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

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INSTITUTION
Blue Cross Blue Shield of North Dakota
Fargo, North Dakota

PROGRAM
Blue Cross Blue Shield Hospice
Matters of Life and Death Coalition (MOLD), A State End-of-Life Coalition

DIRECTORS
Jon Rice, MD
Managed Care Medical Director
(701) 282-1048
[email protected]

Mike Hamerlik
Sr. Vice President of Corporate Services
(701) 282-1868
[email protected]

"Death is a touchy subject, especially in this culture. We try to step delicately. In North Dakota it’s a societal issue, and it’s hard to address. This is Lake Woebegone Country."

                                     — Dan Ulmer

Program Mission/Objectives
The mission and objectives of hospice are well known, which is why Blue Cross Blue Shield of North Dakota is pleased to be a part of the Matters Of Life and Death Coalition (MOLD). Mike Hamerlik said, "It is not our primary mission to ‘save money’ through the activities of MOLD, but more thoughtful and better use of resources is a goal."

Program Description & Historical Perspective
The hospice benefit of Blue Cross Blue Shield of North Dakota goes back more than eleven years. It began, Hamerlik said, in a reactive way, as an offshoot of Medicare. The hospice benefit parallels the Medicare qualifications. Any person diagnosed with terminal illness, with a life expectancy of six months or less, who is a member of any plan, or is self-insured may use the benefit. The hospice benefit covers all services related to terminal diagnosis. Blue Cross pays a per diem to the hospice unit for home care, hospice, or respite care. There are no maximums in the program and no dollar limits; however, families are responsible for whatever their policy requires. Jon Rice, MD notes that usually people who get into the hospice program have consumed their deductibles. The hospice benefit is included in all policies, and all levels of care are available within that benefit.

Authorization for a patient to enter a hospice program is required through the case management division. A case manager, a nurse, is assigned to work with the family, hospice, Blue Cross and physicians to make sure patient needs are being met.

Blue Cross Blue Shield of North Dakota joined the MOLD coalition, a group of over fifty organizations in North Dakota "committed to improving care given to the dying and their families." The collaborative project is working to develop professional and community educational opportunities, and to identify a continuum of end-of-life care for the people of North Dakota.

The Matters of Life and Death Project began in 1998, when representatives from a broad spectrum of health and social service agencies joined with other interested organizations and individuals to seek ways to improve the quality of life for North Dakota residents.

The coalition is working to find ways to address four key areas of end-of-life care: professional education; continuum of services, access, and finance; public education; and advance care planning. Expertise is drawn from throughout the community to look creatively at ways of addressing these issues.

Education
The MOLD coalition is working to enhance curricula and provide educational materials for both professionals and students entering fields of health care delivery. In this way they hope to more effectively address end-of-life issues, and increase community awareness of  existing resources. Their effort extends to public education through forums, panels, and discussions. One hope is that with education, physicians will be encouraged to enroll patients in hospice earlier, so that they will have a better quality to their end of life.

Partnerships
The MOLD coalition is a broad partnership of representatives of organizations, both public and private, including:

Dan Ulmer, Assistant Vice President of Government Relations, and Jon Rice, Managed Care Medical Director represent Blue Cross Blue Shield in the coalition. Because of their history of delivery of care in hospice, Blue Cross Blue Shield of North Dakota is enthusiastic about joining in the work of the MOLD coalition.

Funding
The MOLD coalition is funded through grants from The Robert Wood Johnson Foundation, and the Dakota Medical Association.

Vision
The hope for the Matters of Life and Death coalition is that it will ignite and maintain an interest in finding ways to address issues of quality of end-of-life care in North Dakota. As Hamerlik said, "the hope is that champions for these issues will come out of the MOLD coalition." Progress may be incremental, but it’s still progress. Ulmer noted that the legislature did not pass a living will law, but they were able to pass a durable power of attorney law. If working on end-of-life care issues is approached on many fronts, educationally, legally, and through delivery of appropriate services, the whole community will benefit.

Key Elements of Success

Measures of Program Success

This descriptive summary is based on an interview conducted by Susan Butler with Mike Hamerlik; Jon Rice, MD; and Dan Ulmer, 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