Limited reimbursement opportunities are complicating palliative care providers’ ability to bring their services to seriously ill patients. This problem is often exacerbated in rural areas due to low population density, potentially long travel times to reach patients in remote areas and lack of infrastructure.
Karla Weng, senior program manager for the health care quality improvement organization Stratis Health, recently presented on the challenges that providers face when developing financially sustainable palliative care programs to support rural patients. A 20-year veteran of the industry, Weng has spearheaded programs to support rural health care providers, improve quality and patient safety and implement population health methodologies.
Hospice News caught up with Weng to talk about the gaps in care that the system needs to fill and how payment models need to adapt to keep up with patient needs.
Can you expound on some of the challenges that are involved in trying to bring access to hospice and palliative care to rural patients?
There certainly are pretty big gaps in the country, particularly in the more frontier areas where the services just aren’t available. They often don’t have the volume of patients or resources to meet the requirements to offer formal hospice services.
In our most recent effort, we were focused on supporting development of palliative care services in rural communities. I would say maybe half of the communities we were working in didn’t have hospice available. In some rural communities, when they’re trying to figure out ways to provide palliative care services, they do have that hospice resource to be able to build on as a foundation. Oftentimes it ends up being kind of a wrap-around, working with the hospice staff and connecting with other community resources to provide those services.
If you’re in communities where there’s no hospice available, then you’re really at a different starting point in terms of skills and resources.
You’ve spoken about the need for providers to establish relationships with other community organizations and support systems. Can you give some examples of the types of organizations providers should be working with?
It looks different across rural communities. For the teams that we’ve worked with, they typically engage the full suite of health care providers that are in the community. This includes traditional partners like assisted living, home care, long term care, clinics and those kinds of supports.
Oftentimes, they might work with local clergy. A lot of the rural providers may not have chaplaincy services, so local clergy are engaged to help provide that support. They may work with perhaps the local pharmacist or senior services and volunteers. They often work with public health or social service agencies that might be doing Meals on Wheels, or other services and support. It becomes a pretty good mix of who is in their community and what resources they can tap into outside of the more traditional partners.
What kind of business-case opportunity does value-based contracting offer to providers that could help address these needs?
For palliative care, there’s not a really good reimbursement mechanism in most states. You can get paid for some of the provider visits. If you’re doing the coding, you can get some advanced care planning reimbursement or chronic care management billing. But it’s a challenge to have that direct reimbursement for a full interdisciplinary team.
If you are participating in a value-based purchasing arrangement, an Accountable Care Organization for example, you have responsibility for a set of members or patients and are looking to both improve their care and help manage their total health care costs. By providing palliative care services, you can oftentimes help reduce emergency room visits, prevent hospitalizations and provide some additional support. There might be some cost savings that then actually accrue back to the organization because they are participating in a value-based care arrangement.
It’s a cost savings argument in terms of how you think through the business case of how you’re supporting palliative care. I’m not sure anybody’s doing that as a sole source, especially in a rural community. For the most part we see in rural communities that they’re offering the services because they think it’s really important. Then they are trying to figure out ways to help offset the costs.
What needs to change in terms of reimbursement to really meet the palliative care needs within rural communities?
I would love to see a Medicare fee-for-service benefit that is more comprehensive in terms of the interdisciplinary team that’s needed to serve palliative care. That would probably be the easiest route.
I do think there’s a lot of opportunity under the value-based arrangements. Rural providers get paid differently for the most part in terms of critical access hospitals and rural health clinics. Some of the incentives might help support services in an urban area don’t apply. For example, the [the U.S. Centers for Medicare & Medicaid Services (CMS)] hospital readmissions reduction program in which the hospitals have a penalty for readmissions doesn’t apply to critical access hospitals.
I think opportunities to connect the dots and provide support or reimbursement for more of an interdisciplinary approach or have more consistency in value-based reimbursement would also work.
For example, there’s the Pennsylvania Rural Health model where the participating hospitals get paid on a global budget. A couple of them have been able to leverage participation in that model to help support development of palliative care services in their community, because the financial incentives are more in-line
In the absence of a Medicare benefit and the limited availability of value-based contracting, what are providers doing now to make their programs financially sustainable?
They’re essentially trying to braid together what they can. Most are billing for what they can. If they are in a value-based arrangement, they are trying to line up the dots underneath that. Certainly, some are using grants or philanthropy dollars to help make the ends meet. That works quite well for program development, but isn’t quite the same as having an ongoing kind of payment mechanism.
It’s really a combination of those, paired with the fact that a lot of the communities that offer this have just decided it’s something that they need to do in terms of providing high quality care in their community.
I think in rural communities oftentimes word of mouth is a good marketing opportunity. There’s some recognition when they’re able to provide that really high quality, interdisciplinary care to community members when they’re at their most vulnerable. A lot of times that word spreads in their community and can be an important aspect in their relationships with the community members and partners.
Right now, there’s not an easy answer. It really is a braided strategy that’s underpinned by the belief that it’s the right way to deliver care. So they’re going to figure out a way to kind of make it happen. We certainly do see that as a limiting factor for some of the programs. We have seen programs that recognize that there’s probably more need in their community for the service than they’re able to provide. They’ve pulled together what they can with the resources that they have. If there was something more consistent in terms of reimbursement they might be able to do even more.
Has the recent boom in telehealth during the pandemic helped to relieve any of the pressures on rural providers and help increase access for patients?
I think it’s an interesting conversation. There are opportunities to use telehealth as a mechanism to help support this type of care, and we’ve seen some of the rural communities using telehealth to support palliative care services. However, if you’re talking about delivering services to people in their home, there’s a bandwidth issue. There’s a lot of rural places in the United States that do not have high-speed internet or sometimes internet access at all. That is an issue.
Telehealth is an important piece of the puzzle, I don’t think it’s the silver bullet answer. It’s pretty important to have connections to other resources in the community. Telehealth may add some value, but if it’s not connected to the other local services then it’s a real missed opportunity. It’s part of the solution, but I don’t think it is the total solution.