How Can Hospice and Palliative Care Clinicians Find Their Home in Population Health

Larry Beresford

Population health is the term applied to a variety of new and emerging coverage approaches aimed at more efficiently managing the health care of covered populations—all under the banner of promoting value for the system and quality of care for the beneficiary.

Models for managing a defined population’s health include bundled and other alternative payments, capitation, and per-member-per-month rates. Specific government-defined approaches include accountable care organizations (ACOs), the ACO Realizing Equity, Access, and Community Health (REACH) Model, the Merit-Based Incentive Payment System, the Value-Based Insurance Design (VBID) Model, Medicare Shared Savings Programs, and variations on Medicare Advantage. All were developed to increase value in health care while moving away from fee-for-service healthcare coverage, changing how clinicians are incentivized to provide their care.

But what does this bewildering array of acronyms mean to AAHPM members and the hospice and palliative care programs where they work? Clinicians should possess the clinical skills to care for patients with serious and life-threatening illnesses under these new models, but can they find their place in value-based care? What kinds of new relationships, new service packages, new team configurations, new settings, and new mechanisms for payment will enable them to play important roles in an evolving healthcare system that is busy pursuing the “triple aim,” namely increased quality, reduced cost, and enhanced patient experience?

Experiments like the Medicare Advantage VBID pilot,¹ which “carves in” for the hospice benefit, point toward redefining hospice under Medicare, transforming the benefit that was first implemented to cover hospice care 40 years ago. For palliative care programs, growing emphasis on home-based care models² means meeting patients where they are at or want to be—in their own homes. AAHPM members are naturally concerned that they are being asked to do something new—or worse, that they could be shut out of these new models.

Providers Coming Together

Mark Angelo, MD, a palliative care physician, former fellowship director, and now value-based care executive, runs a large ACO in Philadelphia, PA, called Delaware Valley ACO. An ACO, he explained, is “a group of providers that have come together under some agreement where we strive to improve the costs of care, the value of what we’re delivering, and quality outcomes for a given set of patients. ACOs can be organized in a bunch of different ways—by a health system, by a payer, or maybe a Medicare Advantage plan, helping to manage its patients to improve quality outcomes and decrease costs,” he said.

“The health system under that kind of arrangement is rewarded not for delivering more care but for delivering better care, care that keeps the patient healthy for as long as possible, with a good experience of care,” Dr. Angelo explained. “The good thing for hospice and palliative care in a value-based world is that we have been doing value-based care from the inception of our field. [Hospice and palliative medicine (HPM)] programs have always considered patients’ costs of care and actual needs. Really, that’s at the heart of what we do in palliative medicine and it’s at the heart of what we do in value-based care,” he said.

One of the best ways to find your role (or a role) in a value-based healthcare world is to collaborate with either an ACO or a value-based care arrangement like Medicare Advantage. “Palliative care providers deliver a service that is essential to the lifeblood of accountable care, which, in order to succeed, has to focus on its sickest patients,” he added.

According to Dr. Angelo, “If I owned a hospice, one of the first calls I would make [would be] to a local accountable care organization, saying: ‘How can we partner to improve the care delivered to your patients? I think I can be of value to you as a provider because my patients don’t get admitted to the hospital frequently. My patients in hospice get exceptional care and receive exceptional communication. And their goals are met.’”

“We, as HPM providers, offer patients the opportunity to say what they actually want, what they are hoping for. We listen carefully to our patients. We hear them say: ‘I don’t want to be in an ICU’; ‘I don’t want to have another surgery’; ‘I don’t want to have this fourth round of chemotherapy.’ Or simply, ‘I want to be comfortable’; ‘I don’t want to be a burden on my family.’ If you really can understand the patient’s goals of care, and you can help them get care consistent with their actual goals, it’s a win-win for everybody.”

Possibilities for Collaboration

Hosparus Health in Louisville, KY, is a hospice-based, diversified palliative care entity that has been pursuing these kinds of managed care relationships for the past 6 years, said its Chief Medical Officer Bethany Snider, MD. “I think the reason people are struggling (with population health) is because it is so complex,” she said. “In the palliative space, we’re not really helping with a geographic population. We’re focused on the seriously ill subset of that population and on improving their quality of life.”

Financial risk is the linchpin of all of this, because everyone—from the government to employers to insurance companies—is saying, “‘How do we manage burgeoning healthcare costs without throwing our beneficiaries to the curb? We want providers to help us,’” Dr. Snider said. When the palliative provider goes to the ACO or the Medicare Advantage plan and says we want to take on risk, the possibilities for collaboration are endless.

“We’ve been engaged in contracts to help manage populations for different payers,” Dr. Snider explained. “At first, they didn’t know a lot about what we do. But now they’re getting more interested and more sophisticated. The game changer was when we figured out who was at risk in our market: the health systems that were already spending significant amounts of money on a seriously ill population for which they were at risk. So we pulled them into the conversation with the payer, and now we have longitudinal contracts that have been going on for years with great outcomes for patients,” she said.

“Some contracts are direct to payers or Medicare managed care health plans or three-way agreements with a large payer, with the health care system taking on risk, and then us. We agree upon the diagnoses where we could add value, and the payer identifies the patients.” Hosparus Health does a total cost of care evaluation but then segments out certain costs that the palliative care program can’t be held responsible for, such as the Part D spend since palliative care can’t always impact that spend. “That’s [why] knowing your value and where you can have impact is really important when you’re at the table negotiating, because you don’t want to overpromise and underdeliver,” Dr. Snider said.

Hosparus Health’s population health model is strong in three areas: care management, advance care planning, and symptom management. It uses a dedicated team of palliative care experts, interdisciplinary in nature, working alongside primary care teams to help address specific needs, such as psychosocial needs in the home environment and social determinants of health—which can be a huge burden and unmet need for these patients.

“Those are our three aims, which we’ve stayed committed to in all the models. This is what we know we can excel at and where we can add value. And what wraps all of that together is 24/7 access to on-call support, which we learned from our hospice roots,” Dr. Snider said.

What Does Palliative Care Contribute?

Sandra Gomez, MD, a one-time palliative care physician in Houston, TX, now works for a primary care medical group running a Medicare Advantage population health program for patients 65 and older or disabled. Sage Health operates currently in four states. “I’m the administrator who helps design what we call the care model innovation, and home-based services and palliative care fall under that,” Dr. Gomez said.

“I have taken on a broader role, not just palliative care or serious illness care but working with the bread-and-butter primary care doctors and how to support them in their patient care,” Dr. Gomez explained. “So my career path has gone from being very focused on the subspecialty of palliative care to now going back to my primary care roots, expanding into population health to actually try to prevent serious illnesses.”

Dr. Gomez recently conducted an informal focus group of primary care physicians (PCPs) in her medical group to ask them what they considered the role of palliative care in their everyday practice of population health. “What’s in it for the patients is better access to the right level of care at the right time,” she related. For example, with palliative care's involvement, can patients access hospice care more easily when that becomes timely? Can they have fewer symptoms from their illness and better communication with their PCP?

The other stakeholder is the family, and what’s in it for them is advocacy, Dr. Gomez said. “You know, family members don’t always understand what’s going on, so palliative care helps to advocate for them in a population health model. One of the themes of population health is addressing health inequities and access. People need to feel heard. So palliative care is like an ambassador, a translator, helping to build trust.”

For the doctors, palliative care is their eyes and ears in the patient’s home,” Gomez noted. In a value-based environment, the clinician is looked upon to provide preventive services and improve outcomes, not for the volume of patients seen. “If you have diabetes or heart failure or kidney disease, how can I as your primary doctor anticipate that? How do I slow down your progression to dialysis?” she explained.

“One of the things I love about population health and Medicare Advantage plans is their openness to things that just seem like common sense, like paying for food. I used to work for a company through Optum where we had a food pantry for people running low on food, and I was a volunteer. We could get on the computer and literally order food to be delivered to them, because we saw that the need for food security was driving their healthcare utilization. And we arranged for rides to dialysis or medical appointments. The other thing we would do is treat loneliness, which is another big driver of healthcare utilization and the morbidity of patients.”

A Clinician at Heart

Heidi Young, MD FAAHPM, is associate chief medical officer and medical director for primary care at Capital Caring Health, which has provided innovative hospice and then palliative care services in the Washington, DC, metro area for about 45 years. “You know, I’m a clinician at heart. Every time I think about these very big picture systems of care, I try to think about it in terms of what does this mean for the patient that’s right in front of me on a given day,” she said.

“And really, to me, we’ve been talking about value-based care for 40 years under the Medicare hospice benefit,” she added. But experience has shown that many patients need some of the services of hospice long before they are eligible for or would choose to enroll in hospice. So how can HPM organizations work with payers to individualize that care upstream from hospice enrollment? Dr. Young asks. That may mean more social work support, home-based caregiver support, advance care planning, or a 24/7 call center for symptoms.

Traditional hospice care is very effective at keeping people out of the hospital, although a month of home hospice care costs about $6,000. The ACO may be interested in some of those services a la carte, and hospice can provide that. “To me, that’s where the innovation can happen,” Dr. Young said.

About 5 years ago, Capital Caring’s CEO at that time, Tom Koutsoumpas, also took the lead in starting a number of organizations, like the National Partnership for Healthcare and Hospice Innovation (NPHI) and the Coalition to Transform Advanced Care, with the thought that hospices need to innovate and figure out how to pool their resources together to get ahead of this avalanche of change. “Locally, we started collaborating with an ACO REACH program called AIP, Advanced Illness Partners. And as part of that, we started a home-based primary care program called PCH, Primary Care at Home, with the idea that we want to approach the population we care for in hospice, but farther upstream,” Dr. Young said.

She explained, “We have physicians, nurse practitioners, social workers, care managers, [and] triage and team coordinators. But we don’t employ custodial caregivers; we partner with other organizations and make recommendations for that service. We also partner with other organizations for home health care, in-home imaging, phlebotomy, etc.” About 80% of visits are in person to the home, with opportunities for telehealth.

These approaches also need to be balanced with the fact that not every patient is covered by value-based arrangements. Some are still under fee-for-service models, with wide variations by region. But CMS has announced its goal of having all the patients it is responsible for (ie, Medicare and Medicaid) in value-based care by 2030.

Dr. Young has participated in some medical director calls for NPHI members, including their chief medical officers and business development officers. “I think that a lot of…the smaller hospices are educating themselves about what this landscape looks like, as a starting point,” she said. Especially since the traditional hospice benefit in its current form is likely to evolve into something similar to, but not the same as, it’s always been.

Capital Caring and hospices like it have margins of less than 3%, yet they are going to be asked to provide more for less. “That’s something everybody everywhere in health care is trying to do, but it’s coming for hospice now. I would encourage people to recognize that while hospice has been doing great value-based care for so long, the rest of the medical system is now leaning into that model. We have a lot to teach them about how, when you bring the care to the patient rather than the patient to the care, there is a huge amount of value in that,” Dr. Young said.

“But that doesn’t mean that we will get to do things the way we’ve always done them. It means we have to evolve in how we deliver that care so that hospice can fit into the rest of the medical system, rather than being carved out like we have been.”

The Patient Comes First, Always

Joe Rotella, MD, the Academy’s chief medical officer, agrees that population health is an important part of the future for academy members. “We strive to offer value-based (or population-based) health care entities a service that helps them meet their goal—the triple aim of better outcomes, better experience of care, and lower costs,” he explained. “But they will want us to do it as cheaply as possible. We can’t just slash spending to get contracts. We must be efficient but still deliver outstanding palliative care.”

The processes and outcomes associated with quality palliative care support effective population health management, Dr. Rotella said. “It’s great that when we do the right thing for our patients, it’s usually also good for payers. But we don’t exist to save money. We also consider clinician well-being and how to be equitable for all patients,” he said.

“We’re happy to work with ACOs and others to improve the value of our healthcare system, but the cheapest approach is not always the best. At the end of the day, our patients must always come first.”

References

VBID Model Hospice Benefit Component Overview. Centers for Medicare and Medicaid Services.
https://innovation.cms.gov/innovation-models/vbid-hospice-benefit-overview. Accessed
August 16, 2023.
Roberts B, Robertson M, Ojukwu EI, Wu DS. Home based palliative care: known benefits and future directions. Curr Geriatr Rep. 2021;10(4):141-147. doi:10.1007/s13670-021-00372-8.

Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.

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