A community-based palliative care benefit may emerge from the U.S. Centers for Medicare & Medicaid Services during 2021, according to National Hospice & Palliative Care Organization (NHPCO) President and CEO Edo Banach. Though nothing is certain, Banach told Hospice News that factors exist that make it more likely to occur, including the COVID-19 pandemic.
Currently Medicare reimburses for palliative care physician services through fee-for-service payment programs that do not sufficiently cover the full range of interdisciplinary care, but calls grew louder among health care stakeholders and policymakers during the pandemic for Medicare to establish a dedicated community-based palliative care benefit.
“We’re incredibly hopeful that this is the year, after decades of talking about it, that we’re actually going to get a benefit that we can wrap our arms around,” said Banach during the opening keynote of NHPCO’s Leadership & Advocacy Conference.
Hospices are uniquely positioned to provide these services, evidenced by how many of those providers are already engaged in palliative care. The Center to Advance Palliative Care (CAPC) reported last year that at least half of the in-home palliative care providers in the United States are hospices.
Efforts have been underway among health care providers, state governments, advocacy groups and payers, among others, to make community-based palliative care more accessible to patients and families. CMS also allows Medicare Advantage plans to cover palliative care as a supplemental benefit. However, these efforts have fallen short of a national model.
In addition to the pandemic, CMS career staff and political appointees coming into the Biden administration have a solid understanding of the need for palliative care, according to Banach, a former deputy director of the agency’s Medicare-Medicaid Coordination Office.
“We’re still in the thick of COVID-19, which is a serious illness, with it comes the need for interdisciplinary care,” Banach told Hospice News. “The crowd that’s coming into CMS and [the Center for Medicare & Medicaid Innovation] are folks who know what we’re talking about and are receptive to what we’re talking about. I’m not making any guarantees, but we’ve also received really good feedback.”
A potential payment system would likely be based on the Medicare Care Choices Model (MCCM) demonstration, Banach said. Through this demonstration, CMS is assessing whether concurrent care can improve the quality of life and care of hospice patients covered by Medicare, boost patient satisfaction, and cut the agency’s costs.
The model allows participating hospices to provide routine home care and at-home respite care while enrollees are also pursuing curative treatments. CMS typically pays participants $400 per patient, per month while they are delivering services under MCCM, including care coordination, case management, symptom management, and other support for beneficiaries and families.
MCCM is helping to awaken policymakers to the cost saving benefits of palliative care. MCCM reduced Medicare costs by $26 million during the first four years of the program, CMS reported. The demonstration was established in 2016 and is scheduled to end in June 2021. The agency attributed most of the savings to associated reductions in acute care utilization.
“Also helpful is the sense that a community-based palliative care demo would be built on the chassis of a successful demo, which is the Medicare Care Choices Model,” Banach said. “The evaluation seems to be showing cost savings and improvements in quality.”
MCCM does have some limitations. To qualify for the program, Medicare beneficiaries must have been enrolled in Medicare fee-for-service as their primary insurance for at least 12 months and have a terminal prognosis or six months or less.
Only patients with a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease or HIV/AIDS are eligible, if they have had at least one hospital encounter during the last 12 months and had at least three office visits with any Medicare provider within the previous 12 months. Eligible patients must live in a private residence, as opposed to a nursing home or assisted living, and they must reside in the service area of a participating hospice.
An effective community-based palliative care model would likely need to be more inclusive, particularly regarding MCCM’s six-month terminal prognosis requirement.