Promoting Excellence : New End-of-Life Benefits Models in Blue Cross & Blue Shield Plans : HealthNow, New York

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HealthNow, New York
Buffalo, New York

Support Blue

Cheryl Howe
Sr. Vice-President of Health Services Management
(716) 887-8402
[email protected]

"These are patients who have life-limiting illness. The program helps move them along the continuum so they get all the help they need. One of the unanticipated benefits of the program was that we had patients who got better. Through education, delivery of services, family care . . . the patient was bombarded with in-home services. They gained an understanding of how to keep their disease under control, and when their health improved, we discharged them from the program."

— Cheryl Howe

Program Mission/Objectives
The program’s mission is to be responsive to the needs of the patients who have chronic life-limiting illness. The objectives are:

Program Description
Chronically ill patients frequently receive treatment at home, and a family member is usually the primary caregiver. Blue Cross Blue Shield of Western New York wanted to be responsive to the needs of these patients, wanted to provide the best services possible, while at the same time wanted to keep these patients out of the hospital whenever possible.

Support Blue is a unique program that packages together services for both a chronically ill patient and their primary caregiver. The program’s plan of attack is to educate customers to learn to control their disease in order to have a good quality of life, even with chronic illness.

Support Blue begins with a patient assessment. Once the needs of the patient have been defined, providers deliver services to both the patient and the caregiver. A case manager coordinates services and acts as facilitator for communication among the involved parties. These services include medical, psychosocial, and spiritual help, as they are needed.

Medical services offered in this program include:

Other provided services include:

The program, designed to be intermittent care, is not limited to adults. It is available to all managed care members, inclusive of Medicaid and Medicare risk. The hospice benefit is consistent across the lines of business with the six-month/210-day standard benefit. Hospice determines which setting the patient requires, whereas case management is available for situations that require extension of benefits.

Support Blue is designed to serve the patient population that is not yet ready for hospice. For example, if the patient and physician agree on continuing aggressive treatment for the illness, if the patient is younger than 65, and significant psychosocial issues exist, Support Blue is available. One goal of the program is to transition patients to hospice as their illness progresses. When that happens, Medicare or Medicaid benefits are initiated.

Historical Perspective
As is so often the case, Cheryl Howe’s interest in this issue was engaged when her mother went through the painful difficulties of providing care for her father’s chronic illness. She said, "Mother struggled with caring for my father, who had congestive heart failure. It brought these issues to me first hand." Initially, the idea was to identify gaps in care for patients with life-limiting illness, including diagnosis and treatment options.

The collaborative discussion began with the Center for Hospice and Palliative Care. Blue Cross Blue Shield of Western New York partnered with Hospice because that organization is the final care provider to chronically ill patients.

Early champions of the program, along with Howe, were Don Schumacher, the CEO of Hospice, and Bill Finn, Executive Vice President and COO of Hospice. These high profile people, with help from many others, implemented the program.

Among the obstacles they face in extending Support Blue to more patients is the fact that physicians are not always easily accessible or always receptive to education about other modes of care. Understandably, physicians need to be convinced that this effort does not result in more work for them. Another consideration is that the average age of this managed care population is 46 years old. For this age group, neither patient nor physician is willing to concede to palliative care. Generally, the physician continues aggressive treatment for longer than they would with a patient of the elderly population. Hence, end-of-life costs are much higher.

Historically, Howe says, the physicians’ comfort level is with patients dying in a hospital setting, if they are comfortable with death at all. The staff of Support Blue is concentrating on educating physicians, including offering and encouraging CME programs. Staff education to home health nurses, who are extremely supportive of the program, and liaison with the largest cancer center where they work with oncology staff, are two initiatives being undertaken by Support Blue.

One of the original objectives was to help place patients in hospice earlier. Most often, Howe reports, physicians do not put patients into hospice until a week or two before their death, thereby depriving them of the opportunity for a good quality of end of life. The people responsible for this program hope after Support Blue care, patients will have an easy transition to hospice. Although they are trying to reduce the number of inpatient ad-missions, they also want to create patient satisfaction. This program differs by the provision of support for the caretaker as well as the patient.

Patients are transitioned out of the program when they enter Hospice, expire or change insurance coverage. Since the program’s inception, 45 percent of the total enrollment in Support Blue has been transitioned to hospice, vs. 17 percent of the general non-participating population.

Support Blue is gathering facts and looking at statistics for the effectiveness of their program. Patient and family satisfaction is 100 percent as measured by satisfaction surveys.

Although there is no formal education component to the program, education of physicians, staff, and community are priorities that need to be addressed. One of the program objectives is to enhance physician education and awareness of critical end-of-life issues. This ongoing endeavor includes offering and encouraging CME programs.


The marketing effort for Support Blue has included a brochure, both member and provider newsletters, newspaper articles, and the intranet for employees. Internet information is in the design stages.

An effort at community education was served through the media with support for Bill Moyers’ series "On Our Own Terms: Moyers On Dying." The company is working on an individual physician marketing plan.

A full-time case manager devoted solely to the program works in each market with the purpose of selling and promoting Support Blue. Publicity also comes from participation in a national study.

Early intervention equates to cost effective end-of-life care by reducing ER visits and hospital admissions; therefore, the company sees the program as financially positive.

The people involved with Support Blue hope to be able to expand the program to include Skilled Nursing Facility palliative care—care for patients unable to stay at home. Next year they hope to be able to expand to an indemnity. They want to continue to expand the numbers of people who receive this benefit at the chronic illness stage of disease before they reach the need for hospice care. Howe allows that they are trying to move patients along the continuum of care so they will receive all the help they need. "Anything we can do to forward that process is a success for us, and a benefit for them."

She thinks it is a selfish distinction to think Support Blue is the only program in the nation that is working to this extent, but she would like to see this care supported across the nation. The formal extension of services to caregivers is unique.

Key Elements of Success

Measures of Program Success

Necessary Steps

Within the next year, Support Blue will measure cost-effectiveness by using Dan Tobin’s Faircare Study methodology.

What I Wish I ’d Known ...
"At the HMO they have a mental health carve out benefit. One of the key components of Support Blue was the mental health benefit."

This descriptive summary is based on an interview by Susan Butler with Cheryl Howe, June 15, 2001.

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Promoting Excellence in End of-Life Care is a National Program Office of The Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

Promoting Excellence