Forthcoming Medicare payment models will likely focus on disease-specific programs that bear similarities to palliative care.
Emerging reimbursement demonstrations have placed a stronger emphasis on addressing a more diverse group of patients with high levels of care needs and complex health trajectories. Examples include the Value-Based Insurance Design (VBID) demonstration, the Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH) model and the Guiding an Improved Dementia Experience (GUIDE) model.
Common threads among these value-based models are the goals of increasing access and improving care transitions and outcomes for seriously ill populations – including underserved groups, Purva Rawal, chief strategy officer at the Center for Medicare and Medicaid Innovation (CMMI), said at the the Coalition to Transform Advanced Care (C-TAC) and the Center to Advance Palliative Care (CAPC) Leadership Summit in Washington D.C.
“Where we are headed and really believe more than ever in (especially for beneficiaries with serious illness and their families) is a need for value-based care to build a more person-centered health system,” Rawal said at the conference. “It is really difficult to meet the needs of patients in a holistic way in a fee-for-service payment system that often unfortunately contributes to fragmentation for families.”
Focus on disease-specific models
Value-based models taking shape have increasingly focused on including better respite care, training and support services for caregivers, as well as improved connections to community-based palliative services, Rawal indicated.
Additionally, she said, value-based payment is stretching to reimburse for improved screening of psychosocial needs among patients, a large part of helping providers understand where underserved populations are in their communities.
As far as CMMI’s pipeline of payment demos, similar to GUIDE, palliative care providers can anticipate more value-based models that are “focused on specific health conditions,” Rawal said.
“We’re testing new ways of delivering and paying for care, and [we] are focused on specific provider types, like primary care or ACO models,” she said.
Addressing workforce issues, health equity
As it designs new demos, CMMI is taking note of the challenges providers are facing – including staffing shortages and closing health disparity gaps.
Addressing the needs of health care workers and unpaid family caregivers is a large part of improving quality and access, Rawal said. Building up palliative care reimbursement around these issues will take time to develop and structure in a sustainable way.
Improving labor pressures and addressing social determinants of health have become important considerations when it comes to program design, according to Dr. Aditi Mallick, acting director of the U.S. Centers for Medicare & Medicaid Services’ (CMS) Office of Minority Health. She is also chief medical officer of CMS’ Medicaid and Children’s Health Insurance Program (CHIP) programs.
“We’re really trying to learn as we advance and implement policies,” Mallick said. “What we’re implementing at CMS across Medicare, Medicaid and in some of our other programs [is] to really align with advancing health equity, addressing what we know to be very substantial workforce challenges, and continuously having our eye on the ball of improving quality of care – in particular for individuals living with serious illness and their families.”
Value-based payment has a larger role to play in the journey toward closing health disparities and improving employee support, Rawal indiciated.
“Clinical care has really been but a fraction of what impacts people’s health outcomes, it’s also things like social needs, housing, food, transportation, and spiritual health and well being,” Mallick said at the summit. “With what’s happening both in burnout among traditional health care providers and family caregivers, the solution is multifaceted.”
Among the disparities CMS hopes to reduce is access to advanced care for individuals with various types of physical and mental disabilities, according to Mallick. Stronger reimbursement systems are being developed to better support individuals with disabilities, she said.
In September, the U.S. Department of Health and Human Services (HHS), through its Office for Civil Rights, proposed a new rule that prohibits discrimination on the basis of disability.
The rule, dubbed the Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance, aims to ensure medical decisions are not based on biases or stereotypes about individuals with disabilities. The rule also contained clarifications around provider obligations around offering services “in the most integrated setting appropriate” for the needs of individuals with disabilities.
“The HHS Office of Civil Rights in conjunction with the Administration for Community Living earlier this year released broad sweeping regulations around protections for individuals with disability and protection specifically against discrimination” Mallick said. “And the reason [for] that is many individuals living with serious illness are also on some form of disability. We know how they live in this space really makes a difference to people on a daily basis.”