Chief Medical Officer Eric Bush: Hospice Can Gain Through Primary Care First Direct Contracting

Eric Bush, M.D., is a board-certified hospice and palliative medicine physician, joining Hospice of the Chesapeake as chief medical officer in 2016. In this role, Bush provides strategic and leadership direction to the medical staff, which includes physicians and nurse practitioners. Having served first as a licensed practical nurse in the U.S. Army Reserve, a pharmacist and then a physician in the Baltimore and Washington corridor, he brings a unique perspective to hospice and palliative care and has authored several publications in these related fields.

Bush has been featured in Hospice News webinars and at national conferences providing insights and education about alternative payment models such as Primary Care First. He will be presenting at the upcoming Hospice News event: Value-Based Care Strategies for Hospice & Palliative Care Virtual Summit.

Many in the hospice and palliative care spaces, as well as other health care stakeholders, have struggled to understand Primary Care First direct contracting payment models. Designed to help the U.S. Centers for Medicare & Medicaid Services (CMS) and health care providers reduce expenditures and improve the quality of care with Medicare fee-for-service programs, the direct contracting options include three voluntary payment models to adapt and integrate from other programs such as Accountable Care Organizations, the Medicare Shared Savings Program, and Medicare Advantage, as well as strategies used in the private sector.

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How would you explain the nature of the Primary Care First payment models as they specifically could apply to the hospice space? With an obvious focus on primary care providers, what would be the draw for hospices to be interested in direct contracting models?

There are several options of the Primary Care First payment models, especially within direct contracting and what’s going to help stratify the type of entity you go in as will depend on the size of your hospice and its patients’ needs, it’s affiliates, whether you’re owned by a hospital or health system. I think you do need to also have support for palliative care and have some infrastructure already built out.

If you look at the application and the model and sift through some of the webinars from CMS, really what they’re looking at is based on some of the next generation Accountable Care Organizations (ACO) models, and it’s an advanced Alternative Payment Model (APM) type system. So, if you’re a hospice that is part of a larger organization or health system — maybe you’re owned by a hospital or a health system, and you have that type of affiliation with population health expertise in house and infrastructure — then something like the global options might be good, where there’s more risk but also possibly more reward. A lot of times these organizations have more experience with true population health management than hospice and palliative care providers. Larger entities and organizations seem more as Accountable Care Organizations, or next generation Accountable Care Organizations, and you would probably need that type of size in order to go along the lines of direct contracting.

If you’re a smaller entity and you don’t necessarily have a large infrastructure, the pro is that you have some autonomy and the con is that maybe you don’t have that population health management expertise within your organization. Something like the high-needs population, direct contracting entity option — where you have to meet a target of 250 beneficiaries that you’re providing primary care to within the first year — that’s an achievable goal for organizations of similar size to ours.

[Hospice of the Chesapeake] is applying for direct contracting as the most appealing and most appropriate to our organization at this time, the high-needs population within the professional option and with primary care capitation. While there are some home-based primary care providers, the focus is not necessarily on making sure that transition from home-based primary care to some supportive or palliative care and hospice is seamless for a coordination of care. For us, the professional option and a high-needs, direct contracting entity with a smaller patient panel works better, where we don’t necessarily have a lot of the history of risk contracting options that maybe organizations who are affiliated with larger health systems do.

We’re trying to evolve from the back end, so to speak, of providing hospice for 40 plus years and providing palliative supportive care for the last 10 years. Now, really, within the last three years, we have more of a community-based palliative care model. We were able to get our Joint Commission certification for our community-based palliative care, and we’re one of only 54 in the country with that certification. And so looking at what is the next tier of patients that we should be serving, those folks that unfortunately don’t really have a safety net out there.

There are different options for differently-sized organizations, so the intent is good and it’s good to see on a national level. It makes you think of the forest for trees. It ties into the mission and vision regarding caring for life throughout the journey with illness, loss and patient-centered care.

How do you think that the current situation with the coronavirus pandemic might impact CMS and health care providers’ ability to implement those models?

I think it is having an impact. Actually, if there’s a silver lining to this cloud, it’s that some of the barriers have been taken down and that CMS has relaxed some of the provisions for hospice care and supportive care. If you’re going to continue to have some laxity with some of the regulations, face-to-face visits and things of that nature that can be done via telemedicine and you’re able to implement technology, then it’s actually going to be markedly beneficial.

Hospice of the Chesapeake has six physicians, eight nurse practitioners, a nurse, a social worker, two coordinators, a director of medical services and a manager for our supportive care. We see all the patients across all spectrums of care on a daily basis, and that’s at least 700 acutely-ill patients that we’re caring for. Any way that we can utilize technology, which I think CMS has wisely allowed for, that’s really been beneficial. I understand maybe from a legislative perspective, it may slow some things down in moving forward with direct contracting or maybe delaying some of those timelines. I think that’s to be expected. Overall, allowing organizations to implement things like telemedicine more broadly, and laxity in some of the hospice regulations has actually helped enhance efficiencies for organizations like ours.

Do the payments models as they are now designed have any shortcomings? Would you change anything if you could?

No, I think they’ve been very carefully designed and that there are enough safeguards regarding limits on capitation and risk that I feel have been the biggest concerns. One of the challenges is IT, or information technology. How do you make sure that you have an electronic medical record (EMR) that’s going to meet the certificate requirements. Do you have any EMR that’s going to ensure that you’re sharing information with the other organizations, the other health systems that you partner with? I think that’s a good challenge because really, ultimately, at the end of the day, that’s going to make you provide better patient-centered care so that the patient ends up getting the right care, in the right place and at the right time.

What are some of the restrictions that exist for participation in these direct contracting payment models? What might be some strategies to approach them?

I think that you have to be an organization that at least has some community-based palliative care experience and have that built out. You could also be a hospice that has longer length-of-stay patients with a really robust community presence, maybe you have doctors and advanced practice nurses, as well as the nursing and social work infrastructure to support this kind of model. It seems more like an upstream management of patients so that you have the capacity to be able to do primary care. You want to make sure that you’re coordinating with your home health partners as a very important partnership to have in this regard. You don’t necessarily need to have everything fully built out or have a completely thought-out infrastructure, but at least have about half of that infrastructure built down. I think if you don’t have these things, then it would be very challenging to be able to implement the direct contracting options. I think it would be extremely challenging and very resource-intensive to do that, especially with all else that’s going on in the world of health care at this time.

How can hospices maximize on like the financial benefits of participating in these payment models?

Number one is utilizing their existing partnerships within the community if they’re not not part of a larger health system to help recruit beneficiaries and provide this primary complex illness care, or this primary care. That really is a win-win-win situation. It’s a win for the patient because they’re going to get more patient-centered care. It’s a win for the partnered health systems because those patients are going to end up having fewer transitions of care, fewer hospitalizations, less utilization of services, and more optimal, quality of life-focused care. And then it’s a win for the hospice organization because if you’re getting that patient sooner in the trajectory of their care, if you’re truly getting that patient a year — or hopefully even 18 months — before you expect them to pass, then the higher the likelihood that they’re going to have a smoother transition from your primary care, to your supportive and hospice care. They’re going to have an appropriate length of stay.

One of the challenges we have here in Maryland is that it’s in the bottom third of the country with regards to hospice utilization and we have a lot of challenges regarding length of stay. Our average length of stay is in the mid-50 day range, whereas nationally it’s closer to three months. Patients and families don’t really get that true longer experience of hospice care and all the benefits of multidisciplinary care.

The other piece — especially in a COVID-19 environment where you have your employees who are worried about getting sick or getting their patients sick or their own families sick —then you throw in the constant churn within that average length of stay. You’re going to have some maybe who truly are on hospice for six months, but then you’re gonna have a lot also that are on your service for less than a week. It’s really challenging because after a while it’s more like acute end-of-life care with patients and families who aren’t getting the support they need, especially in a pandemic where everything is really complicated. It’s taxing on multiple levels.

I think one of the appeals of these payment models is that if you get patients in longer, then that really truly is patient-centered because they benefit, but so do the health systems. If you have rising clusters of COVID-19 patients, and the acuity of these patients is obviously extremely high as very resource-intensive care, then what you want is to have your hospitals who are geared to provide that kind of care to have as much capacity and bandwidth possible to be able to do so.

How can hospices ensure eligibility if they’re making the move towards the direct contracting models?

It’s really seeking out partnerships that are going to help fulfill the criteria to meet the direct contracting me. I think home health is an ideal one. I think those are really the important partnerships to have. Because, again, if you think of it from population health perspective, that again, that that same category patients that we’re talking about with regards to direct contracting primary complex illness, care, And so I think if you have the interdisciplinary care of supportive care, you marry that with the home health care, I think that the ideal situation for patients and families to be able to help patients truly age in place in the community, again, that right care right place right time, but then you really have that safety net because you got really two types of care that complement each other with supportive or palliative care as well.

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