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Aetna's move is the latest in a mounting effort by hospices, the federal government and insurers to ease the psychological and financial burdens on dying patients. Some hospice programs -- which focus on treating pain and offering emotional support for the terminally ill -- are accepting patients earlier in their diseases and offering additional treatments. Programs also are opening their doors to a wider range of patients. While in the past hospices were almost solely used by elderly cancer patients, they are caring for patients dying of a host of illnesses, including dementia and lung diseases.
For its part, Medicare, the federal health-care program for the elderly, has relaxed its rules in recent years, making it easier for doctors to refer patients to hospice.
While some of these efforts are embryonic, they all seek to address the biggest hurdle to using hospice: the requirement that patients give up so-called curative treatments. To receive hospice care, patients usually have to sign a paper that states that they understand that they likely have less than six months to live and that they are choosing to halt curative measures. With the new approach, the automatic trade-off between choosing to battle on or accepting hospice care isn't quite so stark.
Some hospices are accepting patients even before they have stopped aggressive treatment. Les Cramer, a 77-year-old former researcher from Fairfax, Va., has been battling prostate cancer for 17 years. Last July, after many rounds of treatment, his PSA level (for prostate specific antigen), a marker of the virulence of the disease, skyrocketed. His doctor, Richard Binder, started him on an experimental treatment, a round of chemotherapy with the drug Taxotere, a drug more often used in breast cancer. At the same time he enrolled Mr. Cramer in hospice. A hospice nurse visits him weekly and an aide comes to his house twice a week to help him bathe. A doctor prescribes pain medication. The program also has sent over a hospital bed and wheelchair to make it easier for Mr. Cramer to move around.
Even though the hospice isn't paying for the chemotherapy, Mr. Cramer traditionally would have had to wait until he completed treatment before being admitted. As part of its effort to reach more people, Capital Hospice, a program with about 600 patients in the Washington, D.C., area, accepted him right away. After suffering serious side effects, Mr. Cramer recently decided to discontinue the chemotherapy. He isn't ruling out future treatments. "I may yet go back to some kind of therapy if Dr. Binder recommends it," Mr. Cramer says.
While part of the interest in hospice is the growing realization that it is often the most comfortable, dignified way for people to die, there is another force at play: Money. Such care can save insurers a lot of dollars. An average day in the hospital costs $7,353, according to the American Hospital Association. By contrast, insurers pay hospice programs about $120 a day per patient for most care.
The reward for choosing hospice is that patients and their caregivers receive a cornucopia of benefits. These include everything from house calls from doctors and nurses and visits from home-health aides to help with bathing and housekeeping, spiritual support from chaplains and social workers, and massage and physical therapy.
In the past 10 years, the number of people enrolled in hospice programs more than tripled, surging to 885,000 in 2002 from 246,000 in 1992, according to the National Hospice and Palliative Care Organization, a nonprofit in Alexandria, Va.
Despite the expanded approach, doctors still don't often refer patients to hospice until they are near death. Almost 35 percent of hospice patients die within a week of their entry into a program. "It is just hard for doctors to tell their patients that they think they are going to die," says Janet Abrahm, an oncologist and associate professor of medicine at Harvard Medical School.
Aetna is seeking to address the reticence of patients, their families and doctors to choose hospice. It will allow patients to enter into hospice while simultaneously undergoing aggressive treatments that still aim to cure the disease. Patients can continue to fight their illness, but still get the home nursing, spiritual counseling and other support services that hospice offers. Under Aetna's current program, patients have to choose between hospice and aggressive treatment.
"Patients don't switch from hope for a cure to hopeless and dying," says John W. Rowe, chairman and chief executive of the Hartford, Conn., insurer. "This is to offer more choice, offer them an alternative."
The "curative" treatment would be paid for under the patient's regular Aetna medical benefit. So, for example, if a patient had a benefit that paid 80 percent of medical costs, the curative treatment the patient received while in hospice also would be paid at that 80 percent rate. Many hospice services would be paid at 100 percent.
Aetna's new program allows doctors to refer patients to hospice if they have a life expectancy of a year instead of the current six months. The program also will pay for bereavement counseling for the family and so-called respite care, additional help for exhausted caregivers. Kaiser Permanente, an Oakland, Calif., insurer, has offered a small pilot program similar to Aetna's, for about 300 patients in Denver and Hawaii during the past two years.
During the pilot phase of Aetna's program, which will last about a year, the insurer won't charge the companies for the new benefit. It is unclear how many of Aetna's 13 million members ultimately will receive the new benefit, since it depends on how many of their employers are willing to pay extra for it when they eventually do have to cover its costs.
Besides Aetna and Kaiser Permanente, other private insurers are becoming slightly more flexible and are offering to cover certain more aggressive treatments. These aren't new policies. Instead, most extensions of care happen on a patient-by-patient basis. This reflects the increasing power of the insurance company's case managers, usually nurses who coordinate coverage and care of patients with chronic or expensive illnesses.
Michael Chee, spokesman for Blue Cross of California, says case managers often can help patients get better coverage by accessing different portions of their benefits packages. For example, a patient could have additional days of nursing care at home by first maxing out on a separate home-nursing benefit before having to turn to hospice coverage. Cigna Corp., of Philadelphia, will allow patients to enroll in hospice but still covers some expensive medications and therapies under the patient's other benefits.
Even Medicare is lightening up a bit. It tinkered with its rules in 2000 to expand access to care, making it easier for doctors to refer patients to the programs. Before the change, doctors had to be fairly certain a patient would die within six months before they could refer the patient to hospice. Now, the six-month time frame is more of a loose estimate.
Joseph Dorn of Lexington, Ky., is one patient who is benefiting from a more flexible approach by hospices. He entered hospice last June, after being diagnosed with an aggressive form of leukemia. A bone-marrow transplant, the best option for a cure, wasn't really an option for the 84-year-old Mr. Dorn, who was unlikely to benefit from the procedure.
Now, Mr. Dorn is getting weekly nursing visits at home from Hospice of the Bluegrass, a 700-patient program in Lexington, Ky. He also continues to receive blood transfusions that give him the energy to take the walks he enjoys and to help him care for his wife Amy, who has dementia. While the transfusions clearly are extending his life -- his nurse says he would likely have died months ago without them -- the hospice considers them "palliative" and are paying for them. The reason is that they won't cure Mr. Dorn's cancer but are improving his quality of life.Mr. Dorn is planning a trip to California to visit a nephew he hasn't seen in 15 years. And he is enjoying the little things close to home. "If we go out to eat and want a banana split that costs $5.95, we get it," he says.
While hospice care may be the best choice for a terminally ill loved one, there are hurdles to getting good coverage. Here are some ways to maximize coverage.
* Seek out a palliative-care program in the hospital.
These programs focus on treating pain and extending comfort, but patients usually don't have to be certified as terminally ill and can continue with aggressive treatment. Palliative programs are offered at hospitals like Mount Sinai Medical Center in New York and Massachusetts General Hospital in Boston and are usually covered under a patient's regular hospital benefit. Check the National Hospice and Palliative Care OrganizationWeb site (www.nhpco.org) for a list of programs.
* Choose a larger hospice program.
Larger programs such as Capital Hospice in the Washington, D.C., area and Hospice of the Bluegrass in Lexington, Ky., are more likely to allow patients to continue with aggressive treatments even after they enter hospice. Because they can spread their costs around more patients, they are better able to pay for expensive medications. Nhpco.org has a list of programs.
* Know your policy.
Many private health-insurance policies have caps on hospice coverage, usually around $10,000. That will pay for about 85 days of hospice. But check other areas of coverage that could help out: Many large insurers such as Blue Cross of California offer a separate home-health benefit.
* Lobby the case manager.
Insurance case managers have some latitude to expand coverage, even if it is outside the letter of the patient's policy. Case managers can allow patients into hospice and still allow some aggressive treatments, giving what is for many patients the best of both worlds.©2004 Associated Press