Payers to CMMI: We Need a Standardized Definition for Palliative Care

A group of health plans, policymakers and insurance companies recently told the Center for Medicare & Medicaid Innovation (CMMI) that they needed a standardized definition for palliative care in order to improve access.

The Coalition to Transform Advanced Care (C-TAC) recently facilitated discussions between CMMI, health plans and other private payers on ways to integrate palliative care services into existing payment models.

More than 60 participants discussed strategies to lay the groundwork for sustainable pathways to palliative care within existing health plans and payment models.

Torrie Fields, strategic advisor at C-TAC, spoke with Hospice News about the biggest takeaways of these discussions and what’s on the horizon for palliative care payment.

Fields also serves as director of the Center to Advance Palliative Care’s (CAPC) Serious Illness Quality Alignment Hub and as principal of TF Analytics. She was previously founder and CEO of California-based Votive Health, a technology-enabled network manager that offers market assessments for health plans and providers.

The talk with CMMI was just the “tip of the iceberg” on sustainable support for palliative care, Fields told Hospice News. Palliative care providers will need to work closely with payers to define the scope of quality and payment of these services, according to feedback C-TAC and payers received from ongoing conversations with CMMI and the U.S. Centers for Medicare & Medicaid Services (CMS).

When stakeholders come to the table to discuss palliative care, are they all talking about the same thing in terms of the clinical disciplines involved and the care model?

First, it’s not just one provider who is delivering palliative care. We need to be able to assess a team and know that the team has the right competencies and skills to deliver this type of care. Health plans are in alignment that this needs to be a specialty-type of model, and also that there are right ways and wrong ways to deliver palliative care services. We need to standardize training around who can deliver this care and what the competencies for palliative care really are.

There are different domains of care that need to be addressed. The common thread across health plans, accountable care organizations (ACOs), and across state Medicaid and Medicare agencies, is really that the core team includes a physician, a nurse, a social worker and a spiritual care professional, and that pharmacists play a key role in medication management.

They’re often other identifiers as components of a team that some patients will need such as a home health care-type of worker or community health worker. This is somebody who can help with being the eyes and ears in the home — delivering activities of daily living, supporting people who are really unable to do basic things like bathing, dressing or feeding.

How did the discussions that CTAC facilitated proceed? What were some of the biggest concerns and challenges that came to the forefront?

What we continuously heard was that there needs to be some type of shared approach to paying providers who are caring for this population, and a shared approach in evaluating the result.

Health plans have really struggled with getting a sizable enough population enrolled in palliative care programs to really demonstrate the value quantitatively of these initiatives. One of the big reasons for this is that health plans alone cannot really do the engagement, the recruitment or the enrollment in these programs. The health plans are all really doing different things, and this not only confuses providers, but it also confuses the patient population.

When you think about what needs to be done, there needs to be a better understanding and consensus about what palliative care services are, who is eligible, then what providers are able to deliver high quality care.

The No. 1 thing that we heard was that if there was anything that CMMI could do, it would be to define palliative care. 

One of the largest and biggest pieces of feedback that the health plans had was the need for a standard definition of palliative care services and what actually needs to be included in order to “count” as palliative care. That has been something that the plans have been really trying to figure out and need to standardize in order to support their provider network and knowing how they can achieve success.

The definition of palliative care that is out there is something that’s an intangible. It’s like a construct. It’s not something that can be operationalized in a standardized, systematic way.

We understand that palliative care isn’t a stand-alone model, and maybe it doesn’t need to be tested as one. But there does need to be some common elements so that a large enough population can be engaged and payers and providers can evaluate care based on performance to actually compare apples to apples and what the outcomes are over time.

Where are the payer stakeholders coming from on this issue? Is there a prevailing perspective or a set of priorities?

The feedback we got from CMMI was a request going forward to work with health plans in gathering feedback on the different models they’re currently rolling out and implementing.

The health plans have been really focused on ensuring that palliative care is integrated much farther upstream than hospice. There’s a real interest in identifying people with serious illness earlier in their disease trajectory, and then being able to get them the care and services that they need along the continuum of care.

When palliative care first really came onto the scene for health plans, it was much more closely tied to hospice and getting people into hospice earlier. Now, it’s really around keeping people healthier for longer, and aligning their care goals with quality measures, and making sure that they’re actually getting the care that they need.

Part of that is understanding how to use quality measures around care experiences so patients feel heard and understood. It’s answering how they can build that quality measurement into their health plan framework so that they know that whatever intervention somebody with a serious illness receives, it helps them feel empowered and that their care goals are being met.

There is also a major theme around cost savings related to palliative care services.

We heard from the majority of plans who participated that cost savings data are just not as readily available as they should be around palliative care because a lot of times they don’t have a large enough population participating in payment models to evaluate themselves. They rely on published literature to make a business case internally for these services. What’s really necessary and needed is for those health plans with palliative care programs that are succeeding to publish their results.

What have been the biggest takeaways from these discussions so far? What are the outcomes or potential impactful hopes?

There’s a real opportunity here to be able to partner together with the providers to shape that standard model. Providers can make some recommendations about what palliative care services are, and how they show up in three different avenues: as part of the hospice model, as part of an ACO and as part of specialty care.

Because those models could definitely look different. It’s something where palliative care models both need to be feasible and clinically sound. It’s value-based care in a team-based type of model. 

Three models that we’re focusing on include the value-based insurance design (or VBID) for hospice and how to integrate palliative care services upstream from hospice using this VBID model as the framework for that.

The second is really around the ACO Realizing Equity, Access and Community Health (ACO REACH) model, and the ability to integrate core principles and this definition of palliative care into population health. 

The third is around what was just newly released in an enhanced oncology care model, which would allow for palliative care services to be integrated into a specialty care model.

CMMI has requested that we work with the plans in these models to gather feedback on how health plans and providers can participate more effectively, and what things need to change in the request for applications (RFAs) going forward for next year’s VBID in hospice. 

They’re really interested in what the plans have to say, as well as what technical assistance they need shared with them while they’re participating in these models so that they’re actually getting the most up-to-date information in these demonstrations.

Providers are the participants in these models, but health plans play a really critical role in implementing, evaluating, and monitoring these types of models, especially with the VBID for hospice model. Payers hear less often from the plans.

We’re really focusing on collecting and gathering the information from the plans about what is feasible, what they can do and what they need in order to sustain these types of models, and how they can actually make it easier for their providers to be part of their network.

Are the discussions focusing solely on potential Medicare payment models, or do they encompass patients who are not seniors and would be covered by private insurers?

Participants were Medicare Advantage plans, Medicaid plans, commercial health plans, and health systems that are participating in both Medicare fee-for-service and with private payers and ACOs.

It really ran the gamut.

There is so much interest from the plans and providers in how to address the dually eligible patient population. Dual eligibles are the individuals that are most affected, most vulnerable by these payment models. They are older than 65. They’re poor, and they should have access to these palliative care services.

There’s much interest because while there are private payers, they also have to play by state and federal rules. The Medicaid plans that also are adopting palliative care as benefits need clarification from the federal government about whether or not dual eligibles can be included in these models.

In terms of the demographics of the plans, we had many of the Blue Cross Blue Shield plans and other large health insurers participating in this work and wanting to transform care for people with serious illness and do it in a standardized way. 

This is one of the only places that I have seen in health insurance where people come together and really collaborate and share openly about what they need and what they’re doing. This population is so important that there’s more collaboration and competition going on. It’’s not just the small community health plans who are playing here. It’s large plans, it’s small Medicaid plans and it’s regional health plans. So there’s really a beautiful cross section coming to the table, wanting to support these patients and wanting to support providers who are caring for them.

We’re getting together in person with a multi-payer health plan work group at the end of October in the District of Columbia at C-TAC’s Annual Summit conference. We will be able to have representation from CMS and CMMI in those conversations. So this really is just the tip of the iceberg of what we’ve been starting to do.