Promoting Excellence : New End-of-Life Benefits Models in Blue Cross & Blue Shield Plans : Hawaii Medical Services Association (HMSA)

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Hawaii Medical Services Association (HMSA)
Honolulu, Hawaii

The HMSA Foundation, sponsor of Kokua Mau
A collaborative effort

Jim Walsh
Vice President of Provider Services
(808) 948-6100
[email protected]

"Providers all want more money. HMSA is more inclined to address that issue since hospice is a cost-saving program. The fact that it saves us money gives us a greater opportunity to look at increases in the program."

— Jim Walsh

"An aspect that fosters hospice support in Hawaii is the native concept of extended family. The Hawaiian word is Ohana."

— Marv Hanson, Provider Service
Sr. Contracting Officer for Hospice

Program Mission/Objectives
The mission of Kokua Mau is to improve end-of-life care in Hawaii through:

Program Description
Kokua Mau, an ongoing partnership of individuals, community organizations, and public and private leaders of health care and government, seeks to improve end-of-life care in the state of Hawaii. Hawaii Medical Service Association (HMSA) has taken a leading role in Kokua Mau, working alongside the Executive Office on Aging, Hospice Hawaii, St. Francis Hospital, and the University of Hawaii Center on Aging.

Kokua Mau has worked on many initiatives. The HMSA Foundation has funded grants for three of these initiatives. Most recently, while discussing potential entry points to hospice service, Kokua Mau identified the clergy and churches as a population closely in touch with people in need. Realizing that they might not be aware of services available, HMSA sponsored a grant to train clergy around the state to minister to and facilitate program entry of persons in need of hospice care. The next initiative that has been funded by HMSA will be to train providers of long-term care. Kokua Mau provides the trainers who make the presentations.

Historical Perspective
Teachers and social workers began HMSA, so it comes naturally to its commitment to community work. The Board of Directors established the HMSA Foundation in 1996 as a way to repay the community for their support of the company, the dominant health plan in Hawaii.

In 1996, the hospice community approached HMSA to collaborate through a research project to assist families of hospice. Fifteen patients were in the original study, and fourteen of those transitioned to hospice. The patient outcomes showed that all fourteen had increased quality of life. Cost savings were substantial as well.

In 1997, the Governor appointed a blue ribbon panel, asking them to look at issues of death and dying toward improving the quality of care being offered. As a result of that panel, the recommendation was made that hospice care be made more available and offered more expediently to the dying. Because of the nature of the Islands, the high level of collegiality and collaboration is not a new thing to the state. Kokua Mau was born out of the interest of HMSA and other entities that worked on the blue ribbon panel. Initially Kokua Mau was funded by a grant from The Robert Wood Johnson Foundation through Community-State Partnerships to Improve End-of-Life Care. It has since been able to secure other grants to continue its activities. Jim Walsh says the budget and leadership of the partnership is truly shared, so if one of the major partners were to disappear, one of the others would "pick up the ball and go with it." The "volunteers" of Kokua Mau come from the participating agencies, and work collaboratively in a partnership to accomplish the objectives, making this management model somewhat unique.

HMSA has worked with the various partners of Kokua Mau on different initiatives over the years. They participate in community forums, they’ve funded some of their grant proposals, and as unusual as it might seem, they testified with them in favor of the 1999 Hospice Reimbursement Act. HMSA normally opposes mandated benefits, but in this instance they felt an exception should be made. HMSA plans to remain involved in the initiative. Along with their other activities, they print brochures, share some of their advertising spots, and they are creating a Web site for advance directives, with registration for members and access for providers.

Jim Walsh believes that the real champions of these efforts in Hawaii were Mitsuo Aoki, D.D., a professor of religion at the University of Hawaii, and Sister Maureen Kelleher. Aoki had an early interest in issues of death and dying, and along with Kelleher, he pioneered hospice in the state. The two of them were, and are, held in high regard. "They have touched a lot of people in their professional and everyday lives. They weren’t publicity seekers; they were the opposite of self-aggrandizing. People listened when they talked and they were able to pull groups together. They wound up forming a collaboration of the unions, the clergy, providers, social workers, almost everyone with an interest in hospice care. Also, Dr. Aoki is a native Hawaiian, and if Sister Maureen wasn’t native to the Islands, she had lived and worked there for a long time. They had the credibility of long-timers."

The legislature in 1999 passed a law requiring all health plans to pay at least the Medicare level of per diems. These legislative edicts helped to make the public aware of hospice and the programs that HMSA already had in place. All hospice programs participate with HMSA with all lines of business.

The hospice benefit provided by HMSA has two unique components. HMSA will pay for residential services and for one referral visit to a potential hospice patient. They will reimburse the nurse or caregiver to meet with a family or patient. Walsh said that in a sense it is a sales visit. This makes it worthwhile for hospice providers to talk to families, "which they would do anyway, but it validates their services." This benefit introduces people earlier to the potential of hospice care.

The initial hospice study showed that clinical outcomes were:

Although HMSA is in the process of gathering data, they have enough now to know that they want to continue developing and promoting hospice. Both customer and provider responses are positive for the program, and the program has proven to be cost saving rather than cost neutral.

One thing they are looking at is whether hospice participation differs by ethnic group. Because Hawaii is culturally such a complex society, this is a perfect venue to explore this issue. They are currently surveying the community to identify end-of-life issues, and they’re sharing the surveys from their Senior Living Program participants.

Education is one of the main focuses of Kokua Mau. They believe that hospice care is in everyone’s best interest, and part of their mission is to make everyone aware of the program.


Hospice Hawaii presents community service ads on both radio and television. The hospital has sponsored both for hospice.

Kokua Mau, as described earlier, is upheld by grants.

For HMSA, providing education to the community regarding matters of death and dying is a collaborative effort with all community stakeholders involved. Walsh believes that resources for end-of-life care will not be expanding, so "we need to do more with what we have. Well run and caring hospice programs provide an answer." He reflects, "You need the champions, the key public well-respected figures to be out in the community, promoting the program."

Key Elements of Success

Measures of Program Success

Necessary Steps
Jim Walsh summed it up in one word: Commitment. "I think everybody has the resources to provide quality care. I think everyone has the opportunity to do this. I think they just have to believe in it, and that goes back to the issue of education about it."

"Of course," he continued, "there are obstacles to acceptance of the program. Many physicians struggle with their training, which taught them to keep people alive. That often makes it difficult for them to refer their patients early enough to a hospice program. It’s necessary to be sensitive to their desire to want to save their patients. And families have problems with letting people die. That is cross-cultural." Kokua Mau is working to overcome these obstacles.

What I Wish I ’d Known ...
Jim Walsh, a former clinic administrator, has been at HMSA for three and a half years. "I came along after the hospice benefit was already going. I’m probably now the in-house champion of it. Getting involved on the Board as a hospice provider brought me along. The one thing that all the plans don’t do, we don’t go out and involve providers to get their input as much as we should. We need input from providers."

This descriptive summary is based on an interview conducted by Susan Butler with Jim Walsh and Marv Hanson, June 15, 2001.

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Promoting Excellence in End-of-Life Care was a national program 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.

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