Palliative Care Innovation on the Horizon

Many hospices have honed in on community-based palliative care as essential to their growth and particularly to their success within value-based programs. Negotiating in a new payment arena will be key to developing a successful palliative care model as fragmented lines of care entwine.

Palliative care has been expanding in the hospice space. Roughly half of community-based palliative care providers in the United States are hospices, according to the Center to Advance Palliative Care (CAPC). Set to take effect in January 2021, the value-based insurance design (VBID) payment model demonstration project allowing Medicare Advantage plans to carve in hospice has created a financial draw for providers to delve deeper into the palliative care realm. Also coming in 2021 are the direct contracting and Serious Illness Population payment models under the Primary Cares Initiative at the Center for Medicare & Medicaid Innovation.

“What we’re seeing in terms of innovative models [is] a strong interest in expanding access to palliative care beyond the hospital and into the community either near the home virtually or in homes,” said Peggy Maguire of Ore.-based Cambia Health Solutions during the Hospice News Elevate conference. Maguire is executive vice president of Ore.-based Cambia Health Solutions and president of the Cambia Health Foundation. “There’s been a lot of innovation in the Medicare Advantage space, starting with supplemental benefits. There’s a real opportunity to be creative about Medicare Advantage benefits.”

As value-based insurance models evolve to test the waters of hospice, insurance claims data will be key to navigating uncertain reimbursement seas, according to Clevis Parker, M.D., CEO and chief medical officer of ProCare Hospice Nevada, also speaking at the conference. Providers building out palliative care services will need to demonstrate program sustainability by enhancing data analysis in order to develop anchored ties to payers.

Data management and analysis will become increasingly important as hospices move gradually closer to working in value-based payment environments. Among the key metrics that hospices would be tracking are patient outcomes and satisfaction data, hospital readmissions as well as any complications that could later lead to a readmission.

“There’s some give and take with the insurance company. Agree to be open and honest and share the claims data and ask how you can get access to make sure that you’re meeting [payers’] needs,” said Parker. “This truly needs to be negotiated upfront and not on the back end because you find yourself failing to meet the needs of their insurer, and eventually that trickles down to the patients and families. You can’t ever account for everything, but you can account for most things so that there will be little room for surprises.”

In addition to meeting patient needs, a drive towards palliative care could lead to patients’ coming onto hospice further upstream in the course of their illnesses, helping to ensure improved with continuity of care, which is among the goals of the VBID demonstration project, commonly called the Medicare Advantage hospice carve-in.

Through the demonstration CMS will evaluate the inclusion of hospice in VBID using several metrics, including rates of patient length of stay that are less than seven days as well as those that exceed 180 days. The agency will also measure documentation of patients’ goals of care, performance on pain control, family satisfaction and the number of days that patients were in their homes during their final six months of life.

Among Medicare Advantage plans, 53 will be covering hospice and palliative care in 2021 through the VBID model, according to the U.S. Centers for Medicare & Medicaid Services (CMS). The carve-in comes at a time when Medicare Advantage is seeing record-high levels of participation for 2021 among beneficiaries, reaching about 42% for 2021, CMS reported.

“The model reduces the fragmentation and the disruption that [can be] a result of how the payment system is organized,” said Maguire. “The VBID model shows a lot of promise, and that will result in a better experience for the patients, the caregivers and, hopefully, the clinicians.”

With many unknowns ahead, the future of palliative care in hospice may blend the worlds of collaborative and concurrent care in a value-based environment, which many anticipate will have a transformative impact on end-of-life care.

Though value-based models show promise, some have argued that those programs do not go far enough in regards to opening up access to palliative care.

Advocates in the hospice space have called for a dedicated community-based palliative care benefit, with more than 60 senior citizen advocacy and health care groups recently submitting letters to the U.S. Department of Health and Human Services (HHS) and congressional leaders to request a demonstration project. CAPC was among the dozens of organizations, in addition to the National Hospice & Palliative Care Organization (NHPCO), the National Coalition for Hospice & Palliative Care and the National Association of Home Care & Hospice.

Such a benefit would open up the possibility for more concurrent care, in which patients receive palliative support while continuing to receive curative treatment, a care model with the potential to yield significant cost savings.

“I’m not so sure hospice is going to be hospice in the next two years,” Parker told Hospice News. “It’s going to be so blended that it may not necessarily be under palliative or hospice, but it will be there in some form or fashion. [Palliative care] is just the best care for those who have serious illness. However you want to label it, hospice or end-of-life care has to be a part of that.”