Hospice Palliative Care: Palliative Care in CMMI Programs

This article is sponsored by Axxess. This article is based on a discussion with Fred Bentley, Managing Director for Medicare Innovation and ATI Advisory, Allison Silvers, Chief of Healthcare Transformation at the Center to Advance Palliative Care and Ryan Klaustermeier, Vice President of Professional Services at Axxess. The conversation took place on April 20, 2023 during the Hospice News Palliative Care Conference. The article below has been edited for length and clarity.

Hospice News: Medicare Advantage comes up a lot in discussions at palliative care but that is not the only avenue for reimbursement. We have a wonderful panel I’m pleased to introduce. We spoke earlier about Medicare Advantage. What other CMI models have the potential to support palliative care or help it grow? Fred, would you start with this one?

Fred Bentley: I think the two most obvious and the ones we’ll probably spend the bulk of our time talking about are the Accountable Care Organization models, the ACO models. There’s the Medicare Shared Savings Program, MSSP, which has been around for over a decade now, and is the most common type of ACO out there. You will also probably have heard of the REACH or ACO REACH program, which is building off of what was called the Direct Contracting Program.


That’s basically a higher risk, higher reward version of an ACO. There are fewer of those, but they tend to be a little bit larger. Like I said, they take more risks. As I said, we’ll get into the details. Palliative care very much fits into how ACOs, which are responsible for managing the total care for a patient population, typically 10,000, 20,000, maybe even upwards of 50,000 lives. Obviously, palliative care fits in there. Two other quick programs just to note that CMMI also manages, the oncology care model, which as the name suggests, is focused on, in this case, six-month episodes for patients undergoing chemotherapy.

In the OCM model, as it’s known, they actually wrote in or have a lot of requirements around access to palliative care. Again, we can get into the details on how palliative care is used and honestly underutilized in OCM, but that’s another CMMI program that has an obvious palliative care tie-in. Then the final program I had mentioned is the Kidney Care Choices program, which is for obviously folks with CKD and ESRD, and there clearly is a palliative care component to that as well. I think similar to OCM, there is a role for palliative care. In some cases it’s underutilized and underappreciated in these kidney care models.

Hospice News: Excellent. Allison, what would you like to add?


Allison Silvers: I just want to add two things. One, OCM is now completed, and the new one that they’ve taken applications to but haven’t announced who was given it yet is EOM, Enhancing Oncology Model. That one has palliative care written all over it. There are oncology practices who are participating but they are required to do symptom assessments and then come up with plans to address symptoms and side effects. They also are required in the EOM to have, I forgot what they call them, financial partners that can meet holistic needs.

It’s much more explicit. They didn’t come right out and say you need to partner with palliative care, but they seem to be pushing people in that direction. The other thing I want to mention is Primary Care First, that a lot of the Primary Care First participants happen to be dealing with a multi-morbid population. Many of their patients do need palliative care. Now, whether the primary care practices recognize that is another story, but having the right conversations with Primary Care First is, I think, a fertile ground for doing that.

Ryan Klaustermeier: I agree. That was one of my three. I’m going to go a little bit of a different route. I think there’s room in the Comprehensive Care for Joint Replacement Program. While it’s not palliative in nature, I think if we applied palliative care to that program and spent more time with risk versus benefit and how pain can be managed, and just going a little bit deeper with patients, we might produce different results in those surgeries.

Where I go with that is I’m always curious, and I would love to see a study done sometime, of how many new hips we put in the ground within six months of them being put in, and that’s where I think palliative care can really come in and assist with that. Then the Integrated Care for Kids Program also would benefit from palliative care. That’s for complex care trying to integrate the medical, social, and behavioral services, and what better supplement to that really than palliative care?

Bentley: To add another one, and it’s not announced yet or it hasn’t been launched yet, but CMMI will likely later this year be announcing a dementia care model. Not a lot of details around that but you can imagine that palliative care would be a critical piece of how individuals with dementia are being treated and managed.

HSPN: Thank you, Fred. You heard it here first, ladies and gentlemen.


Allison, I’d like to start with you on this next question. Can you describe how palliative care delivery and reimbursement works within some of these programs?

Silvers: Sure. I do have to tell the awful truth that pretty much it’s still fee-for-service, that there’s a technical difference in the partnerships that organizations can join. There’s a participating partner where you have skin in the game and you get a seat at the table. It’s only one seat among many where things are decided. That’s the participating provider. Then there’s just regular partners, sometimes called preferred partners. They get patients in referral ways the way you’re typically used to it.

Right now, what’s really happening, or at least what seems to be the dominant way that palliative care participates is that there are referral services which provide the service, they build part B, and there are conversations about reconciliations at the end. Depending how things go, it doesn’t always result in quite a lot of cash flow. The other thing that people have been negotiating successfully is investment in the front end. If you want us to be able to respond and have capacity for your patients, then you need to give us some upfront money so we can build that capacity.

Bentley: The only thing I would add, because absolutely, the vast majority of cases or instances where we’ve been involved in negotiating arrangements, it is still very much in the fee-for-service space but with some bonus upside potential, but still, fairly rudimentary. It goes without saying there are some organizations that are actually palliative care providers, serious illness providers who are also ACOs.

If you are running the ACO, it is still a fee-for-service model but you are held accountable for managing the total cost of care for the population that you’re serving. You are eligible for capturing the savings and also having to pay the penalties if you generate that. That’s a very small subset of palliative care providers out there. Yes, for the most part, it is still largely fee-for-service.

HSPN: Ryan, what would you like to add?

Klaustermeier: I agree with you both, especially the two programs I mentioned would still be reimbursed fee-for-service. I think as we start to look at different reimbursement models, especially in care at home, which is where I spend my time, I think of making sure you have the right technology and technology partners to be able to accommodate the unique payment models that people are dreaming of, and so you got to be able to make those things actionable. I think that that’s a piece that gets forgotten when we’re thinking of these important things, is how do we actually collect this data, regurgitate that out so the payer is satisfied with what they’re getting, but then we get paid in return.

Silvers: Can I add a quick thing about the data? I’m sure most of you know this, but you can’t find palliative care in the claims. You can’t find the patients, you can’t find the providers, so that’s a real hindrance. I think there are opportunities to make that more transparent. It’ll fall on the palliative care programs to do that. I guess I just wanted to put in a plug that if you do want a seat at the table, you have to be able to identify, on a claim’s basis, who you’re touching and what you’re delivering.

Bentley: The claims, unfortunately, are still driving a lot of these models, that claim system.

HSPN: Allison, I think I’d like you to lead on this one as well, and then Ryan, we’ll go to you and circle back to Fred. Are the care models that these programs are designed to support consistent with one another? For example, is palliative care in an ACO the same thing as palliative care delivered within Medicare Advantage, for example?

Silvers: I would answer that with a qualified yes. I think the MA plans are very interested in interdisciplinary home-based palliative care and as are the ACOs. I will say a couple of things. The slide that the previous panelists put up about the supplemental benefit, that’s only nursing and social work because a prescribing clinician is covered under part B, so you can’t make it supplemental.

There’s a small number of programs that are social work nurse-driven, often collaborating with a prescriber to round out the team. The other thing that I’ll mention that I’ve heard from both MA and ACOs, but it seems to be much more of a pain point for ACOs, is that they’re not really seeing the value from home-based palliative care that the literature is saying, and there’s some discussion of how long do people stay on, and what are you providing them?

I think this is looking forward, but I think there’s going to be more variation. I think ACOs will be starting in what’s delivered, risk stratifying, some palliative is transitional, some of it is consultative, some of it is long-term, some of it is primary and palliative smushed into one in a home-based model. There’s a lot of variation out there.

Klaustermeier: No, I agree with you completely. I think that the ACO model is going to allow for a lot more flexibility and creativity in the care delivery. I think you can negotiate rates that’s going to allow for a more comprehensive interdisciplinary team than we can in MA right now. I think MA is going to follow, but I think it’s, for example, a PMPM is easier to get out of an ACO than it is MA, and I think that the PMPM allows for more comprehensive IDG to be applied to the program.

Bentley: I would just add two things. At least in the instances that we’ve worked on or partnerships between ACOs and palliative care providers, to your point, the ACOs are, and it’s a sad state of affairs, but it’s reality that they’re still trying to figure out what palliative care is. How does it fit in? In a lot of instances, we’ve seen it be a little more of a transitional model. There’s a time limit on it, but it is helping obviously somebody, say, coming out of the hospital who’s transitioning home, helping with all the symptom management aspects of coming home.

That will likely evolve, I think, but that has been an interesting takeaway that it isn’t this more longitudinal type of palliative care model that I was familiar with. The other interesting thing, and this came up in the last panel, is that under Medicare Advantage, the referral patterns are different. I think by and large, the practice of palliative care doesn’t change a ton and the interdisciplinary aspect of it, but how patients get to you is a bit different, because at least some of the more sophisticated MA clients do have that technology, have done that risk stratification.

They have singled out this patient who needs palliative care. For palliative care you have to sell them on it or convince them of the need as opposed to them having requested it or been referred in by a clinician. I think that more traditional model is still the case, even in an ACO because the ACO is still a fee-for-service model and it’s just not as tightly managed. I do think the ACOs are getting more sophisticated, but they don’t have those sets of algorithms and that ability to risk stratify and target, and recommend folks for palliative care.

HSPN: Fred, I’m going to keep the spotlight on you for another minute. Can you talk about what a provider looks like when they are ready to participate in a value-based model? As an organization, what qualities should they possess?

Bentley: I’ll cheat by saying it depends. I think it is important to talk about what are the ways that you can participate because that does run the gamut from you just happen to be part of maybe a preferred partner or part of an ACO’s network. You may go to a couple meetings, but other than that, life doesn’t change, because ACOs are still a fee-for-service model, and if you deliver a service and you bill for it, you’re going to get paid for it. That’s the very basic model all the way up to, we are launching our own ACO, we’re running what’s called a high-needs population ACO.

It’s a reach ACO that is just for very sick, high acuity patients, which that’s who palliative care is serving. The vast majority of palliative care providers, I think, are somewhere in the middle. When you think about the providers that are ready to step up and negotiate, it is still largely fee-for-service, but more bonus upside opportunities, and in some cases some risk arrangements where you are taking more upside and downside financial risk. The technology piece is an obvious point. What I’d say there, it is two things that I think that really set the organizations apart that we work with that we think are ready for this.

One is you do, admittedly the claims data is too challenging, but whether through claims or through EHR, you can demonstrate superior performance. You can’t just say, “We’re really good. We think we provide palliative care, and you should work with us.” That’s not particularly successful, even for very large organizations that cover geography. Being able to demonstrate superior performance on quality and efficiency metrics is critical. The other technology piece of this is the data exchange and your ability to both bring in the data and then share that out to the broader network.

There is a scale piece. In this case, it is true with Medicare Advantage plans, it’s also true with ACOs. They would prefer to enter into value-based arrangements with organizations that don’t have to serve all 10,000 or 20,000, but you need to match the geography or there needs to be a fair amount of overlap.

That just makes it much more attractive and easier from them from a contracting standpoint. The last thing I’d say is, and I think this is tricky for palliative care providers who aren’t part of a broader care continuum, but some evidence that you know how to manage risk, that you’ve been in some advanced payment model, I think is advantageous. It’s obviously very advantageous if you’re sitting down because you then know what you need to negotiate for. I think those are the things that you’d have to check the box on at this point to really go far in value-based care.

HSPN: Ryan, we’ll go to you next, please.

Klaustermeier: I think Fred hit some great points and the technology element is key. Especially the health information exchange and having the ability with other technical vendors to navigate, especially if you’re in the care at home from acute care records to home, and back and forth, and all that exchange, which is possible, but you just have to have the ability to do that. One of the things that I thought of with this right away is you have to have working capital and be prepared to financially invest to get this thing rolling. It’s not a field of dreams where you build it and it will come.

You have to be financially prepared and sound, and have a foundation to move forward with these types of programs. Then I just want to reiterate that the ability to scale, I think is important. I think everyone wants to start here, but as soon as this is going well, they’re going to want it to go here very quickly and you’re going to need to be able to accommodate that. Lastly, just from the human element, having a healthy agency that can maintain change management. This is going to be new for an organization. It’s new things to learn, it’s additional responsibilities, and you have to make sure that the health of your team is prepared to pursue something like this.

Silvers: It’s interesting. I have a different list. I would say that one of the most important skills for both ACOs, EOM, whatever is to be able to talk to the leadership in a way where they could pinpoint where their pain points are and you could pinpoint why you can solve for them. At CAPC we call that a needs assessment, but having skill at that is probably the foundational skill that you would need. I would also add, depending on what they say, being prepared to embed the advantage of some of these CMMI models as opposed to MA is that it typically is clustered at a particular location.

Again, picking oncology, it’s an easy one. Heart failure is another great one that palliative care can make a real difference. Seeing if you could set your team up right there onsite, build those relationships with the clinicians and the patients, but also be able to deliver a drive-by consultation and that’s how you could make an impact there. The third thing I’ll add is capacity for new admissions.

This, I guess, gets into how long do you keep people in service? I have heard a lot of ACO people being very frustrated that they’re like, “We have this palliative care program but there’s a three month waiting list. What’s the point? We don’t really have a palliative care resource.” Just plan your population and how you make your visits in a way that if there’s an urgent need, somebody who’s urgently needed can be seen immediately.

Bentley: I think the capacity point is so spot on, and it’s a moot point if you can’t actually take or you’ve closed for new patients. Ryan’s point on the financial piece is really interesting, but there’s also a recognition and I think a hallmark of organizations that are ready for this, is a recognition that you need to play the long game financially. Because of the way ACOs work, you really don’t find out until after a 12-month period whether the ACO as a whole, not just your organization or your part of the ACO, but the ACO as a whole achieved savings.

If they were able to keep costs down below a certain spending threshold. Once they do that, then the ACOs disperse those dollars to all their different partners. It’s recognizing that you will enter these partnerships and you may not see the financial upside for 13, 14, 15, 16 months. The cash flow, it’s a different model and you have to be thinking about this not as like oh, wow we’re going to start getting bonus checks here. They’re going to start rolling in. It doesn’t work that way in the ACO world.

HSPN: Ryan, I’d like to put the spotlight on you first for this next one. What are some of the questions that a provider should be asking when they start to talk contracts with an ACO?

Klaustermeier: I think for me, Allison hit it, what are their pain points? What is their end game? What are they wanting the palliative program to alleviate within their program? I think having a firm understanding of what their objectives are, and your ability to assess whether or not you can help them meet those objectives is really where you have to start. I think having the ability to have skilled conversations and know what questions to ask is absolutely vital. Should we go down the line? Allison, would you like to follow up?

Silvers: Sure. I guess I answered part of this question before, but I will also add that if you’re going to be talking to not the providers necessary but the care managers, I think you’re going to get some really great insights. If you can get to the people who are in charge of care management, care coordination, you’re going to hear different things. I think if you could just make sure when you’re asking what are your pain points, where are the high needs, where are people bouncing back, what kind of diagnoses, what kind of family situations, what zip code, then you’re going to get a lot of really usable information from the care management as opposed to the leadership. It’s multiple conversations, I guess.

Klaustermeier: I just want to reiterate what Fred said too, but it’s just with the ACOs, they are a little more antiquated than the MA plans right now as far as risk stratification and identifying those patients. I think asking them how they plan on identifying those patients is a really important conversation to have because that really impacts what your program is going to look like and how long you provide care. That was a great point, Fred.

Bentley: I would also be asking them sort of those questions around proof in the pudding just because for most palliative care providers that are negotiating with an ACO, you can maybe negotiate some sort of quality bonus, but really the play is we’re part of this network, we should be seeing more referrals. Prove it. Walk me through examples of where you’ve entered into partnerships maybe not in palliative care but for other types of more specialized services. Is there evidence that you’ve actually been able to shift where patients are going and increase referrals, obviously following patient choice or allowing for patient choice which is sacrosanct and Medicare fee-for-service?

I think that’s critical. Then along those same lines, have them walk you through how they have done risk sharing with other providers especially outside of primary care. ACOs have all sorts of risk sharing upside-down arrangements with the primary care groups that typically form the basis of an ACO. Once you start venturing past that, the level of sophistication and knowledge, and track record around that really starts to drop off. I think that’s where you start to feel out. That’s not to say if they don’t have examples at the ready that you stop talking to them, but you have to gauge, this is a group that really hasn’t done this so we can’t expect a ton from it, and should be a little more careful.

Silvers: Can I get just one quick point when you’re talking about primary care? These are patients that have multiple needs that it’s not hospice care. They have a lot of disease-directed care needs. We’ve heard that some palliative care programs draw a line between, know where we’re palliative, we’ll take care of this but we won’t manage hypertension. That whole bunch of stuff that patients have done to them. You should assess for yourself if you can meet the primary needs, that’s better because then you’re a holistic package.

If you assess that you don’t have that skill set, don’t just say we’re just going to do this, we’re going to go in, and you know what? There wasn’t anything for us to do and go out. I really would encourage you, then at least take on the responsibility of coordinating. We went in, their hypertension was out of control. We’ll make sure that somebody’s on top of that so it doesn’t always flow back to the other. You’re an added layer of support and you really have to add that layer from the perspective of definitely what the patient needs, but also what the ACO or primary care practice, or whatever it is needs. I just wanted to add that.

HSPN: What are some red flags that palliative care providers should be looking for as they go into these contract negotiations? Fred, would you start?

Bentley: Yes. This may be a little too pointed but it’s just based on my experience. ACOs that are based and run by academic medical centers, big teaching hospitals, big hospital systems, they take care of their own first. I think they’re big and bureaucratic. They’re still very much heavily rooted in the inpatient world even now well into 2023. You don’t want to rule out any ACO, but I would be particularly wary of those organizations.

I think another red flag is when you ask about how they do interdisciplinary care, and this is true of academic medical centers, they’re listing off all the different specialties and subspecialties. You can suss out pretty quickly, does palliative care or the types of services that palliative care, and the types of patients treated by palliative care, does that even figure into the discussion? I think a lot of the academic medical centers are just very difficult to work with.

Silvers: I wouldn’t throw academic medicine under the bus just like that. I think what you’re hitting on is hospital-based. Hospital-based has real strong competing priorities. When you come with a potential solution that’s going to cut their volume in half, it’s concerning. The other, I guess I’ll just raise a red flag about termination clauses. I know organizations have learned this the hard way. Don’t get into something that doesn’t have a favorable termination clause. If you want to get out, you need to have that escape hatch, so make sure it’s there.

HSPN: Excellent. Ryan, would you bring this home for us?

Klaustermeier: Sure. You started with hospice and switched to palliative care when you started. I’m actually going to loop it back around to hospice. I’ve witnessed some programs that I think have been a barrier to access to hospice. That is something that I would investigate, and how they’re delivering their program. Especially like a dialysis-based program, I’ve seen them continue on, and it’s time for hospice, and then it’s a five-day length of stay. Making sure that the identification of when to switch them to the appropriate level of care is well embedded within their philosophy as well.

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