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Palliative Care is Value-Based Care
Part I: Palliative Care, Hospice, and the Medicare Care Choices Model
Dana Prommel Strauss
February 08, 2024
Hello to new friends and old,
When I opened CMS’ synthesis of 21 models report at the end of 2023, I scrolled first right to the results tables. One for Population Models, one for Targeted Populations and Specialty Care.
As you can see in the report linked below, the Pioneer ACO Model and the ACO Investment Model had the highest degree of success in the Population-Based models evaluated.
Then in the Targeted/Specialty Populations table, MCCM jumped right out. I first had to Google what it stood for because I honestly forgot! Were people talking about this? Double-digit savings across the whole row!
Look at that row of solid green and percentages of savings over the course of the MCCM!
I am going to get in the weeds about the Medicare Care Choices Model, but first, I want to make sure you walk away with a strong and conversational understanding of what palliative care and palliative medicine are, as palliative care and the bridge to hospice were what was being tested in the model.
Those of you who know me know how passionately I believe in palliative care and hospice. I’ve had the past good fortune of working closely with a Palliative Care phenom physician, Dr. Puneeta Sharma, and her team in a health system.
My life partner is a also a hospice social worker. In addition, I made referrals to both palliative care and hospice regularly when working as a clinical liaison and leading a transitions of care team in a population health department.
Palliative care embodies everything I love about value-based care. You’ll understand why as you keep reading.
Here me out, and please read on. And if you like my newsletter, consider subscribing for free to Health AI Insights, another great healthcare/health tech newsletter.
Anticipated Takeaways:
I hope you leave this two-part series with:
A better understanding of what palliative care is, where it falls in the serious illness journey, and maybe even a desire to find solutions to build/grow/enable/champion palliative care, whether you are in health tech or healthcare delivery or both
A working knowledge of the Medicare Care Choices Model, how the model learnings can be incorporated into other value-based care programs
An appreciation for the important and underutilized piece of the puzzle palliative care can play in managing patients with serious, life-limiting illnesses
How the episode of care from initiation of palliative care through the end of life is one with tangible opportunity to improve quality of life directly through patient-directed and empowered care choices
A great visual about the course of serious, life-limiting illness
Below is one version of a common graphic demonstrating that palliative care can begin at the time of diagnosis of a potentially life-limiting illness. Its inclusion in a patient’s treatment plan is complementary to curative and life-prolonging treatments—not instead of them.
Note that “palliative care” is not the same as hospice. As palliation becomes the predominant care type, patients often choose to progress to hospice for “end of life care,” or EOLC, as above. Palliative care can be a multi-year care approach and may begin around the time of diagnosis.
Palliative “care” support measures are also common to hospice support measures.
Palliative Medicine vs. Palliative Care
Palliative Medicine
Symptom anticipation and management,
goals of care discussions and medical decision-making,
coordination of care with other physicians involved in the patient’s care, often focused on a specialist treating the terminal condition, and
a medical specialty that spans all serious illness management
are some common ways of describing the specialty care type called Palliative Medicine.
These specialty care physicians were the ones having the conversations about what matters to patients with serious illness when there was no monetary value for that treatment time in the physician fee schedule.
They were providing value-based care with no incentive, but rather, because it was in the best interests of patients and their loved ones.
Get this—
The codes for advance care planning were first made available in the physician fee schedule in 2016.
Eight years ago.
That’s it.
Conversations that can take an hour, require multiple conversations over time, were not reimbursable just 8 years ago.
So……it’s going to take “a minute” for most primary care providers to get up to speed and develop comfort with this communication skill set so it can be used as common, everyday parts of practice.
When I was part of a team first encouraging providers to have these conversations for their patients with serious illness, I heard this more times that I can count:
“That’s for the social worker to do.”
Heck, I had more physicians tell me advanced care planning/POLST completion (see more below) was for social workers to do that I can count on 2 hands. While social workers and other clinicians can support, prepare and assist conversations about treatment choices and other decisions that are part of the POLST, it is a physician or NPP who needs to sit with a patient and their loved ones and talk about things like:
what the possible outcomes are if a feeding tube is placed or not,
what to expect if CPR is initiated or not, or
whether I want antibiotics and in what circumstances if I can’t decide on my own when I might need them…
and much more
It is the physician and/or NPP that has ongoing conversations as conditions change to ensure patients continue to make choices based on what matters to them.
I generally had an easier time convincing advanced practice nurses (covering patients in skilled nursing facilities, for example) to engage in these conversations when they were needed than physicians. (Given most APNs were once RNs and communicating was critical to their roles, it never surprised me.)
I also have to call out that I did work with several physicians who WERE remarkably skilled at this, and these physicians were also plugged in closely with the population health team.
…only these practitioners (physicians and non-physician providers) may report CPT® codes 99497 and 99498. ACP services are the provenance of patients and physicians. The billing physician or qualified provider must participate and meaningfully contribute to the provision of ACP, in addition to providing a minimum of direct supervision. The usual physician fee schedule (PFS) payment rules regarding “incident to” services apply.
All other providers (social work, psychology, chaplains) may not report ACP codes independently.
Palliative “Care”
This doesn’t refer to the medical components, but rather, the emotional, spiritual, social support, care coordination, education, empowerment, and other wrap-around psychosocial supportive care.
Palliative medicine and care are about optimizing quality of life, supporting patients with information and education to make decisions based on what matters to them, and are critical to patient and family centered care.
Advance Care Planning may include the completion of a POLST, or similar set of cross-continuum orders
The portable medical orders that can determine options for treatment in advance of needing to be used are called different things in different states, like
POLST: Physician/provider orders for life-sustaining treatment
MOLST: Medical orders for life-sustaining treatment
POST: Physician orders for scope of treatment
involve important decisions made after provider/patient discussions. Below, I linked the National POLST, but many states use their own. There’s also a guide to the form, and a helpful YouTube video that describes the types of decisions made in completing this order.
The Medicare Hospice Benefit is Underutilized
With that foundation of palliative care laid out, let’s talk about hospice.
Like palliative medicine and care, hospice is high-value care. The below snip is from a more comprehensive research summary, linked below.
Hospice saves money for the Medicare trust fund, especially when started 6 or more months before the end of life. There are rich details in that linked report, but to summarize, savings are greatest when hospice has a longer time horizon with the patient.
At the most basic level, terminally ill patients spend more of their last stage of life at home, creating a better end of life experience and saving Medicare dollars for care that may not be the patient’s choice when they truly understand what their choices may mean.
Hospice utilization varies WILDLY! But for all hospice primary diagnosis types, the greatest savings are in the time periods of 6 months or more
4-25% savings across all primary diagnostic groups in hospice stays greater than 6 months
While on average, day 10 of hospice is the break-even day, with diagnostic-specific break-even days in this graphic:
Hospice stays of 3-17 days, depending on primary diagnosis, are when the Medicare trust fund breaks even
Back to The Medicare Care Choices Model
From 2015 to 2021, the CMS Innovation Center tested a model that they hoped would encourage more patients to opt into hospice at the end of life by offering MCCM as an option in a “no wrong door” approach to referring to end of life care.
If a patient was referred to hospice but would not accept the benefit because they wanted to continue curative/life-sustaining treatments, they were offered the MCCM as another option.
As Edo Banach says in Episode 139 of the Care Talk Podcast, “(paraphrasing) When we let patients self-select supportive care without giving up curative treatment, they opt for more support instead of more invasive treatment. It’s not that the medical care they don’t want to give up is curative, it’s just more of a psychological barrier.” Click the link to listen to the full podcast episode.
This benefit paid a monthly fee to participating hospices to provide the palliative care services that are like hospice care services, without medical treatment or other services provided by hospice. This included home visits and services reflected in the below graphic:
The requirements for referral had to be just like that for traditional hospice: less than six months of life expectancy per a physician’s assessment because of a serious, life-limiting illness.
Also, only four diagnosis types were included in MCCM:
Cancer (note: this hospice diagnosis type via the Medicare Hospice Benefit is associated with the least savings to Medicare, for a variety of hypothetical reasons outside the scope of this article)
Congestive Heart Failure
Chronic Obstructive Pulmonary Disease
HIV/AIDS (very small “n” in the model years)
The average savings in the model overall was:
$7604 per beneficiary, or a
13% reduction in net spend, along with a
26% decrease in inpatient admissions and a
12% reduction in ED visits and observations stays
Patients were:
18% more likely to use the Medicare Hospice Benefit
Average 42 days on hospice when transitioning from MCCM to hospice vs. 19 days
Better quality end-of-life care between enrollment and death as measured in a few ways like number of days at home in the last 30 days of life (5 more for the MCCM group)
There was a major problem, however—model attrition by hospices was high.
MCCM was expected to admit about 150,000 beneficiaries to the program. The total number of patients admitted was 7,263.
Hospices reported that the low per member per month payments were insufficient to cover program expenses, with hospice participants that were part of health system ACOs having an easier time covering expenses.
MCCM monthly payments to participating hospices were only a fraction of standard hospice payments, even though qualifications for the illness stage and life expectancy were the same.
This wasn’t palliative care for patients with a range of disease stages, where support would be more intermittent. The average number of home visits per week in MCCM was 2.6, or about 10 per month.
Here are the hospice payment rates for a random location, the NY metropolitan area. The free tool allows you to look up rates for 2024 in any CBSA:
“Routine Home Care” hospice is intermittent hospice services by one or more hospice providers, most commonly nurses and social workers, but also chaplains, music therapists, doulas, and other clinical and support staff. The rate per day in the above example is $272.06 for days 1-60, which is paid to the hospice whether or not a visit is made that day.
As we saw before, even though this may seem high, there is high-value to this relatively high cost per day.
Those visits generally look similar to the types of visits and services in MCCM, except the nurse may be doing more hands-on care like wound care, for example.
The nurse still has to drive to the house, spend the time with the patient, perform a comprehensive visit. The payment for the MONTH for MCCM was about $400 per month.
Even with the disappointing participation numbers, there were invaluable takeaways from the MCCM.
In Part Two, I’ll cover:
How the model components can be incorporated into other CMMI Models like GUIDE, ACO REACH, Kidney Care Choices (KCC), and more
Palliative care as a critical “primary specialty care” to master for primary care practices taking on financial risk
Considerations for a permanent palliative care benefit in Medicare
Additional resources
And more!
Thanks for taking the time to read, and if you haven’t yet, please
All the best,