NCP Guidelines: Domain 1 - Structure and Processes of Care
December 8, 2018
Community-Based Palliative Care: It’s Time to Just Go!
April 27, 2016
The 2016 Management and Leadership Conference, hosted by the National Hospice and Palliative Care Organization, was a great opportunity to explore the factors driving the (slow) growth of community-based palliative care. As I did last year, I’ve written a summary of my takeaways and ah-ha moments, with the caveat that my primary focus was on palliative care.
Value-based healthcare is reshaping healthcare delivery
Dr. Reed Tuckson delivered perhaps the best plenary session I’ve attended as he shared critical information to MLC attendees about the future of healthcare. Dr. Tuckson emphasized the need for providers to get comfortable with producing value in healthcare.
For hospice and palliative care providers, value-based care offers an opportunity to participate in networks that are responsible for delivering high-quality, low cost care. As Dr. Tuckson reflected, hospice and palliative care meet all three objectives of the Institute for Healthcare Improvement’s Triple Aim:
Improving the patient experience of care (including quality and satisfaction)
Improving the health of populations
Reducing the per capita cost of health care
Given the relatively rapid transformation to value-based care into narrow networks, it is essential for hospices to develop palliative care services now before another provider swoops in to provide population health services for those deemed to be high-risk. According to Dr. Tuckson (and other speakers at the MLC) to participate in these networks and receive sufficient reimbursement, we need to be able to demonstrate outcomes with data.
Palliative care activities are invisible to payers
Brian’s point – palliative care activities are invisible to payers – isn’t that payers are uninterested in palliative care. Rather, Brian reminded us that palliative care services aren’t visible in the Medicare data because Medicare doesn’t have a palliative care benefit, nor are there specific CPT codes for palliative care services. As a result, it is impossible for a single provider to use Medicare data alone to compare the cost and quality of palliative care services to “usual care.”
Brian challenged all of us to solve this issue, “As a field we need to do more to solve the issue with identifying palliative care in the data.” The biggest challenge for programs seeking reimbursement for non-hospice palliative care is demonstrating that palliative care can lower costs and improve patient outcomes.
Earlier in the day at the CSU Institute’s Leading the Way Preconference Seminar, Brian summarized the business case for community-based palliative care:
Palliative care “relevant” patients have prolonged, intensive, costly hospitalizations
Palliative care targets high-need patients who happen to have high-cost hospital care
In the context of DRG-type reimbursement, or alternative payment methods such as risk-bearing contracts and ACOs, cost reduction is key to financial sustainability for all providers and commercial payers
Palliative care needs a seat at the population health table
The adoption of the Institute for Healthcare Improvement’s Triple Aim by CMS has led to an increased awareness of the importance of improving the health of populations. While there was little attention to population health at the MLC, during the session entitled Innovations in Advanced Illness Management Care Delivery: A Population Health Approach, Torrie Fields tweeted about the importance of hospice and palliative care being at the table in order to be seen as one of the solutions to improving the health of populations. The session described Mount Carmel Hospice’s approach using predictive analytics, risk stratification, and engagement to deliver the right care to the right patients -- those most at risk for poor health outcomes and preventable healthcare costs.
Greer Myers, President of Turn-Key Health presented a unique visual depiction of the evolution of end-of-life care. While hospice is available to those individuals in the last 180 days of life, in an integrated population health model for palliative care and end-of-life care, pictured below, payers, providers, the patient and family caregivers collaborate together to achieve the Triple Aim.
Risk-sharing agreements are attractive to payers
The vast majority of palliative care services are reimbursed on a fee-for-service basis, which cannot sustain a comprehensive palliative care program. During the 2nd Annual Executive Business Summit Bruce Smith, MD, FACP pointed out that fee-for-service palliative care is hard for payers and providers. Dr. Smith’s point is that the fee-for-service model doesn’t allow payers to control the quality or cost of care. Dr. Smith explained, “All Medicare Advantage payers have an incentive to figure out how to care for complex patients.“
At the Enclara Pharmacia and Turn-Key Health event panelist Torrie Fields, MPH, provided insights into how payers are thinking about palliative care reimbursement “some Medicare Advantage payers looking to create a palliative benefit using severity adjustment model.”
Torrie went on to say, “If palliative care providers are willing to share risk it is very attractive to payers.” Since palliative care can significantly reduce healthcare expenditures through cost avoidance, while improving patient outcomes, a risk sharing agreement can be beneficial to both parties. Risk sharing allows the provider to receive more comprehensive payment that covers your costs for an interdisciplinary palliative care service for a defined population of patients. The advice from the Business Summit panelists is to start off with a fee-for-service arrangement, with both the provider(s) and payer collecting outcome data, prior to moving into a risk-sharing contract with a payer. As Torrie reminded providers, the key to negotiating with payers, ACOs and other risk-bearing organizations is to know the value you deliver and demonstrate that through data. In addition, providers must know their total costs for delivering that care in order to negotiate contracts that generate revenue, or at the very least cover all the costs.
The difficulty of demonstrating the efficacy of community-based palliative care, combined with the lack of a funding stream that can support it, explains why it is taking so long for community-based palliative care. With the rapid transition to value-based care the need for palliative care services will be filled, if not by palliative care providers than by others seeking to fill that void. The potential threat to hospices is that other providers might be less inclined to refer patients to hospice in a timely manner, if at all.
As Nancy-Ann DeParle, the facilitator of the Business Summit stated when discussing the need for community-based palliative care, "We have one foot in the boat and one on the dock. It's time to just go!" kb
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