In 2008 alone, CMS spent approximately $55 billion on physician visits and hospital bills on patients’ last two months of life.1 Other estimates show that nearly 1/4 of all Medicare expenditures occur in the last year of life.2 Why does LaCrosse, WI have the lowest end-of-life healthcare costs in the country? 96 percent of its residents have advance care directives compared to 30 percent nationally, which drastically reduces the amount spent on end-of-life care.3
An advance care directive tells doctors what care you agree to in the event you are not able to speak for yourself due to injury or illness. Patients should be motivated to complete advance directives so they are more likely to receive the care they want at the end of their lives, but most don’t. Without such directives on file, family members can agonize over a patient’s suffering as doctors perform sometimes heroic (and wildly expensive) surgeries to keep them alive, but which turn out to do very little in terms of improving the patient’s condition and quality of life.4
Currently, the vast majority of the public has been left in the dark about what an advance directive is. Further, advance directives are a taboo topic because it is difficult to discuss dying with loved ones and partly because of politicized misnomers such as “death panels”. Helping patients understand advance directives and letting them decide to create one or not empowers patients to make better decisions, and as such, receive better care. Not only does it improve care for patients, payers stand to benefit from a more informed public.
It should be normal and commonplace to talk about death. Public outreach efforts, such as those in Lacrosse, WI are needed to educate people on their options for end-of-life care. A Philadelphia-based design firm, The Action Mill, recently created a card game called “My Gift of Grace” which facilitates discussion about end-of-life care in a non-threatening way. The game was created after interviewing a hospice nurse who stated, unequivocally, “The most important thing you could do to make my job easier would be if you made sure that every patient who walks through the door has had one conversation about the end of their life with their family – just one.’”5
There are also ways providers can make the process of dying less scary. Just as a midwife plans a birth plan, doctors can midwife death. As Dr. Jessica Nutik Zitter argues in a recent New York Times article, we need a “code death” as much as we need a code blue.6 After all, death was an expected and natural process up until the early 20th century when technology and advancing medicine prolonged the inevitable.
Major health plans and/or their foundations should form a consortium to fund a national campaign to inform and educate the public on four aspects of end-of-life directives:
- What is an advance directive?7
- How does one complete an advance directive to make it an active legal document?
- What are the implications of my care selections?
- How does one cancel or change an advance directive?
Because no single payer would want to fund this public service announcement (PSA) individually as competitors would reap the benefits at their expense, a consortium of providers investing together either directly or through their foundations to share costs equally is the best approach to creating this public good. This is not without precedent. ResMed and Phillips Respironics are competitors in the area of sleep disordered breathing devices, and yet they collaborate to fund CME courses to educate physicians on sleep apnea treatment.8These companies indirectly benefit because these companies know that physicians better trained in detecting and treating sleep apnea will increase the number of people diagnosed or improve compliance among current sleep apnea patients, both of which lead to increased use of CPAP devices. Other potential funders for an advance directive PSA campaign that would likely have a financial interest include nolo.com and legalzoom.com which already combine advance directives in their living will products.
Payers have historically focused on leveraging utilization management and nurse coaches to talk with patients about end-of-life care, but at that point it is too late in the game to reach a wide swath of patients at scale. Fortunately, there are other avenues that can fill the gap on the front end of this awareness problem. One example is PREPARE, a free service which walks patients through what an advance directive is and how to create one. This site is cleverly designed to suit individuals from all walks of life. PREPARE has designed the site for a 5th grade reading level, uses large font for the visually impaired, and people who are not web savvy can simply watch a video.9
Another way payers can reduce costs is by encouraging providers to incorporate advance directive alerts into their EHR systems, so any advance directive is not missed when making decisions on types of end-of-life care. A recent study by Mass General Hospital Cancer Center showed only 33.7% of patients had their end-of-life status included in their EHR.10 That bar can certainly be raised.
In summary, payers can play a vital role in improving care and reducing cost by encouraging the use of advance directive alerts in EHR, and most importantly, forming a consortium to launch a national PSA on advance directives. In the end, this good will gesture would be returned many times over in savings to payers, which could be in the billions of dollars. The market is looking for an integrator to curb costs before baby boomers reach end-of-life care. Just as Steve Jobs famously corralled the music industry executives to agree to licensing music to iTunes, payer executives need to coordinate an effort to educate the public on advance directives. Who is going to take the lead?