their prognosis and the full range of care options, including early
palliative care, leads many patients to acquiesce to more aggressive care without fully understanding its impact on the length
and quality of life.” In other words, a lack of communication and
information often results in patients merely going along with
treatments they don’t want (and that may have no proven benefit).
In an effort to explore the effect of targeted care management
(including patient education and support) at the end of life, Aetna
in 2004 implemented its Compassionate Care program. Under
this program, certain members in Aetna’s commercially insured
population, as well as some of its Medicare Advantage members,
require a change in the culture of their practice.
were eligible to receive assistance with medications, education,
and support, as well as help with advanced directives. The support
continued even after a patient chose to enter hospice. Standard
Medicare hospice benefit requirements were applicable in the
standard Aetna program: Participants were required to have a ter-
minal illness with a life expectancy of less than six months, and
they needed to agree to forgo any additional curative treatment for
the disease. Under an enhanced program, a select group of Aetna’s
commercially insured members could continue to receive cura-
tive treatments if they had a life expectancy of less than one year.
Along with a significant increase in enrollment in hospice
care for Aetna’s enhanced program, the enrolled population
experienced a decrease in the use of emergency services and
intensive care compared to a standard group. And costs went
down by 22 percent. At the same time, surveys of enrollees and
family members indicated a high satisfaction rate with the care
management received. Aetna’s leaders concluded that having
knowledgeable experts talk to patients about their needs and
providing information on their options at each step was enough
to increase satisfaction and reduce the use of intensive services.
the profession can help move
the debate beyond heated and
misleading political rhetoric
and toward improving individual
well-being at the end of life .
HEATHER JERBI is the Academy’s senior health policy analyst
(federal). She wrote about the passage of health care reform
legislation in the July/August 2010 issue of Contingencies.
This article is solely the opinion of its author. It does not express the official
policy of the American Academy of Actuaries; nor does it necessarily reflect
the opinions of the Academy’s individual officers, members, or staff.
Changing the Culture
So if there’s evidence to support the notion that people with appropriate education are more likely to consider the implications
of—and potentially forgo—expensive, aggressive care at the end
of life, why then aren’t they getting that information? Some experts suggest that it may be because the incentives in Medicare
encourage overtreatment: Additional tests and treatments often
are more profitable for providers than taking the time to explain
the palliative care options to their patients.
Another reason may be that providers aren’t adequately trained
to counsel patients. Medical training encourages employing whatever means available to heal and cure a patient. For some doctors,
taking the time to talk with their patients about their options may
Brownlee, Shannon, et al., “Improving Patient Decision-Making in Health
Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota,” the
Dartmouth Institute for Health Policy & Clinical Practice, February 2011.
Goodman, David, et al., “Quality of End-of-Life Cancer Care for Medicare
Beneficiaries,” the Dartmouth Institute for Health Policy & Clinical
Practice, November 2010. http://www.dartmouthatlas.org/downloads/
reports/Cancer_report_ 11_ 16_ 10.pdf
Krakauer, Randall, et al., “Opportunities to Improve the Quality of Care
for Advanced Illness.” Health Affairs (28: 5, 2009).
POLST State Programs, Center for Ethics in Health Care, Oregon Health
& Science University. 2008. http://www.ohsu.edu/polst/programs/