Limited pathways to reimbursement and workforce shortages are the largest hurdles for growth among community-based palliative care programs.
Building partnerships with other providers can help mitigate these barriers, according to Dr. Nathan Goldstein, professor of geriatrics and palliative medicine for the Icahn School of Medicine at Mount Sinai.
Some providers have a learning curve around the complex process of working out payer contracts and sustainable business models for their community-based palliative care programs, according to Goldstein.
While they may have the clinical insight to deliver these services, they may have limited experience negotiating contracts specifically for palliative care, which can be particularly challenging in the absence of a standardized care model and payment structure, he said.
“At Mount Sinai we’re really good at creating new models and proving they work to improve care for the sickest patients with serious illness,” Goldstein told Hospice News during the Palliative Care Executive Webinar Series. “But we’re not so good about going out there in the community and figuring out how to bargain with insurance plans.”
As Mt. Sinai looked to expand its palliative care program, the health system opted to pursue partnerships with providers that have a longer history of developing payor contracts for those services. Prior to this initiative, the program was supported primarily through grants and philanthropy.
Last year it launched its community-based Palliative Care at Home Program through Mount Sinai Health System’s joint venture partnership with Amedisys Inc. (NASDAQ: AMED) subsidiary Contessa.
This year the two partners strengthened their JV by forming Mount Sinai at Home, a new entity that provides hospital-at-home, palliative care, and other services. Tennessee-based Contessa and Mount Sinai first partnered in 2017 to provide these services, adding Mount Sinai’s home health agency into the fold with the expansion.
“Working with Contessa, we knew our community needs and they were able to come in and say here are the challenges when you try to expand it across the country,” Goldstein said. “We learned a tremendous amount from Contessa and Amedisys around how to scale the palliative care program. It was putting our shared knowledge on paper and asking how much of this needs to be scaled and tinkered with. Contessa’s expertise in negotiating with insurers, but also scalability and dissemination.”
Based in New York City, Mt. Sinai is among the largest academic medical centers in its area and among the biggest teaching health systems nationwide. However, about 50% of community-based palliative care providers are hospices, according to the Center to Advance Palliative Care. These hospice-based programs are contending with the same pressures from limited reimbursement and labor headwinds.
Currently Medicare reimburses for palliative care physician and licensed independent practitioner services through fee-for-service payment programs that do not sufficiently cover the full range of interdisciplinary care. 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.
Some value-based payment models incorporate palliative care elements. The U.S. Centers for Medicare & Medicaid Services (CMS) allows Medicare Advantage plans to cover palliative care as a supplemental benefit.
This challenge of developing a business case, backed by data, can be difficult for providers who are newly stepping into value-based payment, said Goldstein.
The difficulty lies in how to illustrate their value-proposition to health plans as far as patient outcomes and cost savings., he said.
“There is complexity around the business case and figuring out how to lead with that, how to make that and getting insurers and payers to actually see it,” Goldstein said. “The issue is in the long-term and down the road, not at the bottom of the spreadsheet. It’s trying to adjust it to a way that they can understand in terms of the bottom line and when they’re gonna see the return on an investment and figuring out how to scale it fast enough so the return on investment is visible sooner rather than later.”
Key to working towards the returns payers are looking for is ensuring that a palliative care program is sufficiently staffed. Labor headwinds that have strained providers’ ability to grow these services have only gotten worse during the past two years in a pandemic.
This too, is an area where partnerships can shore up resources in a tight labor market, according to Goldstein.
The palliative care component of Mount Sinai and Contessa’s JV has a training arm that educates clinicians on skills in communication, symptom and disease management, and how these fit into the overall health care delivery model.
The partners also pool clinicians together to provide education and to deliver patient care, which has contributed to the program’s sustainability as well as the return on investment equation, according to Goldstein.
Having different perspectives from various sides of the provider spectrum weigh in on training and patient care can go a long way towards fostering the scale and growth of palliative care services, he added.
“Many of the folks who work with our Palliative Care at Home Program also participate in one way or another in the hospital-at-home program. We have a blended model where some folks are employed by Mount Sinai and some by Contessa, while others are fully remote,” Goldstein said. “It’s a cohesive team who sits through interdisciplinary rounds and discusses patients and can be staff employed by different organizations behind the scenes. We continue to scale the program and teach others how to expand in different areas. We have a couple sites already signed on, and we’re continuing to do that.”