Community Hospice CEO Makes Case for Value-Based Palliative Care

The number of hospice providers that are diversifying their services lines to include palliative care continues to rise. Programs like Medicare Advantage and the Primary Care First initiative, particularly the Serious Illness Population model, present opportunities for further growth as well as improving access and quality of care for patients.

Currently, hospices provide about 50% of home-based palliative care in the United States, according to the Center to Advance Palliative Care.

Florida-based Community Hospice & Palliative Care, one of the largest nonprofit providers in the nation, continues to see substantial growth. Having the CommunityPedsCare pediatric palliative care program in 2019, further plans to expand palliative care programming are on the long-term horizon.

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CEO Susan Ponder-Stansel recently took a deeper dive with Hospice News into the scope of palliative care’s value in the hospice space and how evolving payment models and programs are taking shape further upstream in the industry. She will be speaking on the subject of value-based palliative care at Hospice News’ upcoming virtual summit.

Do you think that the aging population and a rising prevalence of serious and chronic illness are creating a greater need for palliative care?

The way our system is working right now, it not only delivers fragmented care, low-value care, but it’s also not financially sustainable with the old fee-for-service model. It’s not designed to manage serious and chronic illnesses and improve outcomes. If it can’t fix the illness, then it doesn’t know what to do. Focusing on episodic, expensive care as the Baby Boomer generation becomes Medicare beneficiaries over the next 20 years is a real issue.

A lot of the new programs that both the government is testing through the Center for Medicare & Medicaid Innovation (CMMI) and the Medicare Advantage plans themselves are looking at is a way to turn the cost curve down for these folks that consume a lot of resources and get very low return from care that may actually get worse over time. I think demographics are definitely fueling this concern.

Looking at the big demographic trends now, the COVID-19 pandemic has just accelerated some of the things that were already out there. These past four-and-a-half months have put many of the existing issues in this serious illness and hospice space on steroids. An interesting wrinkle that we’ve seen in the older population in particular is that they are now paying more attention to goals of care and expressing that they really want care outside of nursing homes and hospitals, even delivering primary care in a different setting with a different focus. Advance care planning is just skyrocketing, and the pandemic has really pushed that consumerism among the aging population.

What business opportunities does palliative care represent for hospices?

If you’re developing an advanced illness management or palliative care service, there’s an opportunity for hospices to offer added expertise to providers like hospital systems with analytical tools that help them identify who might be appropriate for this kind of care and start flagging these cases sooner.

The biggest thing hospices know how to do well is goals of care discussions and assessing what a patient understands about their illness and prognosis, what worries or bothers them. A key aspect of any Medicare Advantage plan that’s trying to get into the business where they’re managing risk is making sure they have a very active and really usable system for goals of care discussions that will follow the patient as their condition changes or as they come to a different place in their illness.

Hospices have that business opportunity to teach, train and help providers understand who needs palliative care and then actually deliver their value to result in a new plan of care for the patient and help them make different decisions going forward. Packaging that up and making sure you can deliver care while pricing it well is something hospices can help with. We just have to figure out how to get reimbursement systems that support goals of care as the aging population reaches those stages in life.

What are some of the nuances hospices need to navigate as they expand into palliative care?

There could be some real future consequences in remaining relevant if you just stay in the hospice game. There’s also danger in moving upstream into palliative care if you don’t understand what your strategic intent is going to be. Community Hospice & Palliative Care has learned there are building blocks to success in the non-hospice space. It’s important to think of your hospice’s capabilities, core competencies and systems you need to put into place before starting palliative care programming.

One of the big gaps that palliative, upstream care can fill in hospice is in identifying and understanding when a person is starting to receive low-value care and could really benefit from a different approach. We shouldn’t assume that people like primary care physicians, hospitalists, intensivists, discharge planners or care managers really know someone in the last one or two years of life when they’re dealing with them. A lot of times, they’re just focusing on the episode in front of them, hospices can help them look beyond that.

How do hospices currently receive payment for the palliative care many of them provide?

A lot of it depends on who the customer and what your hospice provides, but right now most hospice programs are probably looking at a Medicare Part B billing position as really all we’ve got for a lot of basic palliative care. You have to run that in a way that you maximize the use of your physician extenders and also minimize the use of your physician because the reimbursement levels really don’t cover the cost of care if you have a real physician-heavy model.

If you’re working with providers who are at risk for payment, they may want you to enter into an upside and downside risk agreement with them. If you help them meet their cost-savings goal then you get a bonus, kind of like how the Serious Illness Population model is going to be. It requires a different level of skill and sophistication on the part of the hospice to future things out in managing their interactions with patients and families to get the outcomes they want and avoid ones they don’t. It’s often hospices providing services and hospitals or partners reimbursing that cost, so we really have to hit quality outcomes to get that.

How might this change as new payment models develop such as Medicare Advantage and Primary Care First?

When you look at some of the new payment models coming online like the value-based design, that’s going to be an opportunity if hospices are ready to move upstream into palliative care because they require health plans to provide those transitional services and concurrent care. The same goes for the Serious Illness Population program. If you are able to do that care management in a way that helps the new plan of care come in, then you get that monthly payment plus the quality bonus.

You can contract directly, you can do risk-based contracting where it’s per member per month, or you can be subsidized for your actual costs. It just all depends on who is in your market, and that’s something important for hospices to determine before they get into palliative care or ramp it up if they already have it. You don’t want to build a product that’s chasing a customer, but rather know them and build a product that meets their needs and offer palliative care not as an alternative to hospice but a transition of access to it in a timely manner.

One of the things these payment changes will do is give opportunities to hospices that are ready to offer care transitions like palliative care, but they’ll need to have made the investment in the processes that will allow them to make that financial model work because it’s not a generous one. Primary Care First is testing whether that’s even financially feasible.

Earlier this year your organization established a program of all-inclusive care for the elderly (PACE) program through a joint venture with Aging True Community Senior Services. Why is this kind of service diversification important for hospices?

PACE is an identified program that has a particular population it’s trying to serve. It’s actually a three-way contract between the U.S. Centers for Medicare & Medicaid Services (CMS), your local state Medicaid program office, and then you and the bureaucracy.

Nationally, there aren’t that many people enrolled because they just make it so hard, but it’s a really good program. PACE is kind of a health plan in which you’re responsible for everything that happens to that patient. Hospice providers naturally have risks, but usually around a very narrow part of the terminal illness. With PACE, you’re interacting with the patient over a much longer period of time and over a broader scope, with CMS really transferring much more risk to providers.

With the joint venture, we really wanted to bring in Aging True’s nonmedical and community services of managing older and aging people throughout their illnesses and keeping them at home and out of the hospital settings where they might not belong. Developing these kinds of partnerships and joint ventures with others creates a scale in services.

Going forward as more risk-based reimbursement is out there, we’ll have those capabilities of delivering non-medical services with skill and delivering care to patients who are going to be with us for a longer period of time and have more things happen over that course. We really wanted to figure out how to do those social and non-medical services in a way that resulted in people being able to maintain their independence as long as possible.

I think the basic processes and structures of PACE can be moved to those other audiences beyond just those that are designated for the program slots or legislature. It’s an investment of learning how to deliver care to those who have geriatric frailty or multiple comorbidities across time and across settings — that’s a huge and important part of competency that a post-acute provider has to have going forward.

PACE was a long-term play for us and a program that really does improve the patient’s quality of life. If you can operate a PACE program successfully, you’re learning how to stratify risk and how to assess what the patient needs versus how much you’re responsible for.

Where do you see your organization going next in terms of adding new service lines?

We’re looking at a 10-year horizon, and I think Medicare Advantage programs are going to be the way that we begin to manage this wave of older adults. All of our next steps are really to leverage some of the capacity and competencies we have and deliver these upstream programs. There’s going to be a huge consumer demand and a huge payer demand for geriatric care management, with older adults in search of ways to bring services and support around them. Families and caregivers are looking for organizations that have cost-effective, comprehensive solutions to help their loved ones be able to stay in their home and avoid long-term care settings.

We’re looking at creating a service where patients and families don’t have to do that, and it’s our job to figure it out and make it as easy as possible for them. We’re focusing a lot on developing a geriatric care navigation center that supports and considers all care and goal aspects and makes recommendations that deliver on those for patients. Adding new lines of service will help us as an organization to be flexible with how we’re going to do that.

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