New legislation is leading some hospices to consider what a potential community-based palliative care payment demo would mean for them — as well as what it would look like.
Four U.S. senators recently introduced a bipartisan bill that, if enacted, would steer the Center for Medicare & Medicaid Innovation (CMMI) to develop a palliative care-specific payment model demonstration.
Having this kind of payment avenue could have significant impacts on community-based palliative care providers, according to Davis Baird, director of government affairs in hospice at the National Association for Home Care & Hospice (NAHC). To date, lagging reimbursement has been a barrier to home-based serious illness care, he said.
“A dedicated community-based palliative care benefit that is properly reimbursed would definitely catalyze growth and sustainability of these programs,” Baird told Hospice News in an email. “Lack of adequate payment is the number one barrier currently to scaling and supporting these programs. Because hospices provide the majority of home and community-based palliative care in today’s system, it would signal an especially promising opportunity for hospice providers who deliver it now, or who would be willing to build out the capacity to do so.”
A more competitive market
Hospices represent roughly 41% of community-based palliative care providers in the United States, according to a recent report from the Center to Advance Palliative Care (CAPC). The report includes insight from 83 home-based palliative care programs that together serve more than 38,000 patients annually in rural, urban and suburban communities across the country.
Hospital systems are right behind them with 34%, CAPC found. The remainder includes primary care, physician groups and home health agencies, respectively.
If CMMI were too roll out a community-based palliative-specific (CBPC) payment model, it could have an influence on other home-based providers in the space, as well as how they shape care delivery models, according to Allison Silvers, CAPC’s chief health care transformation officer.
“I think home health care agencies or Part B medical groups have more experience in collaborating across multiple providers to meet needs,” Silvers told Hospice News. “And some hospices may need to improve their capabilities in meeting palliative needs while coordinating with other providers to deliver comprehensive care.”
I think home health care agencies or Part B medical groups have more experience in collaborating across multiple providers to meet needs. And some hospices may need to improve their capabilities in meeting palliative needs while coordinating with other providers to deliver comprehensive care.— Allison Silvers, chief health care transformation officer at the Center to Advance Palliative Care
A dedicated CBPC payment model could spark interest from other health care providers to increasingly step into community-based palliative care, Baird said.
This could have hospices swimming in more competitive streams to attract payer interest in their services, he added.
“It would probably increase interest in the area from non-hospice provider types, which would intensify the competition,” Baird said. “But there is already competition in the community-based palliative care marketplace, and it is growing even in the absence of a dedicated benefit, as Medicare Advantage and other risk- and value-based payment models proliferate. We are not at a point yet where non-hospice entities are out-delivering hospices on CBPC, but other players are stepping up their efforts.”
Quality will also be a key driver as hospices both work with and compete against other health care providers in the community-based palliative care payment realm, Silvers stated.
“I think in terms of competition, the ‘winners’ will be the ones that truly deliver responsive, high-quality care to their patients — like responding with clinically-meaningful interventions off-hours when a crisis occurs, or delivering expert palliative care services that reduce symptoms and stresses beyond what the patient’s treating team can do,” Silvers said. “[It’s also those] who can stratify and manage their patient populations and coordinate well with other providers.”
Building a palliative payment model
Interdisciplinary services require a flexible and diverse approach to reimbursement, Baird stated. The needs of patients and families differ not only across geographic regions, but also at different stages in a serious illness, he explained.
Policymakers should consider a payment model that fully supports sustainable care for patients with complex needs at any stage of their illnesses, Baird said.
“A model must have robust and meaningful quality measures that actually matter to patients and families,” he said. “This means that it needs to be high enough that having one or a few very high-cost outlier patients doesn’t totally sink an organization’s ability to operate financially.”
A model must have robust and meaningful quality measures that actually matter to patients and families. This means that it needs to be high enough that having one or a few very high-cost outlier patients doesn’t totally sink an organization’s ability to operate financially.— Davis Baird, director of government affairs in hospice at the National Association for Home Care & Hospice
In terms of sustainability, having a dedicated payment model could come with advantages like more efficient billing and operational processes, according to Silvers.
An alternative payment model could give palliative care teams greater flexibility to align service options more closely with patients’ needs, she said. It would also improve their ability to more quickly and efficiently deploy staff without taking time to assess how to bill for it, Silvers added.
“As patients stabilize, the intensity of services can be reduced, or they can be discharged from palliative care services,” Silvers said. “To successfully deliver high-quality while growing, programs need to be adept at stratifying their patient population and matching disciplines and time to needs.”
Community-based palliative payment structures could vary as much as the needs of the advanced illness populations that they cover.
Risk-based reimbursement models may be suited to meet the wide breadth of patient needs in the home.
“A model should test a risk-based capitated payment mechanism. While nothing is perfect, this is probably the most appropriate structure our system has to support the kind of team-based, multidisciplinary model that community-based palliative care represents,” Baird stated. “It allows for flexibility in service delivery and the ability to tailor interventions to the unique patient and family needs, which is a philosophy that is core to community-based palliative care’s identity and ‘secret sauce.’”
A risk-based model may not always be appropriate in the community-based setting because palliative patients may reach periods of intense, high-cost care needs in the home, according to Silvers.
Fee-for-service or per diem payment systems may not be a good fit, she added. For one, with a per diem structure, some patients who need lower levels of care may need fewer visits per month, Silvers said.
Additionally, a fee-for-service approach similar to hospice “doesn’t work” in a community-based palliative care setting, because some disciplines would not be able to bill for encounters, she explained.
“Many CBPC payment models use a bundled monthly payment, sometimes called a ‘case rate,’ or [per member per month] — and that seems to be the best fit,” she said. “It provides flexibility to deploy different team members as needed, and if the population is stratified, lower need patients can offset intensive resources needed by those with significant needs.”
Another potential approach could include a two-tiered system in which providers receive a higher monthly payment at the start of a patient’s care, followed by a lower monthly payment for follow-up and monitoring services, Silvers added. Though a model like this would complicate questions about billing and eligibility.
Guidelines on quality, eligibility and standardized care are also important pieces to consider, according to Baird.
A reimbursement model would need to provide guidance on what services are included in palliative care, as well as outline expectations around how providers should coordinate across different care specialities. The ability to collaborate and coordinate on interdisciplinary needs is vital to sustainable services, he said.
“Likewise, a model would need a standardized definition of what CBPC actually entails – there would need to be some room for flexibility in that definition, but for payment and monitoring purposes, a definition is a requisite,” Baird said.