Palliative Care is Value-Based Care

Applying Medicare Care Choices Model Results, Primary Specialty Care, and What a Permanent Palliative Care Benefit Might Look Like:

If you missed Part One of this 2-part series, you can read it here:

Here’s a quick recap:

The Medicare Care Choices Model tested a palliative care benefit for Traditional Medicare beneficiaries that was very successful in reducing costs and improving quality of care. Only beneficiaries who met hospice requirements and had one of only four diagnoses were eligible for inclusion in the model.

MCCM was an option offered to those who met hospice criteria but did not want to end active medical treatments for their serious illness. MCCM beneficiaries also did end up electing hospice at a higher rate than the general population.

Two notable takeaways:

1. Model attrition was high because of the very low monthly payments in comparison to hospice payments. Much of what was provided to patients in MCCM was very similar to the care those same hospices provided to patients electing hospice.

2. The inclusion criteria was not aligned with who is eligible for and can benefit from palliative care, which can be initiated anytime after the diagnosis of a life-limiting illness.

You can read more about the above in my first article, linked above, which includes helpful visuals and YouTube videos embedded within it.

Applying Model Components to Achieve Similar Results to the MCCM

The strong results of the model should make ACOs take notice. This model was able to reduce spend for complex patients with serious specialty care-based illnesses. While we have a ways to go to crack the code on reducing variability, spend, and more in specialty medical care, we can better manage and improve engagement of these patients right now without putting specialists at risk.

How?

I see the ACO REACH model benefit enhancement and waivers as providing much of what a participating ACO would need to mimic the MCCM’s structure and, hopefully, results.

Note:

• NP BEs include things like certification of need for hospice, supervision of cardiac rehabilitation, establishing and reviewing home infusion therapy plans of care 

• CMS added a few additional beneficiary enhancements for 2024, including the addition of PAs to the NP BE flexibilities

Benefit Enhancements that can be helpful in providing services that could also support palliative care (for more detail, please see the ACO REACH RFA):

1. Post-discharge home visit: Up to 9 visits in the home for up to 90 days after discharge from an inpatient stay. These visits are made by auxiliary personnel under general supervision

2. Care management home visits: Up to 20 visits per year for patients deemed a risk of hospitalization. Visits made by auxiliary personnel under general supervision

3. Home health homebound waiver benefit enhancement: For patients who qualify for home health but don’t meet homebound requirements

4. Concurrent care for beneficiaries who elect the hospice benefit: This is essentially MCCM’s concept, only the hospice isn’t paid a small monthly care management fee, but instead, their full hospice rate

5. NP and PA flexibilities, including certification of the need for hospice

GUIDE Model:

I have written about GUIDE in prior newsletters. This is a CMMI Model for dementia beneficiaries where CMS pays a monthly fee to Participants in the model for each aligned beneficiary to help with patient and family education and engagement, as well as to cover many of the preventative and care coordination services available in the physician fee schedule.

I’ll be doing a part 3 on the GUIDE Model in the near future, with some additional insights and considerations. If you are applying and haven’t decided if you will participate or not, definitely catch that one! And if you know someone who might like to read more about GUIDE and my series of articles, please

The GUIDE Model payments continue until death, hospice election, or long-term care placement, primarily. These monthly payments also allow visits to the home by auxiliary personnel. In these home (or telehealth) visits, trust is built, engagement is improved, and needs are identified.

If the Participant is also part of the ACO, those touchpoints identify risks of hospitalization, build trust to address advanced care planning, and ensure the patient’s provider is seeing the patient periodically to address other chronic conditions. The GUIDE team member is hopefully coordinating with other specialists and the PCP (if they are not the PCP themselves), as well.

Primary Specialty Care:

Palliative and hospice physician specialists are not always easy to find. The concept of primary specialty care helps a primary care provider consider how they can meet the specialty care needs of patients when it’s safe, appropriate, and in the best interests of the patient and family, and for other reasons like reducing fragmentation.

Palliative care is an excellent example of being ideal for primary specialty care. Note we are referring here more to Palliative Medicine.

As I wrote about in part one:

Much of what palliative care physicians do in the community can become a skill of primary care providers, as well. Palliative care specialist physicians often practice in ICUs and other higher-touch environments, where their specialty care practice skills are truly needed most.

There are only a few billing codes associated with palliative medicine, but the ones that are the greatest opportunity for primary care are the set of advanced care planning (ACP) codes, which also have no co-pay when used at the time of the annual wellness visit (AWV). If the ACP visit doesn’t meet the time-based requirements, there is a CPT II code set to identify that this ACP service has been done, which can be valuable data for the practice if they are in an ACO or primary care alternative payment model (APM).

What might a Palliative Care benefit look like in Traditional Medicare?

If we build upon and improve the Medicare Care Choices Model, it could look something like this:

• Be available in moderate to end stages of serious illness progression, not just concurrently offered as an option as an alternative to hospice and with just six months to live

• Be available to anyone with a life-limiting illness, not limited by a few diseases

• Using one or more well-studied tools, it could base monthly payments on functional and medical stages of limitation and disease, so reimbursement is higher when needs for engagement with the care team are higher

• Be able to be administered by entities other than only hospice agencies

In my opinion, the first two bullets are essential to the success of the benefit. I’m defining success as reducing hospitalizations and other inpatient stays, increasing hospice utilization and the median time on hospice, and reduced Medicare spending, at a minimum.

In the meantime, wouldn’t it be great to see ACO REACH entities and GUIDE participants testing the MCCM concepts within their own models?

Another way to think about this concept is that the start of palliative care is the start of an episode of care that ends either at death, or when hospice is initiated.

While the medical and value-based care communities are opining on episodes of care concepts and developing policy proposals and CMS is building models and model concepts, this non-disease specific episode of care program could be of greatest value and can be started in the present.

Thanks for reading, and as always, I welcome your comments, feedback, and requests! Just reply back directly to this email and I’ll respond thoughtfully!

All the best,

Dana