Gary Bacher in January became chief of strategy, policy and legal affairs for Virginia-based Capital Caring Health, which provides hospice, palliative care, home-based primary care and other services to seniors and the seriously ill.
Prior to joining Capital Caring Health, Bacher served as chief strategy officer for the Center for Medicare & Medicaid Innovation (CMMI), where he spearheaded the development of new payment models expected to have a profound impact on hospice and palliative care providers, including the Primary Care First initiative and its Serious Illness Population model, set to launch in 2021.
In this Changemakers interview, Bacher discusses the role that payment models play in driving change in the health care space and the additional changes needed to fully integrate hospice and palliative services into the wider care continuum.
I find it interesting that you went from CMMI, which addresses the entire health care system, to Capital Caring Health, which focuses on hospice, palliative care and other home- and community-based services. What do you see is your own personal mission in relation to hospice palliative and end-of-life care?
It’s really providing an opportunity for beneficiaries or families and caregivers to access a better system of care, and I really believe that happens when providers and others are able to take full care for a population of patients who have serious or advanced illness, and see them all the way through from the time that they develop the advanced illness through the end of life.
You participated in the development of the Primary Care First and Serious Illness Population models during your tenure at CMMI, in which many hospice and palliative care providers are planning to participate. What was your role as those programs came together, and where did you see hospice and palliative care providers fitting into those programs?
As the Chief Strategy Officer for CMMI, I oversaw the development of those and other new models that came out. My role was to ensure that the model is designed and focused on finding those beneficiaries, who are really in need of better coordinated care, particularly in terms of the Serious Illness Population [payment model].
That focus on finding those beneficiaries was central to the model, as was the idea of not trying to disrupt care patterns and accountabilities that were already in place, or beneficiaries who were already being cared for, whether through an ACO [accountable care organization] or obviously a Medicare Advantage plan. It was really honing in on those individuals who had serious illness are experiencing a fragmented care pattern.
With respect to hospice and palliative care, they were always thought to be an important piece, knowing that hospice organizations and palliative care organizations obviously have a lot of experience caring holistically for people with advanced illness. So it was trying to make sure that the model would give those organizations an opportunity to participate, ultimately to help the beneficiary transition into a longer-term care setting, whether a Primary Care First practice, an ACO or ultimately into hospice.
Among the goals of these emerging payment models are improving quality and, as you said, improving care coordination and reducing costs. Do you believe that payment models are the best mechanisms for achieving these goals? Are there other things that perhaps the organizations themselves or government needs to do to also further these goals?
We really need to think about how care should be changed. What are the barriers preventing people from providing the types of care that they want to provide, whether that is non-clinical service or services that aren’t paid for in a fee-for service-system? The first thing is to really imagine what’s the care redesign, and the barriers that keep somebody from doing that.
That’s always the first question I ask: Why doesn’t this happen today? If you can identify the barriers, you can come up with a payment that is designed to eliminate those barriers. The way I usually think about payment is in terms of asking whether it makes the care possible. It comes at sort of the back end in terms of thinking through how we make sure that the model of care that we’re trying to facilitate actually can be done in a sustainable way.
You really have to think about how the payment fits into the rest of the model in context and in terms of the broader interests of government and others to try to help advance care for people with serious and advanced illness. The payment model is a piece of it, but I think really the first thing to do is to envision the problems in the current system and ask what better care looks like, and then work towards removing those barriers with payment as a piece of that.
The health care system at large is constantly evolving. Can you speak to some of the big changes that you’ve seen impact the hospice and palliative care space in recent years?
I think the biggest realization for me is that hospice and palliative care and care of people with advanced illness is really a continuum of care, and I think that more and more hospice and palliative care providers are realizing that. Increasingly, hospice and palliative care are being recognized by Medicare Advantage plans and other provider organizations.
I think the health care industry used to believe that someone became eligible for hospice, and if the beneficiary chose to enroll, they would go into hospice and be kind of separate from the rest of the delivery system. I think there’s a recognition that says this end-of-life care is really a continuation of other care that occurs prior to the focus on the end of life.
How do we then create that continuum to make sure that there are holistic forms of care and supportive services that are available for people before they really become hospice eligible under the current regulatory rules? And how do we do that in a cost-effective, sustainable way, and in a way that really provides the support that families, patients and caregivers need?
Do you believe that there are aspects of the hospice and palliative care space that should be changing, but as of yet are not?
I think there are a couple of things in particular that are probably worth looking at. Look at the whole notion of a hospice provider, for example, under the Medicare Hospice Benefit, even if we’re separate from the Medicare Advantage demo, which is the so-called carve-in. We need to ask if hospices should, for instance, be responsible for all the care of both what we call the “related care” — care that’s related to the terminal condition — as well as care considered unrelated to the terminal diagnosis under the current system.
Hospices are only accountable for the direct costs of the hospice care. They’re not responsible for the unrelated services, and that’s highlighted some fragmentation issues that the [Medicare Payment Advisory Commission] and others have highlighted. It’s probably worth thinking about other ways to address those issues, even with respect to beneficiaries that are just participating in fee-for-service and that will go to hospice as part of that system.
I also think it’s fair to ask how we begin thinking about that continuum. Should someone’s six-month prognosis really determine the care they receive? Or do we really want to think about a longer continuum? Do we want to think about taking some of the dollars that are spent on hospice today and bring those dollars further upstream? That might provide for a much smoother path of care, starting from when a person begins to develop complex chronic conditions, to developing serious or advanced illness, all the way through the end of life, recognizing that at various points along the way there’s an intensity of care that’s required.
We have to think about that from a payment model perspective, but I think it’s time to really begin rethinking this continuum of care. Does our care and payment model match that continuum? I think that’s the longer term question for hospice and palliative care.
Could you describe a success story, a moment when you felt that a new strategy that you had developed really worked?
I don’t know that we can declare success yet, but one of the things that I’m very excited about is harnessing the work of health plans and hospices and tying that to care.
There’s lots of different opinions with respect to the Medicare Advantage [value-based insurance design] model, as it concerns the hospice demonstration. I think people should consider the resources that the health plan can help marshal throughout the patient’s trajectory in the Medicare program. They should think about the expanded set of supplemental benefits and the flexibilities that the plan includes, such as being able to provide room and board for a hospice patient if they otherwise can’t return to home.
Those are all very exciting opportunities that will improve patient care. They are things that Medicare Advantage plans and hospices organizations alike have all been looking for. I’m hopeful that those kinds of efforts will prove successful and can be exported to other parts of the program as well.
Can you tell me about a time when you felt an idea or plan didn’t work out, and can you share from what you learned from that experience?
This really doesn’t have to do with my CMMI work. But thinking about things from the perspective of a nonprofit community-based hospice or palliative care organization, and thinking through how those organizations develop the capabilities and experience to participate in more population-based, risk-based models, the idea of having those organizations collaborate together is going to become essential.
We see a fair bit of it in the primary care space. I think more and more of the idea of community-based nonprofit organizations joining forces and collaborating to create greater capabilities and greater reach is going to be really important.
I was part of an effort several years ago, before I even went to CMMI, where we had the right idea, though we didn’t recognize the importance to those organizations of making sure that they retain their identities and their own independence within their own communities. I think one of the mistakes that has been made in the past is how we go about trying to help organize and encourage collaboration between some of these relatively smaller organizations.
I think that collaboration is absolutely key to the future of those organizations and for the betterment of care in this area, but I think we have to go about it in a way that achieves the synergies and the economies of scale everybody’s looking for and, at the same time, make sure that organizations retain their independence and retain the flavor of their local communities and what they do.