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Earlier this year, palliative care advocates were hopeful that a formal benefit for community-based services would be coming soon.
While that hasn’t happened yet, the clear momentum around a reimbursement pathway for community-based palliative care has prompted more home health agencies and other providers to launch programs of their own. That’s a trend likely to accelerate heading into 2022, thanks to the proposed expansion of the Home Health Value-Based Purchasing (HHVBP) Model and recent legislative updates on Capitol Hill.
“If we get that, that’s a game-changer,” Dr. Nathan Goldstein, a geriatrician and palliative care physician who helps run Mount Sinai’s home-based palliative care program, told Home Health Care News.
Broadly, palliative care offers specialized, whole-person care for people living with serious illnesses, such as cancer, lung disease or advanced liver disease.
It’s very difficult to determine exactly how many community-based palliative care programs there are in the U.S. But past research suggests that roughly half of all counties have at least one service provider, according to Dr. Diane Meier, another well-known geriatrician and palliative care expert within the Mount Sinai system.
“It’s very hard to have accurate data on the prevalence of community-based palliative care delivery in the United States,” Meier told Home Health Care News. “You do get a sense that roughly 50% of all the counties have access to at least one community-based palliative care provider, however. About half of those are sponsored by, or have as an organizational home, a hospice agency. The other half are sponsored by, or have as an organizational home, a health system.”
Meier is the former director of the New York City-based Center to Advance Palliative Care (CAPC), a national organization devoted to increasing the number and quality of the nation’s palliative care programs. She stepped down from that position in mid-April, but still serves as CAPC’s director emerita and strategic medical advisor.
Although Meier didn’t mention home health agencies specifically as dominant providers of community-based palliative care services, there are plenty of successful examples of companies doing just that.
Mission Healthcare, for example, launched a palliative care program to keep its patients out of “no man’s land” in the spring of 2020. The provider — one of the largest home health, hospice and palliative care organizations on the West Coast — then expanded the program this March.
“We found that there was an unmet need,” Mission CEO Paul VerHoeve told HHCN at the time. “A group of patients were kind of falling in between the cracks, going home with a lot of needs but not necessarily being able to be supported or followed accordingly.”
Aging-in-place giant Amedisys Inc. (Nasdaq: AMED) even cited Contessa Health’s strong palliative care track record when it acquired the company for $250 million. Amedisys’ deal for Contessa was originally announced at the end of June.
“With the signing of this deal, we are taking a material step in realizing our innovation strategy to provide more and better care in the home to all who want it,” Amedisys Chairman and CEO Paul Kusserow said. “[We’re] further differentiating ourselves from the traditional home health and hospice industry.”
Existing barriers
Generally, community-based palliative care programs have been found to improve health outcomes and lower total cost of care. In one 2019 study, for instance, researchers found that Medicare Advantage (MA) members who received community-based palliative care had a 20% reduction in total medical costs and a 33% reduction in hospital admissions.
Despite these and similar findings, two major challenges have stood in the way of further growth. The biggest roadblock is a restrictive reimbursement landscape, Goldstein and Meier explained.
“If you do not have the right kind of health insurance, you cannot have access to care,” Meier explained. “That’s another big barrier: If you have fee-for-service Medicare, you’re out of luck.”
More than 26 million people — over 40% of the entire Medicare population — are enrolled in an MA plan for 2021. The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in MA will reach upwards of 51% by 2030.
Community-based palliative care hasn’t broken into traditional Medicare as a mainstay because health care policymakers are often hesitant to pay for longitudinal care models that require a wide range of capabilities. Typically, Medicare tries to control costs by “hyper-defining rigid eligibility criteria,” Meier explained.
“Medicare is not really comfortable with creating benefits that have broad inclusiveness because [regulators] are worried about fraud and abuse,” she said. “And enabling the continued delivery of service to people who may be stable for a period of time, before they have their next crisis.”
Mount Sinai has been operating one of the oldest and largest home-based palliative care operations for years. In February, the health system expanded an existing partnership with Contessa to launch a joint “Palliative Care at Home” program.
Since launching in 2015, Contessa has turned into a skilled negotiator with payers, as far as figuring out creative ways to fund in-home care efforts outside of fee-for-service Medicare. Its partnership has helped Mount Sinai with the reimbursement challenge, Goldstein noted.
Contessa’s involvement also helps Mount Sinai grow its home-based palliative care program, he added.
“We created a model. We proved it improves outcomes,” Goldstein said. “Contessa is helping us sustain our model, so we don’t have to continue to find grant money for it. And it’s helping us disseminate our model, so other patients and families across the country can benefit from it.”
The second major challenge has been a shortage of qualified professionals to staff community-based palliative care programs.
“This trend in home-based palliative care has been going on for a while, and more and more evidence shows that it works,” Goldstein said. “At the same time, we have a significant shortage of specialty-trained palliative care physicians — and even more so when it comes to specialty-trained trained palliative care nurse practitioners.”
The “base” of Mount Sinai’s home-based palliative care “pyramid” is built around a community health worker, an RN and a social worker. That team is then “backed up” by a nurse practitioner and physician.
“What we’ve done is take that model of community health worker and train them up in palliative care specifically,” Goldstein said. “We’ve given them some basic information on the diseases that they’re going to be encountering, including advanced cancer, advanced lung disease, advanced heart disease and [more]. They act as a navigator, while helping patients and families understand their illness.”
Reading the tea leaves
As the home health industry shifts toward value-based care, palliative care will play an increasingly important role, Meier believes.
“If you read the tea leaves the way I do, we are moving faster toward mandatory value-based payments,” she said. “If you are a certified home health agency, you have got to figure out how to deliver care to a broader population under a fixed budget, whether a capitated budget or a population budget.”
The shift is likely coming sooner rather than later, as the U.S. Centers for Medicare & Medicaid Services (CMS) is seeking to expand the HHVBP model to all 50 states next year.
An in-house palliative care line could set agencies up for success, perhaps even by changing their mindset to “longitudinal care” from “episodic care.”
“People who are focused on extracting better value out of the system, they see community-based palliative care as a tool or a solution to do that,” Meier said. “We’re talking about a large group of people who are not hospice-eligible — they’re not dying. They have chronic diseases. Therefore, the traditional episodic basis of a certified home health agency doesn’t meet their needs either.”
Legislation may likewise accelerate home health care’s adoption of community-based palliative care.
Sens. Jacky Rosen (D-Nev.), John Barrasso (R-Wy.), Tammy Baldwin (D-Wisc.) and Deb Fisher (R-Neb.) introduced bipartisan legislation that would direct the Center for Medicare & Medicaid Innovation (CMMI) to develop a demonstration of a community-based palliative care payment and delivery model in July.
Outside of the MA landscape, Medicare reimburses for palliative care physician and licensed independent practitioner services through fee-for-service payment programs, though those often do not sufficiently support the full range of interdisciplinary care.
The closest existing equivalent to a palliative care benefit is the CMS test of the Medicare Care Choices Model (MCCM), which allows hospice patients to receive curative care concurrently with hospice.
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