When deployed at scale, palliative care can help achieve many of the health care systems current goals, including reduced costs, improved patient satisfaction and quality of life.
Despite this potential, existing programs hit barriers created by misconceptions about palliative care among referring physicians, as well as health equity concerns, among others, according to an analysts of four payment model demonstrations carried out by the Center for Medicare & Medicaid Innovation.
The agency’s findings will likely inform the development of future payment models as the U.S. Centers for Medicare & Medicaid Services (CMS) takes a multifaceted approach to further palliative care integration.
This could include demos that fuse palliative care into Accountable Care Organization (ACO) or primary care programs, among others, Ellen Lukens, deputy director of CMMI said at the Hospice News Palliative Care Conference in Washington D.C.
“In terms of models, in general, we’re really thinking about how we leverage accountable care and primary care models and other models to provide flexibility to do different things in things like palliative care,” Lukens told Hospice News at the conference. “It’s really important to give providers and other entities that are testing these models tools to be successful. Thinking about where we go from here, that’s a really important context as we think about the future of palliative care.”
The CMMI analysis examined four programs that the center implemented during the past several years, the Medicare Care Choices Model (MCCM), the Health Care Innovation Awards (HCIA) Community-Based Palliative Care demonstration by Duke University’s Four Seasons Compassion for Life, HCIA Advanced Illness Management project by Sutter Health and the Medicare Health Quality program by Meridian Health System.
CMMI selected these four because participating providers offered palliative care to enrolled Medicare fee-for-service beneficiaries with serious illness, including home visits by interdisciplinary clinical teams. The agency evaluated results based on several metrics: total Medicare spending, service utilization and patient and family satisfaction.
The service utilization component included factors such as transitions to hospice, emergency department visits and inpatient admissions.
Each of the four programs demonstrated palliative care’s potential for generating savings and improving quality to varying degrees.
“Beneficiaries and caregivers reported that their quality of life improved as a result of better symptom management by the palliative care team,” CMMI indicated in its analysis. “Enrollees and their caregivers also benefited from psychosocial and spiritual support, referrals to community-based resources (e.g., caregiver education and support), and help with shared decision-making.”
The MCCM model, for example, reduced total Medicare spending among beneficiaries served by 14%. It also decreased ED visits by 14% and inpatient admissions by 26% while boosting hospice enrollment by 29%. Total savings per patient reached $7,254.
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 later extended the program until December 2021.
Among the four programs, only HCIA-Four Seasons resulted in increased per-patient Medicare spending. Because the project increased enrollment by 59%, it resulted in higher hospice expenditures. Participants also used more care in skilled nursing facilities, though the program decreased ED visits and inpatient admissions.
Lessons learned from these projects will help inform palliative care aspects of other existing and forthcoming models from CMMI.
“A comprehensive approach to palliative care, including access to interdisciplinary teams, home visits, and shared decision-making could improve beneficiary care, appropriately adapted to the target population and setting,” the CMMI report said. “The Innovation Center has been exploring ways to integrate palliative care into the new Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) model, Medicare Advantage Value-Based Insurance Design (VBID) model, and Enhancing Oncology Model (EOM).”
The analysis did identify some significant barriers to expanding palliative care. Among them were misconceptions among referring physicians as to the nature of those services, according to CMMI’s analysis. This made it difficult for participating providers to reach their targeted patient populations.
CMMI concluded that future palliative care projects will need to focus on improving enrollment in order to produce the evidence needed to scale them throughout the Medicare program.
Among the center’s proposed interventions to boost the potential impact of future demonstrations is to improve integration of palliative support in primary and specialist care practices, giving referring providers better tools to identify persons who could benefit from palliative care, and new strategies to ensure health equity.
“Palliative support improved beneficiaries’ and caregivers’ experience of care and quality of life through 24/7 access to the care team, home visits and shared decision-making,” CMMI indicated. “However, misperceptions about palliative care made it difficult to recruit and enroll beneficiaries across all four projects.”