Blue Cross expands benefits for end-of-life care
The state’s largest health insurer this week will begin offering some of the newest and most comprehensive end-of-life benefits in the nation, aiming to prod patients and health care providers to discuss death openly and expand services to help people live out their last days.
The move by Blue Cross Blue Shield of Massachusetts comes as a growing number of health organizations put more emphasis on how patients are treated at the end of life by providing and paying for care that is more in line with patient wishes. Most Americans, for example, say they want to die at home, but most still die in hospitals and other institutions, according to several studies.
And while the primary goal is not cost control, the effort also has the potential to lower health care spending by giving patients more options to replace hospital care with less expensive — and often preferable — alternatives, such as hospice and home care. Medical care at the end of life can be expensive; a 2010 study found that 25 percent of all Medicare payments go toward the 5 percent of people in the last year of their lives.
“The industry is now starting to take this seriously,” said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center. “The industry now not only understands the issues [around death and dying], but understands there are concrete things they can and need to do, and Blue Cross is showing us how to get started.”
As of Jan. 1, Blue Cross Blue Shield of Massachusetts, with 2.8 million members, will pay for more counseling sessions between providers and patients to discuss end-of-life care and expand access to hospice services. It is also developing a home care program that will be launched later in 2016.
Other insurers, including Medicare, the government program for those 65 and older, have decided to cover the cost of end-of-life discussions between doctors and patients. (Medicare’s change takes effect in 2016.)
Blue Cross is taking this a step further. It will also cover costs of visits with psychologists, social workers, and other mental health workers, where patients can ponder questions such as how they want to die, where they want to die, whether they would want doctors to take all possible measures to keep them alive — or whether they prefer to forgo intensive medical treatments to be more comfortable at the end.
Specialists in end-of-life care say people should begin such conversations with providers and loved ones well before they become seriously ill. Blue Cross plans to cover end-of-life counseling sessions for any member who chooses to have one, not just for those who are sick.
“All patients should be thinking about it,” said Andrew Dreyfus, chief executive of Blue Cross.
The insurer’s efforts to expand end-of-life benefits were inspired in part by Dreyfus’s experience of watching his parents and 61-year-old brother die from illnesses, which he detailed in a recent essay in the Globe.
“Each of these losses was excruciating, but my grief was softened because my parents and brother made decisions about their care and died gently, free from invasive medical treatment and touched by loved ones until the very end,” he wrote. “Unfortunately, their experiences are not typical.”
Efforts to improve end-of-life care are gaining traction, though. Massachusetts General Hospital is preparing to launch an initiative in 2016 to train clinicians who treat serious illnesses to help patients plan for death. The hospital also plans to hire more specialists in palliative care, the branch of medicine that treats the symptoms and stresses of disease for the seriously ill, so more patients can receive such care.
Beth Israel Deaconess has revised its electronic health records system to help emergency doctors retrieve information about patients’ end-of-life wishes. Starting early next year, every patient admitted to the hospital will receive a guide outlining options for people with serious illnesses.
Among insurers, several health care specialists said, Blue Cross is leading the field on end-of-life care. But others are focused on the issue, too.
Tufts Health Plan, an insurer based in Watertown, said it will work with some of its sickest members to put their end-of-life wishes on paper, so they can be shared with primary care physicians and the patients’ health care proxies.
Medicare and many health plans limit hospice coverage to people with six months or less to live, but Harvard Pilgrim Health Care, of Wellesley, said it has no such restrictions for terminally ill patients, as long as physicians believe hospice is appropriate.
Blue Cross said it will expand hospice eligibility to patients expected to live 12 months or less, from the current six months.
Dreyfus said Blue Cross’s new benefits may reduce some costs: For example, if a terminally ill patient with shortness of breath gets help at home, instead of going to the hospital. But he said that providing hospice and home care to more patients means costs might also increase. The goal of end-of-life benefits is to improve care for dying patients, he said: “We don’t want anyone to be concerned they may not get the care they need.”
Dr. Vicki Jackson, chief of palliative care at Mass. General, said insurers play a key role in the movement to increase patient-doctor discussions about end-of-life care and help patients decide how they want to spend their remaining time.
“Reimbursement is one important piece,” she said. “That there is a way to be able to bill for it says how important this is. That adds a certain validity.”
Ellen Goodman, a former Boston Globe columnist who now directs The Conversation Project, a campaign to promote end-of-life planning, said that efforts such as the one at Blue Cross show the progress in addressing issues surrounding death and dying.
“We’ve already seen a big culture change in the number of people who recognize that it’s important to have conversations with their families, as well as their providers, to talk in advance about how they want to live the end of their lives,” said Goodman.
“This is about quality of care,” she said. “This is about helping people to live the way they want to at the end of their lives.”