Getting Upstream: A Hospice Playbook for Value-Based Care

With a new arena of payment options emerging in 2021, hospice providers are honing in on strategies to deliver value-based care amid a sea of risks. A heavier focus on advance care planning could be crucial for hospices making the play to participate in the Medicare Advantage demonstration project and Primary Care First payment models.

Beginning January 2021, the U.S. Centers for Medicare & Medicaid Services (CMS) will add a hospice component to the Medicare Advantage Value-Based Insurance Design (VBID) Model, commonly called the Medicare Advantage hospice carve-in. Additionally slated for an early 2021 start is the Primary Care First initiative, rolling out phases in 26 regions nationwide.

These value-based payment models are having a transformative impact on end-of-life care, with many providers focusing on reaching patients sooner for improved outcomes.

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“All the new payment care models are designed to get upstream of the traditional eligibility for hospice and really fill in a gap in care,” said CEO of Community Hospice & Palliative Care, Susan Ponder-Stansel, in a recent Hospice News summit on the topic. “One of the issues that the VBID is designed to address is fragmented care. Hospices can really help ease that burden of transition to hospice care that exists for so many.”

Florida-based Community Hospice & Palliative Care is one of the largest nonprofit providers in the nation, and continues to see substantial growth. 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.

Designed to improve quality and timely access to goal-concordant care, developing relationships with patients and referring partners will boost hospices in their ability to demonstrate value to participating payers in the new payment options.

Bridging gaps in care transitions could bring advance care planning discussions further upstream as hospices connect with a wider pool of providers across different settings under the payment model’s aim towards improved coordination of care.

“When you think about the skills and competencies that hospice has as an organization, we’ve developed experience in helping patients and families develop goals of care, make decisions about what they want and what they don’t want,” Ponder-Stansel said. “Those things are not generally found in our upstream medical system to the extent that they’re needed in order to really address the low-value care problem.”

As Ponder-Stansel stated, hospices have a unique value proposition that other providers don’t when it comes to addressing goals of care, with expertise in advance care planning discussions and documentation processes.

“You may be more successful at getting advanced care planning documents done than others in this whole ecosystem,” said Ponder-Stansel. “Understanding what your customer is really looking to solve will help you position your value proposition in a crowded market, or even if you’re pitching it for the first time.”

While advance care planning has been shown to have a significant impact on the quality and experience of end-of-life care, public perception has been a barrier to access.

Research has found that many are reluctant to pursue conversations and establish directives due in part to misunderstandings surrounding hospice and palliative care. Providers have wrangled with an additional barrier of public policy limiting growth of advance care planning services.

With a shift towards value-based goal-concordant reimbursement models, hospices could reap the benefits of experience in providing serious illness and end-of-planning services among competitors.

“Remaining relevant is focusing on what we do best in goals of care conversations,” Cathy Conway, chief mission officer for the Hospice of Santa Cruz County, said at the value-based care summit. “Hospices are experts at goals of care conversations and advance care planning, which can take up a lot of time for other health care providers.”

Hospice of Santa Cruz County is one of the founding members of the California Hospice Network, a statewide partnership with the Mission Hospice & Home Care in San Mateo. The strategic partnership was developed to support the growth of community-based hospice care throughout their state.

“Advance care planning isn’t where other providers’ focus is,” Conway said. “They’re looking for partners to provide that level of care and support. Find out in talking with health plans what’s important to them. In this case, it’s the care that we do so well.”

While forthcoming legislation seeks to delay the hospice carve-in’s start to 2023, providers continue to take steps towards the value-base payment environment. Community education and engagement has been key to spreading advance care planning awareness, with the coronavirus pandemic shedding more light in public and provider interest.

“We started to do advance care planning workshops in a webinar series as COVID-19 was hitting,” Conway said. “The workshops were to specifically address advanced care planning and questions people may have around COVID-19. The first one we did 150 people got on the webinar. We were happy before when something like 25 to 30 people showed up. Clearly there was a need that was specific to what was happening at this time to address it. I think we have a real opportunity to speak directly to the consumer in ways that we haven’t been able to before.”

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