While some palliative care programs mirror the hospice model, more operators are working to tailor their services to patients’ specific needs, with varying intensity.

This is increasingly important as payment shifts towards value-based payment models in which demonstrating cost savings is crucial to success. Providers need to demonstrate strong performance on quality scores as well as a track record of effectively preventing avoidable hospitalizations, readmissions and emergency department visits.

This is particularly the case when negotiating contracts with Medicare Advantage plans, Accountable Care Organizations (ACOs) and other value-based payment arrangements, Sue Lynn Schramm, a partner of the hospice and palliative care consulting company Confidis, LLC, said in a presentation at the National Hospice and Palliative Care Organization Annual Leadership Conference.

“Payment streams for palliative care, most palliative programs are relying on a combination of Medicare Part B and grants and fundraising,” Schramm said. “Where they really should be thinking about heading strategically in terms of their service design is in getting contracts with those upstream providers or payers that are going to help to cover the costs of providing that palliative service.”

Currently, palliative care providers can bill for physician and nurse practitioner services through Medicare Part B, and also to a limited extent through supplemental benefits included in Medicare Advantage. Other reimbursement options exist via payment arrangements with Accountable Care Organizations (ACOs) and Managed Services Organizations (MSOs).

Palliative care is also part of the hospice component of CMMI’s value-based insurance design (VBID) demonstration, which is set to end on Dec. 31.

Payors are increasingly recognizing the value proposition of palliative care services, especially those that operate in the value-based reimbursement sphere, according to Schramm.

“Palliative care in particular can help [Accountable Care Organizations (ACOs)] reduce costs in other high priority spending areas. Some of those high priority spending areas in particular reducing avoidable emergency department visits and inpatient admissions; 81% of all ACOs surveyed said this was a key focus area for them, preventing readmissions, managing high-need patients,” she said. “This list carries a lot of overlap with our patient population as hospice and palliative providers, which is why I’m so optimistic that we have a role to play when it comes to cost management for these organizations.”

The Wisconsin-based hospice and palliative care provider Unity has designed its program with the intent of seeking value-based contracts in the long term, Alisa Gerke, the agency’s executive director, said at the NHPCO event.

A key aspect of this is expanding geographic scale. Value-based payers, including ACOs and Medicare Advantage Plans, often prefer to contract with a single provider that can cover a larger area than with multiple smaller providers, Gerke indicated. Unity is in the process of growing its service area from 13 Wisconsin counties to 23.

Unity’s palliative care program is branded as Supportive Care Management. To be admitted, patients must have an advanced illness or condition with potential hospice eligibility within two years. Other admission criteria include a need for aid in activities of daily living and the frequency of hospital admissions and emergency department visits, according to Gerke.

“When we designed this program, we really designed it so that it’s kind of an exportable design to whatever payer,” Gerke said. “Whether it be a large national payer, whether it be a regional payer, whether it be an ACO — we wanted to make sure that we weren’t going to have multiple supportive care management models in place. That would be way too difficult to manage.”

The company’s care model is interdisciplinary, with nurse practitioners and registered nurses playing key roles. Social workers and chaplains provide services on a PRN basis, Gerke said. Patients receive an initial comprehensive assessment done by a nurse practitioner, and then a plan of care is established with a follow-up visit schedule. Patients and families also have 24/7 access to nurses via telephone.

But within this structure, Unity does not take a “cookie cutter” approach to care delivery. Service intensity is tailored to patients’ specific needs. Patients are stratified into three different care levels, each of which is color-coded. Patients in the red category have the highest needs, whereas those in the yellow or green designations may require less intense services.

“There’s different levels of care delivery that are rendered, and those care intensity levels will change with the fluctuating disease process, disease progression of that patient. Sometimes they’re going to need more. Sometimes they’re going to need less,” Gerke said. “We do this so that our patients get the care that they need when they need it, but also making sure that our program that we use our resources efficiently, so that we can be sustainable”