Building relationships with payers is key to financially sustainable hospice palliative care


According to Anne Tumlinson, CEO of consultancy firm ATI Advisory at the Hospice News Palliative Care Summit, creating and sustaining a financially viable palliative care program will largely depend on a hospice’s ability to demonstrate quality of care. and negotiating reimbursement for these services with payers. .

The demand for palliative care has exploded in recent years. Last year, more than 70% of US hospitals with 50 or more beds had a palliative care program, up from 67% in 2015 and 7% in 2001, according to the Center to Advance Palliative Care (CAPC) , which reported that these facilities treated 87% of all inpatients nationwide in 2020 and at least half of home hospice providers in the United States were in hospices that same year.

Value-based care initiatives have expanded the number of payment mechanisms available to hospice providers starting this year. Many providers see their best opportunities within Medicare Advantage, including supplemental benefit programs and the value-based insurance design (VBID) model demonstration, or the Medicare Advantage hospice carve-in. Only 53 Medicare Advantage health plans participate in VBID in 2021, but that number is expected to increase in subsequent years.

“We’ll see more plans coming to VBID, so keep an eye out. There’s a lot to learn about this model and where you can add value, but there are also some trigger threads you need to be very aware of, ”Tumlinson told Hospice News.

Value-based models of care link payments to quality of care and motivate health care providers to achieve efficiencies and savings. Improving quality and reducing costs are the two pillars of value-based care, as healthcare and political leaders increasingly recognize the unsustainable trajectory of the country’s healthcare spending.

Value-based care presents both an opportunity for providers who make the right calculations and risks for those who do wrong, Tumlinson told Hospice News. Providers who are evaluating which health plans they should work with should be aware of the payer‘s ability to help them grow their patient population and engage patients earlier in life.

“For performance-based payments [the payers] might suggest that you focus on quality, I would be very wary of any risk-based payment in this environment because they’re really hard to build, ”Tumlinson said. “You have to do the math. Do I believe this plan can generate enough volume for me and will be effective in generating volume dedicated to it? It means reaching people sooner or getting them to elect a hospice to get the necessary volume that will be worth those compromises. ”

Months after the start of the carve-in, hospices are seeing an increase in patient volumes while expanding their service offerings and adapting to new billing processes. Despite growing demand, hospices have struggled to navigate uncertain payment waters without a clearly defined hospice provision for reimbursement for these services. Through VBID, CMS aims to create a reimbursement structure in which Medicare beneficiaries who are critically ill receive a coordinated package of benefits, including palliative care. Among Medicare Advantage plans, CMS looks for those that can deliver a personalized experience, Tumlinson told Hospice News.

In the absence of a dedicated Medicare benefit for palliative care, hospice providers will have to negotiate rates and coverage with private payers and health plans. According to Tumlinson, the ability to demonstrate quality care and cost savings will be critical for hospices to collapse or swim as hospices seek to build relationships with payers in value-based care.

In addition to working within the VBID, Medicare Advantage plans have the option of offering palliative care as an additional benefit. According to an analysis of ATI Advisory, 61 health plans nationwide offer palliative home care as a benefit. There were 29 in 2019. More than 455,000 beneficiaries are registered with these plans.

Congress of 2018 passed the Creating High Quality Outcomes and Results Needed to Improve Chronic Care Act (CHRONIC), which expanded the range of additional benefits within Medicare Advantage to include programs to treat social determinants of health as well as palliative home care.

“Tactically, there are a number of different ways to engage with these plans, and it varies by plan,” Tumlinson said. “Medicare Advantage plans can make deals with their networked providers. They can create a network of palliative care providers and essentially make a deal, and those deals will involve three things: following quality measures; accept reduced rates; and the palliative care provider offering some level of concurrent care, supplemental care, or transitional care.

Payers look for hospices that can demonstrate value. They want to see solid data when it comes to quality measures and are particularly interested in a provider’s track record of reducing hospital admissions, using skilled nursing facilities, emergency department visits. and readmissions.

Being able to demonstrate that you are able to provide hospice palliative care in a predictable way is important to attracting and retaining the interest of payers from a cost perspective, according to Tumlinson. This includes obtaining consistent results on quality, reducing high acuity care.

“What they really like is working with suppliers who can operate under a cap per capita, who are willing to put a little skin in the game around performance, who have a good point of view. target for intervention, ”Tumlinson said. .


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