A Conversation with Daniel Knecht, MD

‘No One Here Gets Out Alive’: Preparing Patients for the End

Aetna’s vice president of health strategy and innovation explains how tweaking an established program will offer vulnerable beneficiaries more value.

Interview by Frank Diamond
Managing Editor

Daniel Knecht, MD

Last December Aetna, in collaboration with the not-for-profit Advance Care Planning (ACP) Decisions, launched a pilot that fine-tuned Aetna’s Compassionate Care Program, which has been around for about 15 years. This adjustment involved assisting Medicare Advantage beneficiaries in making decisions about end-of-life care. Launched in Pennsylvania, Maine, and Illinois, the effort utilizes an extensive video library—among other educational tools—to be used by members and the Aetna nurse care managers who care for them. Managed Care talked with Daniel Knecht, MD, Aetna’s vice president of health strategy and innovation, about the impetus behind the effort, how it works, and what Aetna hopes to achieve by it.

What’s changed?

Multimedia. Leveraging videos. Additional training for our care managers. That’s sort of it in a nutshell. I think it’s really unique. This is pretty innovative that a health insurer is really so focused on support of its most vulnerable members, leveraging new technology and high tech and videos as well as high-quality training to make this program successful.

How does it work?

The program is twofold. One is we’re providing additional training and education for our care managers. It’s so challenging to have a meaningful conversation about end of life because it’s such a sensitive topic. Everyone has their own cultural and personal beliefs. It’s important that our care managers are trained and comfortable with engaging our members in these conversations.

Number two is the technology piece. We’re taking this suite of easy-to-understand videos that have been developed by ACP Decisions. Then we share the appropriate videos with our Aetna members who would benefit from these discussions.

How many nurse care managers?

About 30. There’s a substantial amount of training that goes into it because we don’t want to send in our care managers incompletely prepared and educated to have these conversations. We’re being very deliberate and thoughtful about how much training and support these individuals get.

How much training do they get?

All of our case managers receive training in a variety of clinical topics, including hospice care, advanced illness and symptom management, and advanced directives. In addition, case managers receive training in motivational interviewing and are required to complete end-of-life–related continuing education units annually.

How do you find the patients?

We have an analytic tool where we can identify Aetna members who may be struggling with serious illness. We also take referrals from providers and our own case managers. You want to reach out to them at the beginning of a serious illness as opposed to the 11th hour.

I noticed that ACP Decisions was founded by Angelo Volandes.

That alone is quite meaningful. Care managers get group teaching and they actually have one-on-one instruction from Dr. Volandes, a Harvard-affiliated physician who is nationally recognized as a leader in palliative care. There’s also a lot of role playing in this because it’s really a valuable tool.

I am a patient in my late 80s. I don’t have more than a year to live. Take it from there.

Our care managers, either in person or telephonically, will start the conversation with the patient. It’s trying to understand where the patient is. What their understanding of the disease is. What their perceived trajectory of the disease is. I see this all the time in the hospital: Patients with advanced diseases don’t know sometimes how advanced their disease is. Or they think it’s not a life-limiting condition.

If the patient does understand it’s a terminal condition, the critical questions are: What’s really important to them? Is it quality of life? Is it symptom mitigation? Perhaps some people want to battle the condition to the very end. That’s fine, too. It’s also important to find out if there’s a loved one or somebody they can trust to help make decisions in the event the patients are unable to articulate what their preferences are around a given issue.

“More often than not, people just don’t have the time and the opportunity to understand what aggressive care in the face of a terminal illness looks like.”

If you can really help patients struggling with serious illness to navigate their choices in a way that’s patient-centric, it is incredibly rewarding for the clinician. I personally had the privilege of participating in a number of end-of-life discussions in the hospital, and it’s challenging. But, frankly, I would say it is also one of the most rewarding experiences as a clinician.

Any plans to expand it beyond the three pilot states?

We’re studying the impact of it. Based on what we see in the pilot, we might expand it.

How do you measure success?

We’re looking at how frequently the videos are being used. Because if we’re not using the videos, then it’s not a really good tool. But if members are using the videos and watching them in their entirety, that’s an important process measure. We’re looking at how many advanced care planning documents are filled out. We will also likely survey our members to see if they thought the encounter was meaningful.

How do you know if the videos are being used and how long someone may watch one?

We leverage analytics that allow us to know which videos are being used and if they are watched for their entirety or not. Additionally, our care managers provide us ongoing feedback to ensure optimal engagement with our members.

And the content?

They run the gamut from just talking about advanced care planning for a healthy 65-year-old all the way to what is a feeding tube, what is advanced dementia, what is dialysis. There is a number of clinical domains highlighted in the video library. The videos are simple and easy to understand. They’re developed for patient and caregiver consumption.

I have to ask: Is there a cost-saving aspect to this?

It’s about helping in the delivery of compassionate, patient-centric care. I will point to a pivotal study in the New England Journal of Medicine back in 2010. What it showed was that patients with lung cancer who received early palliative care had less depression and improved quality of life. And, in fact, they lived almost three months longer than patients who did not pursue palliative care.

Reducing unnecessary care is part of it.

More importantly than reducing unnecessary care is reducing unwanted care. More often than not, people just don’t have the time and the opportunity to understand what aggressive care in the face of a terminal illness looks like.

Will people trust care managers who work for an insurance company?

Our care managers are trained and skilled in the ways of having these conversations, but even more important: They’re coming from a position of compassion and empathy. Most of them are really excited to do this kind of work, and I think many times it has to do with past experience—a loved one who had a serious illness. That experience, that firsthand experience, really is eye opening.