Palliative Care the Next Generation: How the Service May Grow and Evolve

Based on current trends, risk-based payment systems will likely shape the future of palliative care.

The palliative care market is projected to swell during the next decade. However, no standardized definition exists for “palliative care.” Providers use a range of approaches to providing the service, from consults with advance care planning to short-term transitional care or longer-term symptom management for the chronically ill.

Nevertheless, hospices have played a “major part” in the development of palliative care thus far and will have an important role guiding further innovation, according to Robin Stawasz, program development executive at Acclivity Health. These types of care are distinct from one another, and providers often have to emphasize the differences between the two in their marketing.

“Hospices have helped to define the holistic approach to addressing the patient as a whole in the palliative model,” Stawasz told Palliative Care News. “But that model is at risk of losing focus on addressing medical, mental, spiritual and psychosocial needs of patients and caregivers. Palliative care needs to be embraced as its own discipline — rather than a service line — if we’re going to succeed in delivering quality, or it risks falling to the wayside.”

The rise of risk

Risk-based reimbursement may be giving the palliative care market a push.

The U.S. Centers for Medicare & Medicaid Services (CMS) currently allows Medicare Advantage (MA) plans to cover palliative care as a supplemental benefit. Palliative care is also an element in the hospice component of the value-based insurance design (VBID) model, which is in its third year of testing. Some providers also receive palliative care reimbursement through payment arrangements with Accountable Care Organizations (ACOs) and Managed Services Organizations (MSOs).

The palliative care market is projected to reach several billion dollars over the next decade, market reports suggest.

Without a federally established benefit, the scope of palliative care delivery and payment varies from market to market, and sometimes from provider to provider.

This not only creates wide variations in patients’ and families’ palliative care experiences, but also uncertainty about sustainable growth, Stawasz said.

“The current patient profile for palliative care is limited and restricted, when it could be proactive and not reactive to health crises for both the patient and their caregivers,” Stawasz told PCN. “The real linchpin holding palliative care back right now is a good payment model and benefit that sets the bar on both the provider and payer side.”

Medicare Advantage a prime mover

For now, both sides are focused on MA.

Most providers of community-based palliative care receive at least some payment through MA, unless their services are covered through philanthropy.

Moveover, some of the industry’s largest companies are making substantial investments in at-risk palliative care, with MA plans emerging as leading payer sources.

Among them is Amedisys (NASDAQ: AMED), the company’s chairman and former CEO, Paul Kusserow, recently indicated. The company recently announced a partnership with BlueCross BlueShield of Tennessee to cover palliative care through the Amedisys subsidiary Contessa.

Amedisys’ $250 million acquisition of Contessa in 2021 expanded the home health and hospice provider’s fledgling high-acuity home care and palliative care business lines.

The parent company continued Contessa’s existing strategy of developing joint ventures with health systems to augment their home-based services, including palliative care. Recent partnerships include Baylor Scott & White HealthMemorial Hermann Health System and Henry Ford Health System, among others.

The company has embraced at-risk payment models to demonstrate cost savings potential to payers in the form of reduced hospitalizations and emergency department visits, Kusserow previously told Hospice News. Amedisys is currently positioning itself to deliver palliative care on a larger scale, according to Kusserow.

AccentCare, a portfolio company of private equity firm Advent International, is another example. The company has expanded its palliative care services through partnerships with hospitals and other managed care providers, according to AccentCare CEO Stephan Rodgers.

“We’ve got a very large palliative care practice,” Rodgers told PCN. “What we’ve seen to make it really work is you either have to be in the hospital, where we’ve taken over palliative care in the hospital, or you have to be contracted with managed care and get it at some kind of risk, because community-based palliative care is very difficult to make operate right now from a profitable [perspective].”

Taking palliative care beyond Medicare

Much of the development in palliative care thus far has been underfunded, according to Hosparus Health CEO David Cook. Moving the needle towards change requires setting parameters around patient eligibility, for starters, he said.

In addition to VBID and at-risk payment models, traditional Medicare reimburses for palliative care. But the coverage is limited to physician services, rather than the full range of interdisciplinary care. This is among the reasons that palliative care is often a loss leader for many organizations.

“It’s not supported the way it needs to be as more people face serious illness that don’t fit in the hospice box,” Cook told PCN. “[With] the complexity of care of people living longer and advances in medicine, they’re suffering and still need support. Palliative care is going to need to fill that, and there’s a lot of discussion around where does palliative care start and stop.”

Wherever the care ultimately starts or stops, access and reimbursement should not be limited to the Medicare population, according to some stakeholders.

Reimbursement models should also be established with Medicaid and private insurance plans, according to Bill Dombi, president of the National Association for Home Care & Hospice (NAHC). This would help develop an established structure for palliative care across the continuum that better supports patients’ needs, he stated.

“It’s essential that we develop palliative care programs and benefits to support those programs under Medicare, Medicaid and private insurance as well,” Dombi said during a recent NAHC webinar. “The great opportunity that’s out there has been driven by success of breaking down that continuum of care to where it’s not setting-specific.”

The time to build a framework for a regulated palliative care benefit is now, according to St. Croix Hospice CEO Heath Bartness.

“There’s no payer for palliative care right now, and there’s no regulated benefit of palliative care,” Bartness told PCN. “Payers and private insurers need to be the ones to take action on that. Palliative care should indeed be something that we factor into [payment].”

It’s not supported the way it needs to be as more people face serious illness that don’t fit in the hospice box.

– Hosparus Health CEO David Cook

Laying the groundwork for palliative payment

The trajectory of value-based payment models may in time better integrate palliative care into the health care system from both provider and payer standpoints, according to Ben Marcantonio, COO and interim CEO at the National Hospice and Palliative Care Organization (NHPCO).

This may come to mean that providers outside of hospices and health systems could become more involved.

“What we see happening with palliative care outside of hospice is a real desire to integrate it into the primary care setting really at the roots of community-based care,” Marcantonio told PCN. “[But] it’s yet to be seen how successful that can be and how sustainable that is, because there’s not a lot of resources for payment. How [palliative] will be sourced on a long-term basis is something we have yet to see, but that seems to be the direction.

To move forward in that direction, palliative care providers can leverage the vital data they already have to lay the foundation for more formalized delivery and payment, according to Stawasz.

This includes palliative care’s association with reductions in hospitalizations and other high-acuity services.

Building an established palliative care benefit should start with the patient and build from there, Stawasz said.

“I see palliative care payment narrowing down to be rolled into more specialized models that support many serious illnesses,” Stawasz explained. “It all boils down to starting with patient needs, understanding their perspective, and then setting a palliative program of care around this – not the other way around as it often goes. One size does not fit all. We have to tailor these programs with data that proves how we identify different patient needs in specific regions, what inpatient and outpatient payment looks like, and be able to make adjustments around specialized care for a wide range of diagnoses.”

Palliative Care the Next Generation: How the Service May Grow and Evolve – Hospice News