The COVID-19 pandemic has highlighted gaps in the health care system that bring into sharp relief the need for a community-based palliative care benefit, according to the National Hospice & Palliative Care Organization (NHPCO). Representatives of NHPCO have been meeting with the Center for Medicare & Medicaid Innovation and stakeholders on Capitol Hill to move such a benefit forward.
A rising number of hospice providers have been diversifying their services in recent years to include palliative care in an effort to engage patients further upstream and to open up new lines of revenue. Hospices provide about 50% of home- and community-based palliative care in the United States according to 2019 research by the Center to Advance Palliative Care (CAPC).
“COVID-19 has really been a catalyst both for [NHPCO] and for others thinking about this. The pandemic has had a very severe impact on the quality of life of those people that are living with serious illness, when many people have had to social distance or quarantine at home,” said Annie Acs, NHPCO’s director of health policy and innovation. “From an innovation standpoint, we feel like this is the right time to test a community-based palliative care benefit. COVID-19 has really highlighted the need more than ever”
The closest existing equivalent to such a benefit is the U.S. Centers for Medicare & Medicaid Services’ (CMS) test of the Medicare Care Choices Model, which allows hospice patients to receive curative care concurrently with hospice. The agency recently announced that it was extending the program by one year. The test was originally scheduled to close at the end of 2020.
NHPCO President and CEO Edo Banach indicated that the industry group would like to see action taken on a palliative care benefit by the current presidential administration. CMMI has the authority to create a demonstration project to test such a care model. Congress could also create a model through legislative action.
“If it turns out that providing people with access to community-based care at the same time as they’re seeking curative care doesn’t cost more and improves quality, then that’s very productive in terms of a foundation to move,” Banach said. “There’s going to be a second wave of COVID-19 in the Fall, and we want to make sure that we have the appropriate tools to provide care to folks where they are at home, which is where the country is telling people they should be.”
Many stakeholders in the hospice space anticipate that forthcoming Medicare payment models could have a positive impact on the availability of palliative care in the home, including the Medicare Advantage hospice “carve-in,” and the Serious Illness Population (SIP) program under the auspices of Primary Care First. However, limitations in those programs could limit their impact.
CMS beginning in 2020 allows Medicare Advantage plans to offer palliative care as a supplemental benefit, and a rising number of plans are indeed covering those services. However, plans are not required to provide that coverage, and many still do not offer it.
The SIP program will initially be available in 26 regions throughout the country, meaning that providers in nearly half the states would be unable to participate. Some COVID-19 hotspots, including Texas, will not have access to the program. The SIP model is also designed specifically for patients who have received fragmented care, making a large proportion of patients ineligible.
“We really want a model that is person and family centered, and therefore we have to have an interdisciplinary team providing that care. We know that the current traditional Medicare fee for service does not support financially the interdisciplinary team,” said Lori Bishop, vice president of palliative and advanced care at NHPCO. “I think that even SIP has some opportunity for an interdisciplinary team, but not as much as we would have liked to see in that model.”
One goal of a new community-based model would be to help prevent or reduce the need for seriously ill patients to seek acute care or visit the emergency department, which is also a key goal for CMS and private payers seeking to reduce overall health care expenditures.
Home-based palliative care could reduce societal health care costs by $103 billion nationwide within two decades, the nonprofit economic research group Florida TaxWatch reported last year.
“We wait for people with heart failure to drown, for example, and then we save them in the acute care setting and congratulate ourselves when we know all along that that is what is going to happen with their disease,” Bishop told Hospice News. “If we would do a better job of managing them proactively in their home, they would never have to get to that point. Right now, we wait for people to be desperate enough to access the emergency room in the hospital, often multiple times, because that is the only way to get their needs met.”