For the time being, Medicare Advantage may be providers’ best bet for palliative care reimbursement.
The U.S. Centers for Medicare & Medicaid Services (CMS) also allows Medicare Advantage plans to cover palliative care as a supplemental benefit. In addition, the agency has integrated palliative care components into the Value-Based Insurance Design Model (VBID), often called the Medicare Advantage hospice carve-in.
But primarily, Medicare still reimburses for palliative care through fee-for-service payment programs that cover physician and licensed independent practitioner services. That model does not sufficiently cover the full range of interdisciplinary care, according to Rory Farrand, vice president of palliative and advanced care at the National Hospice and Palliative Care Organization (NHPCO).
“My concern is that from a Medicare Part B reimbursement perspective the only billable clinicians that you can have in that situation are physicians, a Physician Fee Schedule,” Farrand said at the Home Health Care News FUTURE conference. “So when you think about a home-based palliative care program, and you were hoping to include RNs and social workers in there, they’re not considered billable clinicians. You can’t do incident billing in the home, you can only do that in a clinic setting or in an office-based setting.”
This year, the number of MA plans swelled to 3,998 nationwide, up 6% from 2022. Last year these plans covered more than 28 million Americans, or nearly half of the entire Medicare population, according to the Kaiser Health Foundation.
In 2022, 147 plans offered home-based palliative care across 17 states, a 7% increase in the number of plans compared to the prior year. That growth has continued into 2023, with at least 157 plans offering home-based palliative care, according to data from Washington, D.C.-based research and consulting firm ATI Advisory.
A key attractor for MA payers is the opportunity to reduce costs and improve outcomes, according to Trina Lanier, COO of Choice Health at Home. She is also co-founder of the company’s hospice and home health service segment.
“The use of palliative aspects does reduce [high-acuity] care and provides quality of care to the patient,” Lanier said at FUTURE. “That’s where our focus has to be, to identify patients early, having those conversations and getting the patient to the right level of service at the right time.”
Several factors are crucial to working within Medicare Advantage, including complete and accurate clinical documentation, as well as strong performance on quality metrics.
Some key metrics include CMS star ratings in the agency’s Care Compare system, as well as results from Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys and the Hospice Item Set.
However, providers will also need to demonstrate a track record of reducing hospitalizations, readmissions and emergency department visits.
“Where there is an opportunity to partner with [Medicare Advantage] plans, [providers] can say, ‘Listen, we can show these outcomes through our home-based palliative care program. But we would like to be paid on a per-member, per-month basis or some sort of capitated payment arrangement,” Farrand said. “That’s going to be a little more sustainable than billing fee for service.”