Establishing a dedicated community-based palliative care benefit within Medicare has been a critical goal for many providers nationwide, but the COVID-19 pandemic has led stakeholders to redouble their efforts. The outbreak exposed millions of people and their families to serious illness, and a sizable contingent is realizing that they could have benefited from interdisciplinary person-centered palliative care.
Providers have seen a rise in demand for palliative care during the last year. More patients and families are also seeking serious illness care in their homes — a trend that began in earnest long before the pandemic, but the pace has accelerated.
COVID-19 has made the need for a Medicare palliative care benefit all the more pressing, according to National Hospice & Palliative Care Organization President & CEO Edo Banach, speaking at the Hospice News Palliative Care Summit.
“Much like other situations we found ourselves in within this country with various illnesses, we didn’t have the tools as a country to deal with [COVID-19],” Banach said during the summit. “People had to get sick; people had to decline; people had to be hospitalized; and people were lucky if they made it out alive. When I began to talk to [the U.S. Centers for Medicare & Medicaid Services (CMS)] about community-based palliative care, it was in the context of making sure that we had a benefit.”
These factors have contributed to a new sense of optimism for some in the field. Though nothing is certain, a community-based palliative care benefit may emerge from CMS during 2021, according to Banach.
“We have had really good conversations and receptivity both with the last administration and increasingly with this administration at the political level and then also at the staff level, which lead me to make statements [that] I am hopeful this is going to be the year we finally get a benefit we can wrap our arms around,” Banach said.
Complicating the move towards an established benefit is the lack of a standardized definition of the term “palliative care.” CMS defines these services as “patient and family-centered care that optimizes quality of life by anticipating, preventing and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and to facilitate patient autonomy, access to information and choice.”
A community-based benefit would likely originate as a Center for Medicare & Medicaid Innovation (CMMI) demonstration project designed to allow patients to receive palliative services concurrently with curative treatments. Patients would be eligible to receive palliative care without the six-month terminal prognosis currently required for hospice election. Such a program would also need to be supported by robust quality metrics.
“There are many kinds of entities and many kinds of people who could benefit from holistic, interdisciplinary community-based care,” Banach said. “This would be a pre-hospice demo that would pay a certain amount of money for providers to offer concurrent care. If we end up having successful metrics, then the endgame for that would be a community-based palliative care benefit, not a demo any more, but a benefit in Medicare.”
Currently Medicare reimburses for palliative care physician and licensed independent practitioner services through fee-for-service payment programs that often do not sufficiently support the full range of interdisciplinary care.
Absent a dedicated payment model, many palliative care providers are turning their eyes towards Medicare Advantage. CMS in 2020 began allowing Medicare Advantage plans to cover palliative care as a supplemental benefit. Recent analysis by the consulting firm ATI Advisory indicated that the number of Medicare Advantage plans offering home-based palliative care coverage jumped to 134 in 2021, up from 61 last year. Other supplemental coverage such as In-home support services, food services and social needs benefits also saw a substantial rise.
Additionally, CMS is currently testing the inclusion of hospice in Medicare Advantage through its value-based insurance design model demonstration. Often called the Medicare Advantage hospice carve-in, this demonstration is driving many hospice providers to diversify their services to include more upstream care. Only 53 Medicare Advantage health plans are participating in VBID during 2021, but that number is expected to grow in subsequent years.
A move to Medicare Advantage in hospice will foster palliative care growth, according to Denis Viscek, CFO of California-based By the Bay Health.
“If you don’t have a palliative care program, you’re rowing upstream and you’re going to have a tough time getting in front of the managed Medicare Advantage programs and being appealing to them,” Viscek told Hospice News at the summit. “They want to see this continuum of care, this seamless movement of patients.”