Palliative care providers are problem solvers, and keeping that perspective in mind can help them design programs and build payer relationships more effectively, experts told Palliative Care News.
Though palliative care is picking up steam among payers, providers and investors, significant variation exists in eligibility, reimbursement and care delivery models.
This reality can be a double-edged sword. On the one hand, carefully selected eligibility criteria can help ensure that the right care is going to the right patients at the right time, and prevent capacity overload for providers capacity. On the other, patients who receive palliative care from different providers may be getting a disparate set of services.
“Defining the patient population that you want to serve and what type of program that you want to develop because you can be at risk for opening the floodgates to overwhelming any palliative care program,” Dr. Andrew Mayo, chief medical officer, St. Croix Hospice, said at the Hospice News Palliative Care Conference in Washington D.C. “That definition of who you’re going to serve, and in what capacity you are going to design your palliative care program is a very, very important question.”
When it comes to program design, payers also play a role. The services provided generally correspond to the services they are willing to cover, with some exceptions such as those paid for through philanthropy or other means.
Like providers, each payer can to a large degree take a different approach to coverage, as well as the care models they support. Most have the option to limit the types of patients who can receive palliative care based on factors like age, diagnosis or a history of hospitalizations.
The patients most likely to be eligible for palliative care include those who suffer from dementia-related illnesses, cancer, diabetes, heart or kidney disease, Parkinson’s disease or stroke, according to the Center to Advance Palliative Care.
Some payers also stipulate that eligible patients must have had a recent hospitalization or a history of fragmented care, such as those who don’t have a primary care physician.
‘Articulate the problem, Be the Solution’
When payers or referral partners come to the negotiation table, providers should come prepared to show how they can help identify and mitigate the problems those organizations and their patients face, according to Rory Farrand, vice president of palliative and advanced care, National Hospice and Palliative Care Organization (NHPCO).
To some extent, eligibility becomes a balancing act. While some exclusionary criteria are important, those that may be too strict or less adaptable may not be very cost-effective, Farrand indicated.
The provider’s goal is to ensure they are providing care to the right patients while remaining within the scope of their resources, she added.
To achieve this, providers need to have a clear understanding of what patients, payers and referral partners are looking for, and to stay flexible as circumstances evolve.
“If you’re not solving a problem for your patients, for your co-workers or the health system in general, then palliative care might not be the correct line of business. You need to really be able to articulate the problem and how palliative care can provide that solution,’” Farrand told Hospice News. “Then you need to do a needs assessment of your organization to make sure that you are putting the right things together in order to solve that problem. But that’s not a one-and-done process. You have to assess, evaluate, and then redesign as appropriate.”