Exploring partnerships with Accountable Care Organizations (ACOs) may help palliative care providers grow and sustain their programs, but they would need to prioritize cost effectiveness and their capacity to receive new patients.
ACOs are among the many health care stakeholders that are grappling with the question of how to best serve the burgeoning population of chronically or seriously ill seniors. This includes reducing preventable hospitalizations and emergency department visits.
Increasingly, palliative care is coming up in those conversations.
“There are a lot of opportunities to partner with ACOs. To take advantage of those opportunities, more attention might be focused on [the provider’s] own capacity and making sure they can take the volume of patients that might be sent their way,” Allison Silvers, chief of health care transformation at the Center to Advance Palliative Care, told Hospice News. “I think the field also has a little more to learn about how to deliver care more efficiently. That is something that would be important if folks are going to be successful.”
While many ACOs have implemented systems to identify high-needs patients, few have figured out the right mix of specific care strategies to manage their care and meet their needs, according to 2020 research published in Health Affairs.
ACOs can encounter challenges that can hamper their ability to launch a new palliative care service. These often include limited access to start-up capital, difficulty getting buy-in from organization leaders and workforce constraints, the Health Affairs research found. For palliative care in particular, it can take an ACO four to five years to get a program up and running.
In the quest to balance patient needs with limited resources, more ACOs are implementing short-term, transitional delivery models that layer palliative care on top of the patient’s other services.
“Because palliative care resources are so limited, this idea of a time-limited episodic support seems to have some value and should be explored more,” Silvers said. “There is some dissatisfaction with the ongoing home-based care and concerns about capacity, because new admissions can’t always be accommodated, and the cost effectiveness. Roughly half of them were wondering if there was a more efficient way to do things.”
Generally, these short-term models offer patients a comprehensive assessment followed by home-based palliative care for a limited time. The palliative care provider in these arrangements typically co-manages the patient with another agency, such as home health or primary care and receives per-patient, per-month payments.
The palliative care team’s objective is to ensure the patient has a sustainable regimen for symptom management, conduct goals-of-care discussions as well as any necessary education. If the patient later experiences breakthrough symptoms, the palliative care team can re-engage temporarily to address those issues.
The most significant payer for these patients, of course, is Medicare.
Historically, the U.S. Centers for Medicare & Medicaid Services (CMS) has reimbursed palliative care through a fee-for-service model that only covers physician and licensed independent practitioner services, rather than the full range of interdisciplinary care.
In recent years, the agency has allowed for some value-based reimbursement through Medicare Advantage supplemental benefits, as well as some palliative care elements included within the value-based insurance design model demonstration.
But in time, ACOs may play a greater role in palliative care delivery.
As the Center for Medicare & Medicaid Innovation continues to test new payment models, more palliative care features may be integrated into ACO-centric programs, according to Silvers.
“People who are working on models such as the ACO REACH, have stated that they want to incorporate palliative care into those models, to put ACOs in the driver’s seat of who should be getting palliative care and how it should be structured,” Silvers said. “There’s a number of ACOs that are using those short-term, home-based interventions. It’s a different way of going about it, but I think it actually is a really effective way of caring for a good number of people with serious illness.”
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