End-of-life treatment in managed care. The potential and the peril.

T he conduct of end-of-life health care in managed care organizations is important, mysterious, and interesting. It is important because some form of managed care is involved in most health care provided in the United States. ' Managed health care applies to many ways of organizing the provision and financing of health care, all of which have in common that they provide a specific set of health services to a defined group of people within a defined budget. This definition encompasses staff model health maintenance organizations, contractual relationships by which health care providers share the financial risk of providing health care to a health plan's members, and new forms of "integrated service networks. " Health maintenance organizations (HMOs), preferred provider plans, and managed indemnity insurance cover 80% of the privately insured persons in the United States. Recent large-scale extensions of managed care to public programs of Medicare and Medicaid ensure the continued rapid growth of managed care. The raison d'etre of managed care is to contain the growth of the cost of health care for groups of enrollees or to ensure that those costs do not exceed a predetermined budget. Managed care plans cannot afford to ignore the cost of end-of-life care. About 10% of health care resources are used for the care of persons in their last year of life. ", This percentage is higher for Medicare, which meets the needs of older people who have more long-standing disease and who are more likely to die. It is correspondingly lower in non-Medicare managed care groups. Patterns of end-of-life health care for chronically ill persons differ dramatically from those of persons who become suddenly ill before death. The latter primarily require hospital and physician services; the former use more long-term care and home care.4 Patterns of care also vary from region to region, according to demography, the habits and evolution of local health care systems, and regulatory issues. The organization of managed end-oflife care varies greatly; no single set of concerns or guidelines will apply equally well to all plans. As yet, little has been published about the current practices or potential for large-scale management of end-of-life care.5" In addition, little has been published about the experiences of death and dying of patients in health plans. This may reflect the relative isolation of academic health centers from managed care. Some authors focus on the high cost of dying and on predicting which patients will have catastrophic costs.7' There is no profile of the various courses of end-of-life care in various types of managed care organizations. The nature of hospice coverage in managed care contracts has not been systematically analyzed, except that it varies from none, to partial and disjointed, to comprehensive. Studies show that hospice, a form of managed end-oflife care, can be cost-effective and cost-saving, although the variety of institutional forms and changing patterns of use justify continued research. '2 Managed end-of-life health care is interesting because its different financial organizations, relationships between primary and specialized providers, and incentives on health care professionals offer areas of concern and opportunities for improving this form of health care. In one view, managed end-of-life care threatens patients and families with rationing of important emerging therapies, limited access to costly beneficial treatments, impersonal bureaucracies, and physicians whose advocacy to patients' interest is tempered by financial conflicts of interest and "loyalty" to the managed care organization. '3 A brighter perspective is that the duty of managed care plans to provide comprehensive, longitudinal, and cost-effective care possibly offers a way out of the fragmented, bewildering, and