Increasingly, Medicare Advantage (MA) plans have found real value in offering community-based palliative care as a supplemental benefit.
Since 2018, the U.S. Centers for Medicare & Medicaid Services (CMS) has allowed MA health plans to cover new supplemental benefits for eligible patients. This flexibility has allowed insurance companies to offer assistance beyond what is available within traditional Medicare, including palliative care for members, delivered right to the home.
Companies offering MA plans are still in the early to middle stages of really understanding and appreciating the value of the benefits of palliative care for members, according to Fred Bentley, managing director for ATI Advisory’s Medicare Innovation Team. But those organizations that have invested in palliative care have begun to see how much it helps lower medical costs.
“It has proven its worth and its value from a pure dollars and cents perspective, in terms of helping to minimize emergency department visits, hospitalizations and utilization of high-cost services,” Bentley told Palliative Care News.
A variety of studies back up Bentley’s assertion, such as a 2022 survey by the Journal of Palliative Medicine that found that adult home-based palliative care is effective in decreasing total medical costs by 16.7% during a calendar year compared with a control group.
Additional research shows that when non-medical benefits and additional services like palliative care are delivered alongside medical care, both patients and the entire health care system are better off.
Overall, the MA program has seen incredible growth in recent years. Medicare Advantage now provides Medicare coverage for just over half of all of the program’s beneficiaries. In January 2023, 30.19 million of the 59.82 million people with both Medicare Part A and Part B were enrolled in a private plan, according to CMS data.
In 2022, 147 plans offered home-based palliative care across 17 states, a 7% increase in the number of plans compared to the prior year. That growth has continued into 2023, with at least 157 plans offering home-based palliative care, according to data from Washington, D.C.-based research and consulting firm ATI Advisory.
Defining palliative care
Establishing exactly what palliative care means in any plan, however, can be a challenge.
The various available care models remain somewhat amorphous, according to Bentley.
“One of the things people can agree on is that palliative care means lots of different things to different people. There isn’t a standard checklist,” he said. “There’s a lot of permutations on it. That’s a good thing, but it also makes it hard for health plans. So, companies have to do the work to spell out what they cover and include. What does palliative mean? What are the goals?”
One of the obstacles MA programs face while answering those questions is explaining what palliative care means to members.
“I think a lot of members don’t necessarily know what palliative care is. But members who do receive it find it highly valuable. I know, because I have a family member who is receiving palliative care right now, and is in Medicare Advantage,” Bentley said. “I think it is indicative of the Medicare Advantage member experience. They have to be educated that palliative care isn’t hospice.”
The difference between palliative care and hospice is something people can find difficult to distinguish, due to the stigma hospice often carries. While the objective of both hospice and palliative care is pain and symptom relief, palliative care focuses on reducing discomfort and stress and helping patients have the highest quality of life possible, with or without the intent to cure. Hospice care focuses on quality of life when a cure may no longer be possible.
“I still encounter Medicare Advantage executives, who like the general public, think palliative care is just hospice; that it’s end-of-life care that they aren’t covering right now as an industry,” Bentley said. “So, there is still education to be done about what palliative care is. No, it’s not just a stepping stone to hospice care. It is a valuable benefit.”
At the same time, Bentley does see leaders embracing the palliative care approach.
“When ATI investigates how and why plans are covering palliative care, it is often the chief medical officer or the VP of Medical Affairs who drive the move toward offering the benefit,” he added. “So, leaders have started to see the value because they have treated patients themselves or looked at the clinical outcomes and the member experience.”
Providing palliative care
When it comes to supplemental benefits reimbursement for palliative care providers, Bentley said payment is likely more favorable when it’s covered as a standard health care benefit versus a supplemental benefit.
As a supplemental benefit, palliative care is simply offered from a smaller pool of money, according to Bentley.
“A big chunk of those dollars are almost immediately funneled into helping bring down cost sharing and out-of-pocket costs and premium levels for core members. Then what’s leftover gets divided up across lots of different supplemental benefits,” he said.
However, Bentley pointed out that in a number of Medicare Advantage plans, the financial risk is being delegated to primary care groups who get paid a per member per month fee to manage the health care.
“My sense is that there is significant uptake there because we’re delegating dollars to physicians. These are the individuals who are directly treating and managing patients. Many of those doctors see the benefit of having palliative care. They’re dedicated to symptom management as a separate and distinct, value-add service above and beyond what primary care can do,” Bentley said. “So, I think there’s even more of an inclination and better understanding amongst those medical groups of the value of palliative care. Depending on their capitation rate, they may or may not have as many dollars that they can work with.”
Growing palliative care
According to Bentley, palliative care as an MA benefit will continue to grow as those in the industry discover its worth, but uncertainties remain about its exact trajectory
“There will be growth,” Bentley said. “But I think there is a question of how exactly plans will cover palliative care? Will plans cover palliative care through the clinical side to the medical services? Or are they going to cover it as a supplemental benefit?”
For now, MA plans looking to offer palliative care can market and differentiate themselves by putting in the work. Bentley said it all starts with data.
“Data and the analytics – that’s the currency that starts to open doors. Being able to have those proof points of the value that you’re generating,” he said. “The other big piece of this is scale. Health plans and capitated medical groups, and ACOs are all looking for lives. They want to be able to expand their membership or their attribution.”
As a palliative care group looking to increase scale, Bentley recommends looking into a partnership or affiliation to help create some sort of virtual network.
“They could go to a plan that’s covering a chunk of South Florida, and say, ‘Hey, we are your partner here and we’ve got this network. We’ll figure out how the finances work within our network, but we will partner with you as a single entity,’” Bentley stated. “So, getting to that scale in some form or fashion I think is critical.”