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Innovations in caring for the patient with advanced cancer
When I hear the word “innovation,” too often it is associated only with a technological wonder, such as a new stent or catheter.
This past spring, Frontiers of Health Services Management published an issue that explored innovations in how we care for our sickest patients. A program by Aetna, in which hospice benefits were “expanded” for Medicare patients, was among those highlighted.
This made me curious as to what exactly it meant.
In a 2009 Health Affairs article, Randall Krakauer, MD, and colleagues described a pilot study at Aetna to improve the quality of care for patients with advanced illness through a care management program.
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Basically, Aetna launched a comprehensive care management program for a group of its Medicare Advantage patients who had advanced illness. The most common primary diagnosis for these patients was cancer.
Each of these patients received individualized case management by a nurse case manager specially trained in palliative care. The care included a comprehensive assessment of their physical, emotional and psychosocial needs.
The program also ensured that the patient had advance directives in place and that those directives were known.
For one arm of the study, the hospice benefit was “enhanced,” meaning that patients could enroll in hospice with a prognosis of 12 months or less rather than the usual 6-month prognosis. Patients on hospice also were able to continue their disease-directed therapies simultaneously, creating a more “open-access hospice.”
Several interesting things occurred with the patients in this pilot.
First, Medicare Advantage patients overall elected hospice at a higher rate than in prior years, regardless of whether it was enhanced.
The group of patients who had access to “enhanced hospice” benefits had increased average length of stay on hospice compared with patients who had just case management alone. This increase has continued, and in 2010, the rate had tripled since initiation of the pilot.
The usage of acute care and intensive care both decreased as well.
In 2010, the number of acute care days utilized for patients in the program decreased by 82%, and the number of intensive care days utilized decreased by 88%, Krakauer reported. Patient and family satisfaction also was high.
In an era when quantity of care does not necessarily equate to quality of care, this Aetna program demonstrates how a service innovation can have a remarkable effect on patient satisfaction and reduce unnecessary and unwanted health care utilization.
This kind of programming offers much needed guidance and support to help our patients with cancer navigate our complex health systems and receive care that aligns with their preferences.
Stephanie M. Harman, MD, FACP, is a palliative care physician at Stanford University Medical Center and director of its inpatient palliative care service. Disclosure: Dr. Harman reports no relevant financial disclosures.
For more information:
- Krakauer R. Front Health Serv Manage. 2011;27:43-48.
- Krakauer R. Health Affairs. 2009;28:1357-1359.