Caregiver Support a ‘Significant’ Priority in CMMI Models, VBID

Unmet caregiver needs are a top issue to address in developing end-of-life care models encircling the Medicare landscape.

Among top priorities in current and future payment models is to improve care for those with serious and terminal illnesses, which includes caregiver support, according to Purva Rawal, chief strategy officer for the Center for Medicare and Medicaid Innovation (CMMI).

“Addressing unpaid caregiver needs [and] respite services, these are two very significant innovations that we’re testing. {It’s about the] choices they have to make day-to-day,” Rawal said at the Coalition to Transform Advanced Care (C-TAC)–Center to Advance Palliative Care (CAPC) Leadership Summit.


Among these models is the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) program, which last year replaced the Global and Professional Direct Contracting (GPDC) model. The U.S. Centers for Medicare & Medicaid launched the program to reflect its redesigned strategy for payment system demonstrations, with advancing health equity as a key tenet.

Improving access and quality disparities for terminally ill patients includes addressing unpaid caregiver needs are important priorities addressed in elements of the ACO REACH model, Rawal stated.

“We’re really excited to see how some of these new options in this [ACO REACH] model actually are better able to support caregivers and families,” Rawal said. “The model is aimed to address the burdens experienced by unpaid caregivers by requiring not only providing assistance with caregiver training and support services, including 24/7 access to a support line, as well as connections to community-based providers that might be able to offer additional support.”


An important element in how CMMI’s approach to designing payment model demonstrations centers around supporting needs in the “patient and caregiver dyad” of serious illness care, Rawal said.

CMMI is not the only federal agency seeking to Improve family caregiver support. The U.S. Department of Health and Human Services (HHS) last year unveiled its National Strategy to Support Family Caregivers, which includes nearly 350 federal programs to assist the more than 53 million Americans who care for seriously ill or disabled loved ones in their homes.

The burden on caregivers can have an adverse effect on hospice access and utilization. Family caregivers can face systemic barriers that threaten patients’ ability to receive end-of-life care in home-based settings.

Among the barriers are a heavy financial toll and substantial direct caregiving costs, which are often worsened by lost wages or missed work days. Caregiving also comes with an emotional and physical cost. Additionally, caregivers often see their own health decline.

Similar to issues mirrored among the hospice workforce, caregivers can face high levels of burnout — issues that need “multifaceted” payment support mechanisms, according to Dr. Aditi Mallick, acting director of CMS’ Office of Minority Health. She is also chief medical officer of CMS’ Medicaid and Children’s Health Insurance Program (CHIP) programs.

“It’s about connecting folks to care navigators to help with high burdens [and] high levels of burnout,” Mallick said at the summit. “[Caregivers have] high levels of burnout, especially those caring for people with multiple chronic conditions.”

Reimbursement in both Medicare (and Medicaid) payment models has had a “long and sorted” history as far as improving support around caregiver respite services, making this a high priority for payers to address, Mallick said.

Elements of the Medicare Advantage hospice carve-in within the value-based insurance design (VBID) model are also increasingly focused on ways to support caregivers, Mallick indicated.

“We are excited to continue to innovate and how value-based payment models can meet the needs of beneficiaries with serious illness and their families,” Mallick said. “Oftentimes, you don’t have very direct levers to enforce in the fee-for-service paradigm, but this is something that’s top of mind as we’re thinking about in value-based payment models, which not only think about including improving access to quality care, but also think about how those models can improve the care delivery system for [those] that are caring for our beneficiaries.”

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