Paula Gibson Massey, once an avid hiker, initially resisted signing up for palliative care while fighting lymphoma. Massey Family
Insurers are establishing programs that give the sickest patients the chance to receive extra care for their pain, suffering and emotional needs, in a move that turns out to cut spending substantially.

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Such palliative-care programs aim to provide assistance to patients with chronic or terminal illnesses, and go beyond the drug prescriptions and surgeries such patients typically receive. Under the programs, doctors are often called in to prescribe drugs treating pain, anxiety and depression, while home-care aides visit residences to give baths and change sheets. Social workers may try to resolve conflicts between estranged siblings.
The programs have their critics, who say the insurers' real goal is to bolster profits by pushing patients to forgo costly treatments that could prolong their lives. But supporters counter that the lowered costs are simply a fortunate side effect, and that fulfilling patients' wishes and needs is the main goal.
"By improving quality of care for that group, it can also reduce the number of repeat hospitalizations and other emergency interventions, which is extremely expensive for payers," says Emily Warner, a senior policy analyst at the Center to Advance Palliative Care at the Icahn School of Medicine at Mount Sinai.
More to Come
In recent years, insurers including UnitedHealth Group's Optum unit and Highmark Inc. have created such programs—a trend that is likely to continue as the population ages and efforts are made to both cut costs and improve care for patients at the end of their lives.
Studies show that treatment of the most complex patients during their final months accounts for a disproportionate amount of health-care spending. About 25% of Medicare costs cover the last year of patients' lives, while 80% of the government health program's spending during the last month is for hospitalization. A visit to an intensive-care unit alone can cost more than $4,000 a day.
Evidence suggests that the palliative-care programs can make a major dent in those costs. Studies by Kaiser Permanente, for instance, found that such programs can save $5,000 to $7,000 a patient by preventing costly trips to emergency rooms and avoidable readmissions to hospitals. AetnaInc. says it saved $55 million in 2012 among its Medicare Advantage patients.
"If there is an opportunity to impact at the intersection of quality and cost, this is the mother lode," says Randall Krakauer, Aetna's director of medical strategy, who helped establish his company's program.
Typical candidates for palliative care include patients suffering from congestive heart failure, chronic obstructive pulmonary disease and dementia. Many participants have cancer, typically at an advanced stage. Dedicated teams of doctors, nurses, chaplains and social workers step in to interview the patients to assess their needs and develop a plan for their extra care.
Team Effort
Often team members sit in on meetings between patients and their doctors, help explain medical conditions, and help the patients and families reach decisions about the course of treatment. A palliative-care team might also help coordinate a patient's treatment among different doctors.
Many programs offer help drawing up wills and do-not-resuscitate orders. Such orders let doctors and nurses know the patient wants to forgo cardiopulmonary resuscitation, being put on a ventilator and other measures if there is a low chance for recovery. Sometimes, the patients get care in hospices or from visiting hospice nurses for their pain, suffering and emotional needs but give up aggressive medical treatment.
During the 2009-10 health-care-overhaul debate, a proposal to pay doctors for providing counseling about end-of-life services drew fire from some Republicans about "death panels" determining care.
But Thomas Smith, director of the Johns Hopkins Palliative Care Program, points to studies that show patients in such programs do better on quality measures like hospital readmission rates than people who don't elect palliative care. Patient satisfaction levels improve as well. Dr. Smith also cites studies showing members who receive these benefits live as long as or longer than those who aren't participants.
Aetna, which first tried palliative care in 2004, now offers it to anyone with medical coverage in both its commercial and Medicare plans.
In 2012, the company saved an average of $12,600 for each patient who chose to participate, while improving the quality of and satisfaction with their care, Dr. Krakauer says. Aetna bases its data on hospital admissions, survival rates and other data about medical treatment, as well as surveys of patients and their families.
About 90% of eligible members choose to participate, Dr. Krakauer says. And members don't have to give up aggressive treatment in order to participate, though Dr. Krakauer says some ultimately do so. Medicare requires it for patients electing to receive hospice care.
"We will not steer them toward a decision," adds Dr. Krakauer. "If they want the maximum aggressive therapy to the last, we will support them."
To identify members who might be candidates, Aetna uses algorithms to sift through billing and other records. Doctors and nurses also make referrals.
Tough Decisions
Then case managers like Margaret Warnock call the patients. Case managers ask questions to see what the patient's wishes and needs are and whether they might be eligible. They explain what participation would mean.
The decision can be difficult for members like Paula Gibson Massey, an avid hiker and yoga student from Sylvania, Ohio, who died at age 51 after battling cancer.
Mrs. Massey was diagnosed with lymphoma in 2007, and chemotherapy and other treatments progressively lost effectiveness, recalls her husband, Stan Massey. By early 2013, the cancer had spread to Mrs. Massey's spine, causing fractures in her lower back. She was prescribed narcotics for the pain and physical assistance to help her move.
Mrs. Warnock says she spoke with Mrs. Massey about this time, explained the benefits available under her plan and concluded she would be a good candidate for Aetna's palliative-care program. Mrs. Warnock says she explained that Mrs. Massey could receive the program's benefits while continuing with treatment aiming to cure her. But Mrs. Massey didn't want to go on the program.
"She felt it meant admitting she was dying," recalls Mr. Massey, 56, who works in marketing public relations in the Toledo, Ohio, area, including representing hospices and health-care systems.
Mr. Massey says at first he ignored Aetna's calls. The idea appealed to him that his wife could stick with aggressive treatment of her cancer and receive regular visits from hospice nurses who would adjust her medicines, manage her pain and provide other care. Still, he respected his wife's wishes.
Mrs. Warnock stayed in touch. Then, last March, Mrs. Massey's cancer doctor said she probably wouldn't live another 12 months. Later that month, Mrs. Massey signed up for Aetna's program and agreed to start receiving palliative care in her home, Mr. Massey says.
A day later, she suffered a pulmonary embolism. Although she was taken to an emergency room, she had indicated through Aetna's program that she wanted to forgo treatment if her condition was hopeless, and she confirmed her choice with an emergency doctor at the hospital, her husband recalls.
After 90 minutes at the hospital, Mrs. Massey was taken to a hospice center, where she passed away about 36 hours later.
Mr. Rockoff is a staff reporter for The Wall Street Journal in New York. He can be reached at jonathan.rockoff@wsj.com.