Though revenue streams for palliative care are often shallow, these services can generate sustainable growth for providers who can play their cards right with payers.
Providers walk a tightrope when it comes to ensuring that their palliative care services are financially sustainable, according to Lynn Spragens, founder and partner of Spragens & Gualtieri-Reed, a North Carolina-based health care consulting company.
Trying to manage care delivery needs while running a palliative care business can be frustrating for leaders and “really throw [them] for a loop” financially, Spragens said, speaking at the American Academy of Hospice and Palliative Medicine (AAHPM) and the Hospice and Palliative Nurses Association (HPNA) Annual Assembly.
“[It’s] trying to provide context to help you think creatively about how you can make the business needs complement your priorities,” Spragens said. “It’s hard for business leaders in the operational throes of things to think about. You’re not going to justify your existence based upon your tremendously great billing when it’s not sufficient. Even though billing will not justify your existence, it’s still important to be good at it.”
When it comes to palliative care, billing teams need to have a firm grasp on the different levels of codes to apply when submitting claims, she continued. This can be challenging when reimbursement takes on different forms in various payment models, Spragens said.
Primarily, palliative care providers can bill for physician services through Medicare Part B, and also through supplemental benefits included in Medicare Advantage. Other reimbursement options exist via payment arrangements with Accountable Care Organizations (ACOs) and Managed Services Organizations (MSOs). Palliative care is also part of the hospice component of CMMI’s value-based insurance design (VBID) demonstration.
Payors are increasingly recognizing the value proposition of palliative care services, especially those that operate in the value-based reimbursement sphere, according to Allison Silvers, chief health care transformation officer at the Center to Advance Palliative Care (CAPC).
“There is growing interest among Medicare Advantage plans to improve access to palliative care,” Silvers said during the assembly. “And they do understand the math that better payment results in more access.”
Value-based payers are seeking to work with providers who can demonstrate lower high-acuity utilization and reduced health care costs, including expensive emergency and urgent care services. There are data that palliative providers can gather and report across many care points in the continuum that they touch, including in the home, Silvers said.
“There is growing interest among Medicare Advantage plans to improve access to palliative care. And they do understand the math that better payment results in more access.”— Allison Silvers, chief health care transformation officer, Center to Advance Palliative Care (CAPC)
Current reimbursement pathways are insufficient to support palliative care providers and their patients, she added. However, payers are incentivizing health care providers to work across the continuum to improve patient quality and care coordination, two keys tied tightly to cost metrics.
For instance, hospitals in some value-based arrangement models can earn quality bonuses through having a good palliative care program that meets certain criteria, Silvers said. Value-based insurers determine the bonus by looking at how many appropriate patients received a palliative care consult during a hospital stay against those who did not, she explained.
This is just one health care setting that payors are eying for palliative care reimbursement. More opportunities exist in other facility- and home-based spheres, according to Silvers.
“There’s a growing industry of conveners putting together groups of providers who then work with the payer to organize value-based payment, often in Medicare Advantage,” she said. “So as these Medicare Advantage plans are getting smarter to the value of palliative care, so are these conveners. And they make it a lot easier [for] community-based programs who may not have the juice to knock on the door of [UnitedHealth Group’s (NYSE: UNH)] or [Anthem Inc. (NYSE: ANTM)] to get something going. By joining these convener networks, that gives you an opportunity. There’s a lot of opportunities for financial partners to participate in shared savings.”