HMO patients receive less futile aggressive care
A widely reported study, published in late September in the Journal of the American Medical Association,1 has concluded that protracted, painful deaths are less common for Medicare HMO enrollees than for matched patients in fee-for-service medicine. However, the provocative data raise unanswered questions about mortality rates, treatment preferences, and decisions, and thus whether or not the results represent a success story for the managed care industry which has been attacked recently for denying essential care based on economic motives.
Researchers Daniel Cher, MD, of the Palo Alto, CA, Veterans Administration Medical Center and Leslie Lenert, MD, an internist at Stanford University, have identified a category of high-cost, low-benefit hospital interventions, which they call potentially ineffective care (PIC). PIC is defined as "the occurrence of in-hospital death or death within 100 days of hospital discharge and resource use (total hospital costs) above the 90th percentile," adjusted for factors such as age, sex, race, and elective admissions. When they reviewed 81,500 California Medicare beneficiaries, they found that those enrolled on Medicare risk HMOs were 25% less likely to receive PIC. While the HMO patients had no higher rates of in-hospital mortality, they were 8% more likely to die within 100 days of discharge.
Some commentators viewed the results as evidence that the economic incentives of HMOs can steer patients away from needlessly futile, protracted, painful, invasive, and unwanted treatments when they are dying. Others wonder whether HMO reimbursement encourages "the right care for the wrong reasons,"2 or denies seriously ill patients potentially effective, life-saving treatments along with the futile care. It may also be that patient treatment preference drives choice of a health plan, or that more seriously ill patients shy away from HMOs in the first place.
Given a slight difference in risk-adjusted mortality and significantly fewer episodes of PIC, "there is something about the financial incentives of managed care that suggests they choose better the cases in which to do intensive interventions or work more effectively with families to withdraw care," thus limiting or reducing the injudicious use of critical care near the end of life, says co-author Lenert.
"What we want to do is make sure critical care is used appropriately. There are few cases of people who can’t benefit from ICU care, and you need to try intensive care to find out what its benefit is," Lenert tells Hospice Management Advisor. "Then you have to be willing to stop it, when you find it hasn’t benefitted. This requires courage from physicians at the front lines. Physicians in fee-for-service appear to have stronger financial incentives to probe those limits of critical care. We believe it’s in the patient’s interests to have a physician who understands those limits and does not exceed them. If you feel PIC is a bad outcome, and we do, then HMOs have an advantage."
Lenert acknowledges that the research does not address patients’ and families’ end-of-life treatment wishes and must be taken in the context of SUPPORT’s considerable data regarding such preferences. SUPPORT has highlighted, for example, how all parties tend to avoid the frank discussion of treatment options that might facilitate effective advance planning, the avoidance of potentially futile care or timely referrals to hospice. "In my opinion, physicians should have to make these hard calls," Lenert concludes. "It’s our duty to our patients to use our judgment. We don’t want to play God, but it’s irresponsible to abdicate this responsibility and just do everything possible."
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The National Task Force on End-of-Life Care in Managed Care, convened by the Education Development Center (EDC) in Newton, MA, held its second two-day retreat in September, with a third planned for next spring. This task force brings together representatives from hospice, palliative medicine, HMOs, and national policy organizations to explore how to improve access and care for HMO beneficiaries at the end of life.
EDC has sent surveys to all 237 Medicare-risk HMOs nationally about their care for patients at the end of life and is gathering information from health plans, hospice providers, and others regarding barriers to care and optimal strategies. The Task Force project will culminate in a set of recommendations, papers to explain them, and a press conference to announce them probably in late summer 1998. Hospices are encouraged to share their experiences and recommendations with the task force, by contacting Anna Romer, PhD, at EDC, (617) 969-7100.
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Johnson Foundation continues to push end-of-life advances. Last Acts: Leverage Points, the 1997 national leadership conference of the Princeton, NJ-based Robert Wood Johnson Foundation’s Last Acts national end-of-life coalition, was scheduled for Oct. 29 and 30 at Gallaudet University in Washington, DC. (See HMA, April 1997, pp. 42-44.)
Given the growing attention to end-of-life care issues nationally and the mounting documentation of what doesn’t work, conference organizers viewed this meeting as an opportunity to examine what progress has been made and to start "making significant strides in improving care of the seriously and terminally ill."
This conference attempted to bring together health professionals and consumer leaders, as well as artists such as choreographer/poet Bill T. Jones, authors such as Ira Byock, MD (Dying Well), and representatives from front-line demonstration projects now tackling end-of-life challenges.
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Replies were sent in late October to the 677 groups that submitted letters of intent to apply for the Robert Wood Johnson Foundation’s $12 million initiative Promoting Excellence in End of Life Care, whose National Program Office is based at the University of Montana in Missoula. Only 56 of these groups have been given the green light to submit a full application, which is due Jan. 22, 1998, says deputy director Jeanne Twohig, MPA.
"Letters came from every part of the country and all kinds of settings and contexts of care, including academic medical centers, nursing homes, hospices, state departments of health, prison groups you name it," she adds. Proposals spanned the life cycle, from pediatrics to old age, addressing different disease categories as well as multiple diseases. "A lot of the letters talked about the [hospice] barrier of six months or less to live," Twohig says.
"The overwhelming response to our call for proposals provided clear indication of the interest being felt on this issue. It’s hard to receive that many responses and not feel there’s a lot of work to be done." As a result, the project will be establishing work groups for funded and nonfunded providers sharing similar interests. "The National Program Office will take an active role in bringing people together," starting early next year, Twohig says.
Look for a report from Last Acts: Leverage Points in next month’s HMA.
[For more information, contact the Robert Wood Johnson Foundation at (609) 243-5926. Or see the Last Acts site on the foundation’s Web page: www.rwjf.org. For more information on Promoting Excellence in End of Life Care, contact Twohig or Byock at (406) 243-6601. Fax: (406) 243-6633. Or write Practical Ethics Center, University of Montana, Missoula, MT 59813.]
References:
1. Cher DJ, Lenert LA. Method of Medicare reimbursement and the rate of potentially ineffective care of critically ill patients. JAMA 1997; 278:1,001-1,007.
2. Curtis JR, Rubenfeld GD. Editorial: Aggressive medical care at the end of life: Does capitated reimbursement encourage the right care for the wrong reasons? JAMA 1997; 278:1,025-1,026.
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