Accountable Care Organizations (ACOs) are key for scaling palliative care through value-based models.
Hospices and palliative care providers can collaborate with ACOs by becoming members of those organizations themselves, or by contracting with them through a preferred provider network. These arrangements allow for the negotiation of mutually beneficial terms that are tailored to the needs and characteristics of patient populations.
However, successfully negotiating such contracts requires a strategic approach and a deep understanding of ACOs’ priorities. As the U.S. Centers for Medicare & Medicaid Services (CMS) moves to align all Medicare beneficiaries with an accountable care relationship, these negotiations will become even more paramount.
Dr. Mark Angelo, chief medical officer for population health at the Delaware Valley ACO, told Palliative Care News that when it comes to selecting palliative care providers to work with, ACOs typically prioritize those who can enhance patient outcomes and reduce overall health care costs.
“We are clear that palliative providers can improve quality outcomes and experience for our most vulnerable patients. That is well established,” Angelo told Palliative Care News. “What we are finding more recently is that palliative providers also improve efficiency in health care delivery and decrease cost of care to patients, to the health system and to the health payment system at-large.”
However, while these organizations are incentivized to improve patient experiences and reduce total care costs, no incentives in existing Medicare ACO programs ensure access to palliative care, according to Allison Silvers, chief health care transformation officer at the Center to Advance Palliative Care (CAPC).
“No payer is measuring how often palliative care is consulted, if symptoms are well-managed, or rates of hospice utilization,” Silvers told Palliative Care News in an email. “The only incentives are implicit — if I contract with palliative care, I should be able to improve satisfaction and cost-effectiveness.”
That being said, CAPC and the National Coalition for Hospice and Palliative Care (NCHPC) have been making recommendations to explicitly include palliative care specialists as participating providers in population- and disease-based models, Silvers added.
But palliative care providers can leverage their skill sets to demonstrate their value proposition, she stated.
“They would need to make the case that they can simultaneously improve patient and family satisfaction while reducing unnecessary spending,” Silvers said. “It might help to start by asking, ‘In what population are re-admissions highest in your ACO?’”
According to Melody Danko-Holsomback, VP of education at the National Association of Accountable Care Organizations (NAACOS), the number one way providers can demonstrate their value to ACOs is through effective communication.
“Communication between providers and their patients in coordinating and administering services is a key piece that is often missing in much of health care today,” Danko-Holsomback told Palliative Care News.
Providers must also show evidence of their program’s impact on reducing ED visits, hospitalizations, and de-prescribing, Silvers said. This doesn’t have to be statistical studies, she clarified, just information about pre- or post-utilization.
When it comes to opportunities for palliative care providers, certain ACO models may offer more than others.
According to Angelo, the higher the risk that a program is taking on, the more likely they will be interested in palliative services.
“Often, experienced ACOs will move toward higher risk models where they share cost outcomes with Medicare or other payers,” Angelo said. “The more efficient care delivery in those high-risk models will tend to be matched with higher reward for the ACO.”
Those rewards are then used to support an organization’s journey toward even deeper relationships with CMS and other payers, Mark added, meaning providers who participate in an ACO have both better care for their patients and additional funding for their operations.
Silvers pointed to the High Needs Population ACO Reach model, which exclusively serves patients with complex needs, as particularly promising.
“The required patient volumes are much lower, and the required care model aligns with palliative care delivery,” she said. “… A high proportion, perhaps even the majority, of patients likely have unmet palliative needs, and palliative care co-management is something that is often familiar to clinicians who focus on high-need patients.”
When contemplating entering into an ACO palliative care contract, some provider networks may wonder whether there are any commonalities in the way these contracts are structured, such as shared savings arrangements.
Sue Lyn Schramm, MA, a partner of hospice and palliative care consulting company Confidis, LLC. (previously Schramm Consulting, LLC.), told Hospice News she has not seen any providers receive shared savings bonuses unless they were also owners of the ACO.
“That’s one reason why you see several provider groups that are themselves ACO REACH entities, for example,” Schramm told Palliative Care News. “It’s more likely that a contracted provider will receive a per member-per month payment, which requires careful management. In some cases the provider then benefits from palliative patients that later convert to another care modality, such as hospice care.”
If a provider wants to successfully negotiate for the best possible payment for palliative services, Schramm recommends that they have strong data analysis capabilities; design the palliative care model to suit the ACO’s needs; resist over-building or over-delivering care beyond what’s required; build broad geographic coverage so they can care for all the ACO’s enrollees; and lastly, understand their own costs intimately so they can negotiate payments that allows them to avoid losses.
Silvers encourages providers to leverage strong relationship-building skills when negotiating these contracts.
“Asking what is not working well, and figuring out how to address those issues is the key – which means, you need to be communicating with ACO leaders and participating providers about what their pain points are, how your own services are helping (or not), and continue to modify so the relationship works for both parties,” she said.