CMMI Working on Payment Models That Include Palliative Care

The Center for Medicare & Medicaid Innovation (CMMI) is developing new reimbursement pathways for palliative care.

As part of that process, CMMI is applying elements of its Medicare Care Choices Model (MCCM) demonstration, which ended Dec. 31, 2021, according to a new CMMI white paper. MCCM was designed to test the impact of concurrent hospice and curative care.

“Aspects of MCCM are being used in the development of new CMS Innovation Center models related to palliative care,” the center indicated in the white paper.

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To date, the U.S. Centers for Medicare & Medicaid Service (CMS) has not announced a specific palliative care payment demonstration nor any details about a future model. Those now in development at CMMI may or may not be dedicated exclusively to palliative care, or they could include those services as part of a larger program.

MCCM showed some of the strongest results in terms of cost savings and patient and family satisfaction among the 21 payment models and demonstrations that CMS examined in the white paper.

“MCCM beneficiaries ultimately appeared to have received better-quality end-of-life care according to established quality measures, such as spending more days at home at the end of life,” CMMI authors wrote in a report attached to the paper. “They also had lower average Medicare expenditures and acute care service use than beneficiaries in the comparison group, due in large part to increases in hospice use among model enrollees. Thus, the model provides important lessons for policymakers.”

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Such an announcement would be welcome news to hospices and palliative care providers, who often finance their programs through grants or philanthropic donations. Others run their palliative care businesses as loss leaders in hopes of driving increased or earlier hospice referrals when patients become eligible.

A range of stakeholders in the space — and some lawmakers — have called on CMS to establish a dedicated community-based palliative care benefit within Medicare.

“I’m optimistic that we see some progress and potential closure on the formalization of a community-based palliative care demo,” Nick Westfall, CEO of Chemed (NYSE: CHEM) subsidiary VITAS Healthcare, told Hospice News earlier this year. “As a country, we really need to get formalization around what palliative care is going to mean in a community-based setting, the services, and who is going to provide those services.”

Some of those advocates have suggested that MCCM could form the basis of such a model.

CMS launched the MCCM in 2016 to explore the idea of allowing hospice patients to receive concurrent curative care. Initially slated to complete in 2020, CMS extended the program until December 2021.

The total net cost of care for MCCM patients was 14% less than those for a control group, generating about $7,254 in savings per individual, CMMI’s recent white paper indicated. This was largely due to a 26% reduction in hospitalizations, a 28% drop in readmissions, and a 14% fall in emergency department visits.

Those who were hospitalized spent fewer days in intensive care units and had shorter stays, according to CMS. They also were more likely to eventually accept the Medicare Hospice Benefit. About 83% of enrollees transitioned out of MCCM and into traditional hospice, which accounted for nearly 70% of the savings, the agency reported.

A CMMI comparison of 21 payment models and demonstrations found that the MCCM improved outcomes and reduced costs. (Chart by CMS)

MCCM was the only model that yielded significant improvements in self-reported patient and family satisfaction among the 21 programs that CMS analyzed for the white paper.

CMS cited a few caveats in its impact analysis, such as relatively low rates of enrollment in the program and some differences in patient/provider characteristics compared to non-participants. These factors complicate the agency’s ability to gauge how well the specifics of this model would apply to the general Medicare population.

“Our impact estimates largely align with the expectations of the model — that is, they match the pattern of outcomes MCCM intended to produce,” CMS said in the report.

About 141 hospices participated in MCCM, enrolling a total of 6,427 patients during the course of the demonstration, according to CMS. They provided care coordination and case management, 24/7 access to care, person- and family-centered care planning, shared decision-making, symptom management, and counseling.

The participating providers, most of which were larger organizations and/or nonprofits, received payments of about $400 per individual, per month, for patients enrolled in the program. These patients were Medicare beneficiaries with a six-month terminal prognosis with a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS.

“Although their paths varied, MCCM beneficiaries and their caregivers ultimately appeared to have received better-quality end-of-life care according to established quality measures, such as spending more days at home at the end of life,” CMS indicated in its analysis of the program’s results. “Moreover, because we found increased hospice use accounted for substantial savings, this evaluation suggests efforts to increase exposure to palliative care options and reduce barriers to hospice enrollment could be a promising approach for achieving Medicare savings.”

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