Posted on October 24th, 2022

A primary barrier for patient and family access to palliative care is a lack of standardized definitions and payment mechanisms.

Without an established palliative care benefit or universally recognized definition in place, care delivery models, patient experiences and reimbursement of palliative care services vary widely across the nation.

Consequently, many providers and payers don’t have a clear picture of who should be eligible for palliative care, the specific services they should receive, or for how long, according to Jenn Booker, vice president of palliative care programs for Amedisys (NASDAQ: AMED) subsidiary Contessa Health.

“One of the primary reasons that there is limited access is the fact that we don’t have a clear definition of who qualifies for palliative care,” Booker told Hospice News during the Palliative Executive Webinar Series. “What are the clinical components that we’re looking for in a patient? What are the guidelines? It’s fairly loose.”

Currently Medicare reimbursement for palliative care includes physician and licensed independent practitioner services through fee-for-service payment programs that do not sufficiently cover the full range of interdisciplinary care.

Many providers also rely on philanthropic funding to keep their palliative care services going, or operate them as a loss leader in hopes of gaining earlier hospice referrals.

Some value-based payment models incorporate palliative care elements. The U.S. Centers for Medicare & Medicaid Services (CMS) allows Medicare Advantage plans to cover palliative care as a supplemental benefit in the Value-Based Insurance Design (VBID) model, which is in the stages of testing the inclusion of hospice. Through the hospice component of the VBID demonstration, CMS allows plans to develop reimbursement streams for services that help to improve care transitions, such as palliative care.

“When it comes to providing a home-based or a clinical-based intervention and the reimbursement of those things, it’s really getting at identifying patients that would benefit from a palliative service much earlier on,” Booker said. “Patients don’t have to be that sick to benefit from palliative care. Palliative care can and should be the standard foundation of care from the time a patient is diagnosed with a chronic, complex or life-limiting illness.”

Many providers, payers and stakeholders agree that some form of a consistent definition for palliative care should exist.

However, reaching that point is a less than clear-cut process, according to Brynn Bowman, CEO of the Center to Advance Palliative Care (CAPC). The interdisciplinary nature of palliative care can take on different meanings to patient populations versus health care providers and versus payers, according to Bowman.

Without that common ground, operationalizing a financially sustainable program becomes a challenge, she added. For example, providers can have a difficult time determining which services fall under a palliative care umbrella and which staff are eligible to provide and bill for them, said Bowman.

“We have this ‘chicken and egg’ problem where teams may struggle to meet that definition of quality specialty palliative care because the work and those services are non-billable for providers,” Bowman told Hospice News during the webinar. “In the context of Medicare Advantage and a payment contract between a health plan and a palliative care team, there’s a lot more opportunity to achieve what we would consider to be a ‘gold standard’ of specialty palliative care delivery, but that takes providers to educate payers about what those high-quality services really look like.”

Efforts have been underway among health care providers, state and federal governments, advocacy groups and payers, among others, to make community-based palliative care more accessible to patients and families and more clearly defined in payment parameters.

Some flexibilities in the Accountable Care Organization Realizing Equity, Access and Community Health, (ACO REACH) model also include reimbursement pathways for palliative care.

Effective Jan. 1, 2023, ACO REACH will replace the Global and Professional Direct Contracting (GPDC) model. Some options of the GPDC model will be featured in the new program, such as the flexibility for providers to develop customized payment contracts that can include services such as palliative care, among others.

The Center for Medicare & Medicaid Innovation’s (CMMI) Medicare Care Choices Model (MCCM) demonstration may also aid in developing new reimbursement pathways for palliative care. Designed to test the impact of concurrent hospice and curative care, aspects of MCCM are being used in the development of new CMS Innovation Center models related to palliative care, CMMI indicated in a recent white paper.

If some agreement was reached on a standardized payment and definition of palliative care across the board, it could be a triple crown for beneficiaries, providers and payers, according to Booker.

“It’s a win for the providers delivering the care; it’s a win for patients and families; and it’s a win for the payers, because we’re providing high-value care, not just high-cost care,” Booker said. “If we can shift that paradigm and have everyone aligned around that, then we can make [palliative care] more of the norm. It becomes routine care, and part of what we expect in our health care.”

Developing a well-defined criteria would potentially open more doors to an established structured reimbursement palliative care benefit, according to Bowman.

Palliative care services can be “distilled down” to four keys, said Bowman.

These include:

Palliative care needs and assessment consultations that address physical, mental, and emotional health, as well as environmental, financial, psychosocial and caregiving support.
Goals of care and advance care planning discussions with patients and their families, as well as training and education for providers on how to facilitate these conversations.
Pain and symptom management that improve quality of life for the patient and their family.
Care delivery plan models that reduce high cost emergency services and hospitalizations and help patients know what to expect as their disease progresses.

For now, it’s up to providers to help define what palliative care services and payment should encompass, according to Dr. Christopher Comfort, COO at Calvary Hospital.

“Palliative care providers themselves are going to have to create the model of the service that is meaningful to beneficiaries and families and is justified in terms of cost effectiveness to the general medical system,” Comfort told Hospice News during the webinar.

Palliative care payment should be laid out around three basic elements, according to Comfort:

Defining the “unit of care” in need of serious and chronic illness support, including patients, families and caregivers.
Ongoing communication avenues for decision making and ensuring families and patients can take an active participation in care plan decisions.
Establishing roles of an interdisciplinary team for home, community-based and facility-based settings

“You take it to the point where you indicate that there is a sickness and illness that pervades not just an individual with a disease or a diagnosis, but that it spreads metastatically and that deterioration is seen in the family as well,” Comfort said. “Palliative care means care of the patient and the care of the family, not just involvement in the family in decision-making related to disabled or incompetent loved ones. It means that they are being sick and comforted by the work that we do with them.”

Source: hospicenews.com