Partnerships between health care providers and Accountable Care Organizations (ACOs) can help to create effective, value-based palliative care models for patients, but navigating the development of those relationships requires communication and a true commitment to collaboration.

These opportunities extend across both the inpatient and community-based settings, with a mind toward improving quality and improving patients’ quality of life.

“ACOs are looking for high-quality care that reduces avoidable crises, and specialty palliative care has been proven to do just that,” Allison Silvers, chief of health care transformation at the Center to Advance Palliative Care (CAPC), told Palliative Care News. “There is interest in inpatient palliative care, which has been proven to reduce length-of-stay and unnecessary re-admissions, as well as community-based palliative care.”

Sue Lyn Schramm, principal of Confidis Consulting, said that ACOs seek help in managing the biggest cost targets, such as unplanned hospitalizations and emergency department (ED) visits. Partnering with palliative care providers can help ACOs significantly reduce those costs. 

A 2024 study published in the Journal of Pain and Symptom Management found that palliative care is associated with improved patient outcomes from palliative care enrollment until death, including fewer hospitalizations, 5.4 more days at home, 17% fewer deaths in a hospital and $10,393 lower overall health care costs.

Researchers concluded that primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the health care needs of an aging population.

Partnering with ACOs offers palliative care providers advantages too. ACOs can give palliative providers an opportunity to be paid properly for their scope of services, particularly if they’re contracting with an ACO under an arrangement with Medicare, which launched a program called ACO Realizing Equity, Access and Community Health (ACO REACH) in 2023.

According to the U.S. Centers for Medicare & Medicaid Services (CMS), patients aligned within ACO REACH have access to help them navigate the health system and manage their conditions. They may have greater access to enhanced benefits, such as telehealth visits, home care after leaving the hospital and help with copays.

ACOs can also give providers access to data they may not have, such as details about a region’s patient population and their health conditions.

Collaborative learning

Palliative care providers can come to ACOs by becoming members of those organizations, or they can contract with them through a preferred provider network. These partnerships allow the two parties to negotiate mutually beneficial terms that are customized to the needs and characteristics of their patient population, and help to promote effective communication with patients’ primary care providers.

However, Schramm said that few freestanding hospices or palliative providers have succeeded in becoming members of ACOs. In her experience, it comes down to dollars.

“Most [Medicare Shared Savings Program (MSSP)] ACOs are owned by health systems or physician groups, and they’ve shown minimal interest in bringing hospices into their ACOs. ACOs aren’t motivated to bring hospices into the ACO’s membership, as that could mean sharing any performance bonuses with them,” Schramm told Palliative Care News. “That said, under the ACO REACH demonstration there are several consortia of hospice and palliative providers that have organized to care for high-needs populations. That strategy is still in the proof-of-concept phase so far.”

Care model creation

When it comes to designing a care model that works for both palliative care providers and ACOs, as well as their patients, Silvers said that in theory, they have complete flexibility in developing new care models and pathways. She emphasized that integration of palliative care into home-based primary care and complex care management programs have resulted in positive outcomes for some ACOs.

“Others deploy home-based palliative care for their high-risk patients, with the most effective carefully managing both admissions and discharges so the specialty palliative care team remains available for new patients,” Silvers said.

She noted, however, that most ACOs operate on a “fee-for-service chassis,” which means that all the participating providers must continue to bill fee-for-service to sustain their operations, and wait for reconciliation for any shared savings.

“[That can] come well after a year or more in some ACOs,” Silvers said. “An ACO making an investment in palliative care will need to supplement, not replace, fee-for-service revenue, to keep the lights on.”

Schramm said that there are several care models that can be effective, but as a business consultant, she focuses on making sure any palliative service is sustainable for her provider clients.

“My mantra for care model design is, don’t deliver a Lexus when you’re only getting paid for a Camry. In the absence of a funding grant or some other kind of full support, the care model is effectively limited to what Medicare will pay for,” Schramm said. “Even when contracting with an ACO under MSSP, that means a nurse practitioner model for all practical purposes. Other disciplines might add value, but the current structure of palliative reimbursement won’t cover the cost of those services.”

When developing care models, Silvers stated that there shouldn’t be any trade-offs between ACO needs and patient population needs.

“By serving the correct high-need population, managing symptoms and patient and family understanding and decision-making, care quality should improve and the ACO should perform strongly,” Silvers said.

Educational perspectives

When developing and defining partnerships between ACOs and care providers, education is critical.

“I would say education, but also listening – so really a true dialog between ACO leaders and the palliative care program,” Silvers said. “The hospice-led palliative care program needs to learn what’s important to the ACO leaders, and then education comes in to explain how palliative care can help with those important goals.”

Silvers suggests that hospices use best practices when discussing palliative care because there’s a lot of misunderstanding about what it is and is not. “Without what we call ‘messaging discipline,’ ACO leaders and participating providers may not be as interested in collaborating,” she stated.

Schramm said that when working with an ACO, palliative care providers must help ACO physicians clearly identify which patients should be referred to palliative care, and when to do so during their illnesses. Depending on the population being managed, Schramm said this may involve clinical criteria such as recent hospital discharge, activities of daily living (ADL) needs or a Palliative Performance Scale (PPS) score.

“Using palliative care in the community can help manage those frail patients who are at greatest risk,” Schramm said. “The art is in assigning palliative patients to the proper risk ‘buckets’ so providers know how much palliative care is needed for this particular group of patients or enrollees.”