How to Increase Use of Palliative Care in Medicare

I wanted to call your attention to this interesting piece from Health Affairs, entitled, “How Can We Increase the Use of Palliative Care in Medicare?”It discusses a specific model of care, the Four Seasons Hospice Model, that is currently being tested in Western North and South Carolina.

As part of the new Health Affairs Blog series highlighting serious illness and end-of-life care, this post describes a community-based, interdisciplinary palliative care model that spans care settings and is being evaluated in a Center for Medicare and Medicaid Innovation (CMMI) demonstration project. It provides some early lessons on how alternative payment models for palliative care might be developed to increase its provision in Medicare.

The model is being demonstrated by Four Seasons Compassion for Life, a nonprofit hospice and palliative care provider operating with a network of community partners in the Western regions of North and South Carolina. Supported by $9.5 million in funding from the Center for Medicare & Medicaid Innovation (CMMI), the project began in September 2014 and, by the end of its evaluation period in August 2017, approximately 5,200 Medicare patients will have enrolled in the model. Evaluation of the project will include patient outcomes and the total cost of delivering care through the model. From these results, we will propose a new payment model for palliative care that could then be tested in other locations.

Check out the whole article here to learn about this demonstration, what they’re learning from it, and what implications that could have for increasing use of palliative care going forward.

Table 1. Policy Landscape For Financing Palliative Care Services At End Of Life In Medicare

Medicare Benefit
Part A
Hospital Insurance
Part B
Physician Services
(Medical Insurance)
Part C
Commercial Medicare Advantage
Part D
Prescription Drug Coverage
Financing Trust Fund payroll tax and other sources Premiums with deductibles and general revenue (income tax) Commercial premiums with deductibles General revenue (income tax) & premiums with state contributions
Services Hospital, skilled nursing, long-term care, hospice Doctor visits, lab services, durable medical equipment, therapy Private A + B + (D) + additional benefits
• 30 percent population
• Hospice carved out
Prescription drugs
Cost triggers Reduce unnecessary utilization Increase care coordination and goals of care Unknown; unavailable claims for research Symptom management outlay vs. curative
Current movement Hospice “two-tiered” payments with service intensity last seven days Advanced Care Planning CPT codes

Transitioned Care Management codes

Chronic Care Management PBPM

PILOT: Medicare Care Choices Model (test $400 PBPM concurrent care for hospice-eligible beneficiaries)

Aetna Compassionate Care program for under 65 commercial

Numerous proprietary coordinated/ palliative care management programs underway

Review of access, medication reconciliation, polypharmacy, and discontinuation issues
Potential bundles as APM Hospital-based palliative care services

Post-acute care (90-180 days) prior to hospice palliative care services

Primary care (CCM, CPC+, PCMH medical homes) additive for palliative services in PBPM

Specialty care (CCM, medical home) additive in PBPM

Proprietary build on HCC risk score methodology Pharmacy/drug benefit during episode transitions (90-180 days) prior to hospice
Implication of ACO-MSSP Provider groups managing Total Cost of Care (Parts A, B, D) with increasing risk models and flexibility to deliver care across settings where financial control can be leveraged Excluded from MSSP; MA program innovation increasing but not publically shared Clustered resourcing as part of Total Cost of Care

Abbreviations: ACO=accountable care organization; APM=alternative payment model; CCM=chronic care management; CPC+=comprehensive primary care plus; HCC=Hierarchical Condition Category; MSSP=Medicare Shared Savings Program PCMH=patient-centered medical home; PBPM=per-beneficiary per-month