How Payers Use Whole Person, Palliative Care to Address Serious Illness

Payers can play a significant role in decreasing the expense and complexity of serious illness care for patients through whole person care and palliative care, a study from America’s Health Insurance Plans (AHIP) found.

“Recognizing the difficulties of serious illness, health insurance providers have set out to help, support, and ease the journey for patients, caregivers and loved ones,” the AHIP study stated.

“Ensuring access to tools, education, and services for patients and their loved ones during a difficult time can provide the opportunity to plan, allow patients to maintain their dignity and choice, and support loved ones to know their role and how best they can help.”

Serious illnesses such as diabetes, heart disease, and cancer are major drivers of healthcare spending in the US. Those with serious illnesses that limit function and lead to dependence on caregivers make up a small portion of the population but contribute heavily to the nation’s healthcare spending, AHIP stressed.

In 2016, half of the nation’s healthcare expenditures went toward five percent of Americans who spent on average $50,000 annually for healthcare needs.

The challenges of serious illness include healthcare disparities, access to palliative care, mental health effects, quality of life, and caregivers who are too few in number and too overwhelmed in their roles.

Also, as people age they are more likely to have a serious illness, potentially one reason why severe illness is so common in Medicare populations. As America’s population is starting to trend older with 10,000 individuals turning 65 each day, the country could face a steep incline in serious illness diagnoses and costs.

AHIP pointed out payers that have responded well to the challenges of living with a serious illness. These payers incorporated case managers and whole person care into their serious illness care strategies to alleviate costs and complexity for patients.

Regence, the health plan for Cambia Health Solutions (Cambia), developed a support program for members diagnosed with a serious illness, called Personalized Care Support. This program helped members navigate care planning, benefits, and case management.

Members who need palliative care are assigned a case manager who helps the member and his caregivers outline the challenges and goals for his care or treatment.

The health plan also works within Medicare Advantage flexibilities to offer social determinants of health benefits to patients with serious illnesses in need of palliative care.

In addition to these actions, Cambia Health Foundation, Cambia’s philanthropic branch, started donating to programs dedicated to workforce and capacity development as well as putting $44 million toward palliative care, which support those with serious illness. The foundation also worked to spread awareness about serious illnesses.

Cigna has also taken steps to support patients with serious illnesses. Like Regence, Cigna assigns a care manager to members diagnosed with a severe condition. The care manager devises a care strategy for the member that incorporates both internal Cigna team members and external vendors to address physical, mental, and behavioral health needs.

The payer also identifies and addresses social determinants of health barriers including transportation and prescription medication affordability challenges. Members who have just been discharged from the hospital may receive meals and social support.

“As a person’s serious illness progresses and the need for intervention changes from managing disease progression to preparing for a quality end of life, Cigna provides an advanced care program to assist members with care planning, hospice transition, and support at the end of life,” the report added.

“Cigna’s home-based program can include a nurse practitioner, RN, social worker, chaplain, and other identified individuals that may serve the needs of the member or their family and caregivers. Goals of care are discussed frequently to make sure that the member’s wishes are at the center of the care plan.”

As a patient plans end-of-life care, Cigna also ensures that her primary care provider is aware of the conversation.

While much of the responsibility for managing member care and healthcare spending rests on payers like Regence and Cigna, AHIP also pointed out various policy changes that could help patients with serious illnesses and their families.

AHIP highlighted a couple of Medicaid programs that are ending soon which the organization argued should become permanent.

Medicaid’s Spousal Impoverishment Protections should become permanent, AHIP suggested. This policy helps protect the families of those with serious illnesses from being overwhelmed by healthcare costs. The policy ended in March 2020, although states have been allowed to extend for a few months.

Also, Money Follows the Person should be permanent, AHIP said. This program empowers individuals with serious illnesses to access Medicaid long term services and supports. Like the former program, Money Follows the Person has been extended for the short-term but AHIP recommended that it should become permanent.

Policymakers should support regulations that expand long-term care and palliative care access and public education around palliative care. They should also protect Medicare benefits such as advance care planning that support patients who desire to die at home or with other specific wishes.