limits on hospice beneﬁts, and the need to forego curative medical treatment in order to qualify for hospice.7,8 In 2004, a national health plan launched a comprehensive case management (CM) program targeted speciﬁcally to patients with advanced illness and their families. The health
Aetna Informatics, Aetna, Blue Bell, Pennsylvania. Aetna Government Health Plan, Aetna, Hartford, Connecticut. 3 National Care Management, Aetna, Hartford, Connecticut. 4 CVS Caremark, Woonsocket, Rhode Island.
828 plan also piloted a beneﬁt...
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