The hospice component of the value-based insurance design model (VBID) will sunset at the end of this year, but opportunities for payment through Medicare Advantage and other models remain.

The hospice component is part of the larger VBID program, which will continue through 2030. The component was designed to test coverage of hospice through Medicare Advantage. It also contained elements intended to expand access to palliative care, for which reimbursement in general is scarce.

Hospice News spoke with Dr. Bob Parker, chief clinical officer and chief compliance officer for the Texas-based hospice provider Kindful Health, about the opportunities in place for palliative care providers.

Do you anticipate Kindful Health looking into building a palliative care program?

We have already started looking into it more. Where we see the conversation going is really supporting either hospital practices [or] physician groups, where they’re really struggling to keep patients out of the hospital.

We have such a big gap between the serious illness of a patient moving towards what could be a hospice patient, with them sort of falling into these gaps. Some do get home health. Some don’t get home health. They’re not ready for hospice, or they don’t meet criteria for hospice.

So how do we support that continuum from these seriously ill patients? Where can we really do a lot of home-based care to manage them in a more effective way without them using either the emergency room as the source of care?

Most times with the hospital settings or that practice, they don’t really understand what the patient’s environment is. So when we can go into a patient’s home and really understand the social dynamics and everything, that really helps figure out how to better care for that patient.

Do you think that the demise of hospice VBID kind of changed the dynamics of palliative care reimbursement and providers have to operate?

I don’t know. It’ll be interesting to see how this all progresses, where we go and how these conversations get shaped as the next months and years go by.

Is there still an opportunity for palliative care providers within Medicare Advantage, beyond that VBID program?

Yes, because managed care does see the value in physician services. So most of that palliative care is under that physician service or physician practice type of element. So there are certainly mechanisms for payment and reimbursement. 

It’s the other disciplines that are problematic, social workers, CNAs, nurses. But you can certainly get reimbursed for nurse practitioner or physician services through managed care or Medicaid as well.

So that Medicare Advantage model kind of mirrors a fee-for-service approach where it reimburses that physician.

You have to credential with them and do a lot of work, so that your practice can bill for those services. And it’s typically managed care reimbursement might be a little bit lower than, say, the Medicare fee-for-service, but they’re comparable. Medicaid, obviously, is usually much less.

Is the theory that you make up that difference in volume with Medicare Advantage?

So when you think of palliative care, most folks will say that palliative care is a loss leader for a home health organization or hospice organization. But if it’s done correctly, you can at least break even.

A lot of it’s by volume, and I’ve had programs where we actually contributed to the bottom line, so we covered our costs, plus, and other work. Other programs didn’t necessarily do that, but, balancing that out to try and at least to break even.

The advantage to home care is that the patient receives better care. We’re more in tune to helping them transition appropriately, so not bouncing in and out of the hospital, but as a home health organization that has multiple service lines, they can obviously get patients to hospice sooner in the process.

What are providers’ best bets for palliative care reimbursement these days?

We worked with the [National Hospice and Palliative Care Organization] on a couple of program ideas that they brought to [Center for Medicare & Medicaid Innovation], looking at expanding the Medicare Care Choices Model.

We need to get beyond the current Medicare structure, which is very limiting. How do we expand that to a Hospice 2.0-type thing where some of that palliative structure is incorporated into it? How do we reach patients sooner in this process and start eliminating that gap between more of that curative mindset and a comfort mindset?

Is there a way today for palliative care providers to be reimbursed for that full scope of vendor?

There are some payers that will do more of a per-patient, per-month sort of payment where the provider could utilize any of the disciplines to do that. It takes a lot of work. Smaller organizations don’t have the leverage to tap into that, but the larger ones certainly could get in some of those [Accountable Care Organizations (ACO)] and things like that.

But currently, the best course for most home-based programs is creating that practice and utilizing the physician fee schedule to get reimbursed for at least that medical oversight, and if we could utilize that then to get patients either into home health appropriately or into hospice appropriately, you know, then that expands the the ability of those organizations to care for those patients and those payers.

Are those payers predominantly ACOs, or are they some other type?

Commercial payers all have products that could be utilized. The problem is accessing them. Getting a small organization to be able to contract in that way, they don’t pay attention to you. You don’t have enough volume for their purposes.