Hospices Ramp Up Advance Care Planning Through Value-Based Payment Models

More hospices are expanding their advance care planning services as they ramp up participation in value-based payment programs such as Medicare Advantage, direct contracting and participation in Accountable Care Organizations. Several value-based models incorporate advance care planning, which is associated with reductions in the total cost of care and improvements in overall hospice utilization rates.

Advance care planning has been shown to significantly impact the quality and experience when a patient reaches life’s final stages, yet these conversations are often difficult to broach and involve breaking down walls such as public misperceptions around end-of-life and serious illness care. Having advance care planning discussions can be an introduction to hospice and palliative care for patients and their families, while also presenting more opportunities for providers to connect with patients earlier in their illness trajectories.

“Advance care planning is really the off-ramp, entry point or gateway into hospice,” Ryan Van Wert, M.D., president and CEO of Vynca, told Hospice News. “If hospices are looking to engage the greatest number of patients at the appropriate time to benefit from their services, then advance care planning is a primary way in which that goal can be achieved. Most people prefer to have less aggressive care as they move through serious illness, and that means providing the highest quality care by empowering an individual to receive the care that they want.”

Having early and ongoing advance care planning conversations has been positively associated with family satisfaction of end-of-life care, fewer in-hospital deaths, reduced unplanned hospital admissions and shorter hospital stays, according to a study in the March 2019 issue of the Journal of the American Medical Directors Association. Research indicates that advance care planning can reduce hospitalizations by as much as 26%, reduce health care costs, increase community-based palliative care and hospice utilization, as well as significantly increase the likelihood that care will be delivered in accordance with the patient’s wishes.

Hospices have wrangled with barriers in existing public policy and public perception that limit growth of these services, but a turning tide in value-based payment models taking effect this year may have sweeping impacts in expanding advance care planning practices. Participation in these models can help hospices take a more active role in advance care planning.

“Unfortunately, most hospices are either leaving advance care planning discussions up to upstream providers, or they have a relatively limited resource allocation in terms of the outreach function to support these goals of care conversations,” said Van Wert. “That’s understandable, because right now there’s really no payment for that kind of service. That’s one of the benefits that will come from things like value-based insurance designs and otherwise.”

Advance care planning discussions are currently reimbursable through Medicare coverage, with these conversations traditionally taking place in physician offices or other primary care settings. Value-based payment programs such as Medicare Advantage that opened up to hospices in 2021 include a range of new avenues for providers to explore, with advance care planning among the reimbursable services.

Commonly called the Medicare Advantage hospice carve-in, the value-based insurance design model may allow hospices to become a part of these conversations with patients and families earlier on by encouraging collaboration among care providers. Others such as the Primary Care First initiative and direct contracting payment programs also have requirements pertaining to advance care planning.

“One of the things about all of the new risk-bearing or value-based payment systems is that they help to normalize and integrate advanced care planning as part of the ongoing patient care process,” said Susan Ponder Stansel, CEO of Alivia Care, a hospice and palliative care provider headquartered in Florida. “Before it became part of how Medicare Advantage was expected to operate, advance care planning was an outlier sort of thing you did in health emergencies or at the end of a patient’s life. This is putting advance care planning into an expectation for all of these value-based programs, and it’s something to continue to focus on.”

CMS has placed a high priority on advance care planning in part to improve patient outcomes and the quality and experience of health care across the board. Hospices can leverage these programs to engage patients further upstream in the course of their illness.

According to Ponder Stansel, value-based care payment systems are opening doors for hospices. However, much work is necessary to identify best practices for advance care planning so that proliferating those services throughout the care continuum is not such a “heavy lift to get done.”

“[Advance care planning] is there as a requirement and an opportunity, but there’s work to be done on best practice for helping it not be such a heavy lift to get done,” Ponder Stansel told Hospice News. “Just because you get paid for it and just because it’s an expectation, that doesn’t mean it’s going to happen at the rate it should across the board. With a lot of value-based plans there is an incentive for everyone involved to try to do this better. CMS is really focusing on high-need patients and on reducing low-value care to high-need patients. There is a lot of treatment and suffering that can go on without benefits before a patient dies without these advance care planning discussions. It’s a public health issue because it impacts everyone.”