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

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INSTITUTION
Premera Blue Cross
Seattle, Washington

PROGRAM
Pediatric Palliative Care Project

DIRECTOR
Kim Boggess, RN, CCM Peter West, MD, MPH
Premera Liaison for the Project Medical Director of Premera
(425) 670-4442 x6141 (425) 670-4760
[email protected]

"It’s a matter of getting all the stakeholders to understand the issues and objectives and play a flexible role in making that happen. If you get people on the same page, you can get an awful lot done with existing resources."

— Peter West, MD, MPH

Program Mission/Objectives
At Premera, the mission of joining the Pediatric Palliative Care Project (PPCP) was to improve service to members of the health plan. Specific objectives were:

Program Description
The purpose of Premera’s participation in PPCP is to help give families of critically ill children an early entrance to hospice care before they would normally access those services. Seventeen Premera policyholders have enrolled in the Project. Premera has helped these families by creatively using the home health benefits provided by the company, and by promoting active case management.

To provide services, Premera uses a comprehensive Decision Making Tool (DMT). The DMT helps providers, the family, the patient, and Blue Cross coordinate the patient’s care and support services. It provides a format to create discussion about all aspects of a patient’s care, including medical indications and options for treatment, family preferences for care provision, and treatment course elected with end-of-life considerations. Quality of life is considered, including activities and relationships that are important for the patient and family to maintain, and contextual background, including family history, home environment, cultural and spiritual issues, and financial and insurance facts. The tool gives equal weight in discussion to each of these four main areas of the plan. Those present at the update, including the physician, then sign the plan, and it is forwarded to all members of the health care team.

Premera acts as a facilitator in that endeavor, addressing such things as how to adjust appropriate goals, how to extend hospice benefits over a longer period of time, and how to deal with issues creatively as they appear. Case management is the key to coordination and to the flexibility that is needed to concentrate services on the issues at hand. The focus of a case manager helps make the most appropriate use of all available benefits.

Any child with life threatening illness who is covered by Premera is eligible for this program, as all plans have hospice benefits. The program covers medical services, home health care, durable medical equipment, rehabilitation, hospice, and pharmacy. Service is limited only by the patient’s policy and the medical circumstances.

For delivery of services, hospice-trained nurses are involved in home health visits, so that families receive some of the hospice philosophy before they are even enrolled. "The trick," says Peter West, MD, MPH, Medical Director of Premera, "is getting ahead or in advance of the need for care." Jane Stewart, RN, MSN, CM adds: "We are helping parents to see the need for hospice sooner rather than later. This program gives both parent and child a voice."

Premera has tried to build in what they call "reasoned flexibility" as they assess the medical management of a case. "We can provide that," Kim Boggess, RN, CCM explained. "When a child comes into our scope of range, we work with the physician and the home health nurse to develop the best course for the patient. Together, we have the perspective on what will work." Boggess tries to put the payment mechanism together with the needs of the patient. "We’ve had aggressive leadership on this, trying to provide the best member service."

Premera’s case management capacity serves many populations. They have a low volume of patients who are enrolled in the project. They say they have worked hard to demonstrate to their actuaries and accountants that this would be a cost effective way to provide service.

Historical Perspective
"In hospice services and in care for the dying there are a number of great people," noted Boggess. The project began under the leadership of two physicians at Children’s Hospital and Regional Medical Center, J. Russell Geyer, MD, and Ross Hays, MD. Peter West, MD, MPH believes those two physicians also provided the inspiration and motivation for the program. The physicians at the Center for Children with Special Needs at Children’s Hospital were supportive of PPCP from its initiation. At Premera, West has been the champion. Gerri Haynes, RN, the co-manager of the project, has worked in hospice for over a decade. Boggess, currently the Premera liaison for PPCP, has in the past served as Premera’s on-site utilization review nurse for Children’s Hospital and the Premera primary Pediatric Case Manager. The accumulated expertise is impressive.

Each has brought something different to the program. Haynes has strong community background in hospice care. Boggess thinks Haynes has an affinity for knowing how people need help when they’re dying, and an innate ability to listen. West notes that with PPCP, "This was an area where, appropriately, Children’s Hospital could do good and do well at the same time. Because of Kim’s good work at the hospital, it helped move Premera forward to pick up this work. There was already a relationship there which helped move us forward."

At Premera, they have faced the internal challenge of working a process while they’re operating outside of the routine flow of business. Challenges exist in the community as well. Some families are still resistant to having the insurer be in a decision-making role. The solution to that problem has been aided by the fact that this is a collaborative project. Consumers understand that decisions aren’t arbitrary. West notes that here the insurer is functioning as a member of the team, rather than the leader of the team.

Research
The Pediatric Palliative Care Project has its own measurement tools to gather information about patient satisfaction with care from all levels, including baseline and follow-up measures.

Premera is tracking issues of quality (member satisfaction per their case management policies), and cost (assessing cost analysis). Member satisfaction includes surveying case-managed members at set periods about their regard for Premera case management services. Cost analysis includes monthly and decision specific cost comparisons to possible/probable course of treatment without intervention.

Partnerships

Marketing
Premera hasn’t really marketed their participation in the Project, but has tried to keep marketing in the forefront of their medical staff ’s agenda. They viewed PPCP as a pilot program for a good way to treat their policyholders. They are trying to provide a better quality of care.

Funding
Funding for the PPCP came from a Robert Wood Johnson Foundation grant through the Promoting Excellence in End-of-Life Care program.

Vision
Premera is gaining experience with this program, but as Kim Boggess notes, "At some point, this kind of service ought to be built into a physician’s expectations." Premera wants to learn expertise in providing these services.

Key Elements of Success

Measures of Program Success
Kim Boggess recounts "One of my parents, whose child has a chronic disease with severe acute exacerbations, said that before they became involved with the Project, they didn’t know that someone was available at their health plan to assist them in pursuing appropriate care for their child. They’d been trying to get certain services in the provider community, unrelated to whether Premera would pay or not, and they felt they just could not get in the right door to get the support they needed. Their initial conversations with Premera were overwhelmingly intense. But as care for their child increased, our discussions became less of an ‘event’ and more of a collaborative effort about the next course of action. Even the parent could tell that their negative tone and approach had changed. They indicated they would never have come to that place without the Project."

Necessary Steps
For the program to continue, it is necessary to put this mode of cooperation and care out there in front of consumers and providers. "The health plan itself has to seek this kind of engagement," Boggess said.

Beyond that, this is a new role for Premera. Getting operations to be able to respond to creative policy applications has taken work. As an organization, Premera has taken on roles to facilitate communication, to help families understand what might be useful to them, and to facilitate the decision-making process in a timely manner. There’s a capacity external to the insurer to aid that process, but Premera is about to cross that barrier, because staff involved in the Project have been offering those services to both providers and families.

Case finding has been a challenge. "It is not as easy as it should be. We have tried to broaden other resources to find the cases. We’ve beaten the bushes with the doctors, and it has become easier as the physicians have become more familiar with the program," says West. Still, educating the provider community about the project will result in offering this program to more children in need of services.

What I Wish I ’d Known ...
"Our major competitor is Regence, and we’ve been participating collaboratively. Each plan uses its own business systems. We’re doing it on behalf of the most needy group, and we’ve been able to do it so smoothly," says West.

This descriptive summary is based on an interview conducted by Susan Butler with Kim Boggess, RN, CCM; Jane Ramenofsky Stewart, RN, MSN, CM, and Peter West, MD, MPH, June 14, 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 PromotingExcellence.org for more resources.

Promoting Excellence